Table 2.

Themes

Setting	Author & Year	Themes
		Conflict	Fear	Demands
Unspecified Correctional Facilities	Almost et al., 2013	Sources of conflict were reported as correctional officers (28%), nursing colleagues (27%) inmates (24%), managers (17%), and physicians (2%) Correctional officers had different values and expectations, placing safety over healthcare Participants viewed conflict among other staff members as negatively impacting the environment	Over 63% of nurses and 44% of healthcare managers (HCMs) experienced emotional abuse from inmates Over 55% of nurses and 66% of HCMs experienced emotional abuse from someone other than an incarcerated person during the past year Sources of bullying were reported as correctional officers (31%), nursing colleagues (30%), inmates (20%), HCMs (11%), and physicians (5%) During the past year, 25% of nurses and 30% of the HCMs reported frequently observing bulling During the past year, 53% of nurses and 67% of HCMs reported being the subject of bullying	Limited time to provide care paired with inadequate staffing contribute to a demanding workload 66.7% of HCMs and 39.3% of nurses had high levels of emotional exhaustion as a subscale of burnout Lack of time and heavy workload decreased the chances for nurses to achieve continual education needed to improve competencies and practice to the full extent of their scope Overtime hours contributed to the increased role overload and burnout found among the participants
	El Ghaziri et al., 2019	There was significant difference in civility norms experienced by female nurses vs. male nurses	50% of the nurses reported their workplace as unsafe 37% of participants reported a sharps-related injury or exposure to blood-borne pathogens and body fluids within the previous 2–5 years, presenting safety concerns The majority of the participants (99%) reported being at risk for workplace violence and having been victims of workplace violence from an incarcerated person in the past 12 months (96%) Male nurses faced more assault threats and female nurses received more verbal abuse from incarcerated persons Low decision-making authority contributed to stress	Stress is created from the high psychological and physical demands of the work Low supervisor support contributed to the stressful work environment Nurses and healthcare managers slightly disagreed that they felt respect from supervisors
	Husted & Dalton, 2021	Peer support was perceived as beneficial and positive, allowing participants the opportunity to cope with their stress There were conflicting results regarding the perception of organizational support, yet most were negative	Participants experienced daily occurrences of threats yet used coping strategies and personal resilience to mitigate stress Ignoring the threat or remaining calm were common strategies, but staff also reported becoming desensitized to threats, which may potentially impact their long-term mental health	Demanding and stressful aspects of the job involved environmental challenges of workload, staffing, shift length, role conflict, security levels, and other unknown aspects of their role Participants described heavy workload as adding to their daunting work experiences
	Weiskopf, 2005	Ethical dilemmas surrounded: following the rules, not being able to touch patients, and being mandated to disclose otherwise protected patient information There was a conflict of not being able to show the compassion that nurses usually professionally maintain If correctional officers “…did not value health care, particularly related to mental health, [the nurses] did not feel supported or autonomous in their practice” (pg. 339) Participant accounts highlighted the struggle between trying to maintain positive workplace relations while also being caring towards patients	Participants reported corrections as a “difficult environment to work in” (pg. 340) Non-caring thoughts and attitudes towards patients from other nurses and staff members created a negative work environment Hostile and manipulative behavior of incarcerated persons added to the negative environment where nurses felt they couldn’t show their caring emotions Nurses remained vigilant with the premise that security is a vital part of one’s practice	Participants reported difficulty in maintaining the patience and perseverance to try and turn an incarcerated person’s life around Limited opportunities to provide patients with appropriate treatments created unattainable treatment goals Participants reported frustration with feeling as though they were not meeting patient’s basic needs
	Lazzari et al., 2020	91.1% (n=217) of the nurses reported complying with regulations and rules that they believe are contrary to their personal ethics 92.4% (n=220) of the nurses reported working with a doctor or nurse who was incompetent	Among the sample of nurses, 92.4% (N=220) reported not always feeling secure about their personal safety in caring for their patients 99.1% (N=236) reported carrying out activities outside of their nursing role	Incompetent colleagues and short staffing were related to higher levels of moral distress Years of experience in correctional nursing was significantly and positively associated with moral distress (p < 0.001) Among the sample of nurses, 98.3% (n=234) reported working without resources and/or tools to ensure quality care
Prisons	Flanagan & Flanagan, 2002	Difficult patients were rated highly as sources of stress among the nurses	The environment was described as a coercive and threatening setting The experiences of low autonomy in practice were influenced by confidence and competence in their role	Time pressures, competing priorities, and deadlines for trivial tasks were found as sources of stress among nurses A lack of organizational support and understanding were sources of stress. Nurses reported: “I only get feedback when my performance is unsatisfactory” (pg. 291)
	Flanagan, 2006	Difficulty dealing with difficult patients and aggressive people were rated highly as sources of stress among the nurses (M = 3.5, SD = 1.2 and M = 3.4, SD = 1.3, respectively)	One of the highest mean scores on the stress index was that “decisions or changes which affect me are made above without my knowledge or involvement” (M = 3.5, SD = 1.3) (pg. 320)	Nurses experienced difficulties in managing the workload priorities and time effectively, adding to their stress Autonomy was among the top sources of job satisfaction along with pay Lack of organization support and involvement were noted as contributors of stress
	Walsh, 2009	Nurses were impacted by the conflict in relationships with their officer colleagues, the institution, their patients, and themselves. Nurses may suppress their emotional actions in order practice safely in this environment, contrasting their core aspects as a nurse Seeing peers practice below a high standard created anxiety for participants Compromising ethics led to frustration	Safety was influenced by the ethical perspective of self-governance, and the need to adhere to protocols Nurses were reported to be obsessive about record-keeping and overly cautious in case of incidents that could lead to legal repercussions Concerns were expressed for supervision as nurses felt unsure about the best course of action without adequate guidance Some nurses were uncomfortable in making decisions where security was valued over healthcare, provoking anxiety and concerns of punishment Feelings of disempowerment lead to low morale, along with thoughts of low self-importance and the inability to make positive changes	Managing personal and profession conflicts along with the psychological effects of the work added to emotional labor One nurse remarked, “…you need to be strong, other than being professional, you need to be strong and able to detach yourself from situations…” (pg. 146)
	Stephenson & Bell, 2019	A lack of respect and deficient communication from leadership caused participants to view them as ineffective One nurse explained their frustration with leadership, “the proven and accepted best policies in dealing with healthcare workers and structuring a rewarding and progressive work environment are completely lost upon a management that lacks the experience, the training, and the motivation to improve” (pg. 32) Negative coworkers were described to impact the environment (i.e., “So many employees have such a negative outlook on things at work…” (pg. 32)	One participant reported “staff safety is not at its highest” (pg. 32) Main issues of concern for participants included safety Lack of opportunity for continued education and appropriate training was also noted among participants	One nurse participant reported, “We are constantly understaffed, mandated, or work long stretches without days off. . .” (pg. 72) Lack of resources also hindered the quality of care able to be provided Inconsistent standards and expectations for their role was reported, with inconsistencies of workloads
	White et al., 2014	Security and tightly supervised movements of the patients added limitations for providing care Custodial and judicial requirements can often override healthcare A conflict of morality was described where participants needed to choose when to follow their professional obligation and override security protocols, or when to follow security protocols instead of their professional obligation Limiting the healthcare of the incarcerated persons was often viewed as a denial of human rights by participants Certain reporting policies conflict with the professional duty of doctors and nurses to maintain confidentiality	Personal security was raised by participants as an issue One doctor remarked, “there have been, for instance, threats like “I’m going to get [the doctor] next time” … In those situations, you take that seriously and you just alert the guard that this has occurred” (pg. 340) Participants described specific procedures in place including when and how the incarcerated person can enter the clinic/hospital Sight and sound policies allow correctional officers to be within sight and/or sound of the assessment of the incarcerated person Staff regularly take security awareness courses Participants reported there was a sense of doctors and nurses protecting one another	Overcrowding raised concerns for the participants Healthcare personnel have a duty to protect their patients, while also protecting incarcerated persons from each other, and from themselves. This duty requires the staff to be vigilant and report assaults and self-harm instances The environment was described as “…too many patients and not enough health care and other staff” (pg. 340), alluding to understaffing issues Participants reported that roadblocks of policy and security make accessing outside health care facilities or scheduling specialist procedures more difficult Participants described a lack of resources, such as clean needles to give to patients
Jails	Kalra et al., 2016	Stress arose from the conflict in patient/provider relationships, caused by the dual loyalty among nurses to meet the security measures of the jails and provide ethical care to patients The inability to maintain patient confidentiality in their roles was among the most prominent factors affecting ethical compromises and burnout (p < .01) A quarter of survey respondents felt that their ethics as health care providers were regularly compromised by their work environment, creating internal conflict	23.5% of participants frequently or occasionally felt physically afraid or intimidated in their workplace Results found that there were no significant associations between physical assault and burnout directly, potentially related to inadequate measurements	A challenging work environment was described involving draining and negative experiences with patients Multiple security points and small workspaces were reported as a cause of burnout