Inmates Care: Computer-Based Training for Geriatric and End-of-Life Care in Prisons

Abstract

The growing aged and dying incarcerated population increases demands on corrections health care. People who are incarcerated can assist in care delivery; however, currently, their training is typically face-to-face, home grown, and variable in content and duration. Six focus groups conducted with peer caregivers (PCs) (n = 12) and staff (n = 15) identified priority training topics. Three prototype modules (Standard Precautions; Loss and Grief; and Role of the Inmate Caregiver in the Final Hours) were developed in consultation with an advisory board. Face-to-face usability testing with (n = 20) PCs and staff confirmed contextual relevance and feasibility of the Inmates Care training. The mean system usability score for all participant segments was 86.5. Inmates Care holds promise to complement nurse-led training with a standardized e-training package.

Introduction

More than 2.3 million adults in the United States are held in 1,719 federal and state prisons (Sawyer & Wagner, 2019). The most recently available federal statistics indicate that 20.3% of adults living in U.S. federal and state prisons are age 50 years or greater (Bronson & Carson, 2019). With increased age comes increased probability of experiencing health problems (Murolo, 2020). Furthermore, the health status of people 50 years and older who are incarcerated has been found to be on par with community-living adults who are 10–15 years older (Loeb et al., 2008). Growing numbers of older people who are incarcerated “has raised questions on how corrections departments address this population's needs” (Murolo, 2020, p. 4), both in the United States (Depner et al., 2018) and internationally (Heidari et al., 2017), which has increased the demand on prisons to provide not only geriatric but also end-of-life (EOL) care.

Engaging carefully vetted men and women who are incarcerated to assist with the care of their older or sicker peers, particularly those living with cognitive impairment, is one initiative that can contribute to meeting this pressing health care demand (Berry et al., 2016). Also, trailblazing prison hospice programs began emerging in the United States during the late 1980s and early 1990s with elements of these programs similarly engaging carefully selected incarcerated people to assist with supportive EOL care for their peers (Ratcliff & Craig, 2004) and serving as intermediaries between prison patients and the staff who care for them (Murolo, 2020). Identification, rigorous screening (Murolo, 2020), enlisting, and overseeing willing and able peer caregivers (PCs) are especially important considerations when implementing peer care in correctional settings. For example, the Gold Coat Model for peer caregiving sets the criteria for serving in the PC role as follows: a decade free from disciplinary action, serving a long term or life sentence, history free of either cognitive deficits or emotional health challenges, and evidence of “rehabilitative and community service” within the correctional environment (Berry et al., 2016, p. 31).

Utilization of peer care is not universal (Murolo, 2020) and states sometimes designate one correctional facility as their geriatric care facility for the state. One could safely infer that such a centralized approach allows for specialization and more extensive resources at institutions designated to provide geriatric and/or EOL care, but at the same time would leave no small number of older incarcerated people on an uneven playing field since service availability across institutions would not be consistent. Beyond these considerations, a barrier to high-quality peer caregiving is insufficient and/or inconsistent training. According to a 2016 systematic review, PC training has been highly variable in duration and content across institutions (Wion & Loeb, 2016). Training programs for PCs many times fail to provide boosters or ongoing updates to training and fall short with providing enough grief support. In fact, Penrod et al. (2013) found that although corrections administrators participating in their study universally endorsed grief support as being important for people who are incarcerated, they simultaneously acknowledged that the bereavement needs of PC are often left unmet.

Considering the pressing challenge to meet the health care demands inherent to an increasingly older and sicker prison population, capitalizing on the abundant human resource of PCs can vitally contribute to quality care delivery for those who have grown old and/or are approaching their EOL in prison. Depner et al. (2018) emphasized the importance of continued investigations to further explicate this “unique and potentially helpful model of EOL care delivery within the correctional setting” (p. 971). They noted that the PC role requires evidence-based and accessible training (Depner et al., 2018). PCs also require ongoing support that is not restricted to an initial in-person training if they are to provide safe and effective care while at the same time maintaining their own physical and mental well-being.

One way to address this training gap is to build upon a recent trend toward incarcerated people having access to digital programs for online job-training instruction; video chats with family members from outside of the prison (Holloway, 2019); computer tablets (Brosher, 2016; Coppola, 2017) for gaming, music downloads, and educational videos (Associated Press, 2018); and computer-based training (CBT) in general (Davis et al., 2013; Holloway, 2019). PCs undergo considerable scrutiny to determine eligibility to serve in the peer caregiving role in prisons (Hoffman & Dickinson, 2011; Supiano et al., 2014; Yampolskaya & Winston, 2003). Therefore, it is reasonable to conclude that the likelihood of inmate PCs gaining approval for CBT is far greater than for the typical person who is incarcerated. As found in this team's previous research focused on developing CBT for prison staff (Kitt-Lewis et al., 2019, 2020), computer-based learning (CBL) modules being designed for use with people who are incarcerated should similarly be “short, intensive, engaging, interactive, and contextually sensitive to the correctional environment” (Loeb et al., 2017, p. 184).

Considering the pressing needs already mentioned, as well as current trends toward greater opportunities for people who are incarcerated to engage with technology, the purpose of this Phase I Small Business Technology Transfer funded study was to accomplish two specific aims. The first is to transform free-world best practices in supportive geriatric and EOL care into evidence-based, media-rich, and highly interactive e-training for inmate PCs. The second aim is to complete face-to-face usability testing of the Inmates Care CBT with incarcerated people and interdisciplinary prison staff. Inclusion of both PCs and prison staff is essential to gain perspectives of both the intended end users of the training and those who likely hold responsibility for facilitating such training and/or overseeing the PCs as they assist with the care of older and/or dying men and women in prisons.

Method

The core research team comprised nurse researchers from a large research-intensive university in a Mid-Atlantic state, along with their small business partners from a woman-owned educational technology company in the Rocky Mountain region of the United States. In addition, an advisory board comprising members from states across the United States provided regular consultation, freely sharing their expertise in corrections health and training, hospice and palliative care, geriatrics, bioethics, vulnerable populations, and oversight of a chronic disease self-management program in a state prison system.

Human Subjects Considerations for Aims 1 and 2

For both aims 1 and 2, human subjects considerations included obtaining institutional review board (IRB) approval from the principal investigator's university, research review committee (RRC) approval from the state department of corrections for the two state correctional institutions (SCIs) that were settings for this study, Prisoner Research Certification from the U.S. Office of Human Research Protections, and signed informed consent from each research participant in both the focus group (FG) and the usability testing aims.

Recruitment for Aims 1 and 2

All participants for both study aims were recruited through IRB- and RRC-approved recruitment flyers, which were distributed by the superintendent's assistants at the SCIs. Specifically, paper copies of flyers were distributed through the mail drawers to incarcerated people who met the following inclusion/exclusion criteria: identified as a potential participant by the superintendent's assistant; provide geriatric and/or EOL care to their peers as mental health or peer support specialists; age 18 years or older; able to speak and understand English (Test of Adult Basic Education [TABE] scores were obtained for all incarcerated participants); and able to provide consent. Electronic copies of the recruitment flyers were distributed through email to interdisciplinary staff who met the following criteria: identified as a potential participant by the superintendent's assistant; oversee PCs or deliver geriatric and/or EOL care themselves; have insights on security considerations when delivering e-training to inmates; age 18 years or older; able to speak and understand English; and able to provide consent.

Incarcerated men and women who were interested in learning more about the study completed a tear-off slip from the recruitment flyer and sent it to their SCI's superintendent's assistant, while the staff responded through email. The superintendent's assistant then set a schedule for the interested individuals to meet with the PI and a second study team member to hear more about the study, have any questions answered; and undergo written informed consent if still interested. Also, consented people participated in one FG with their stakeholder group (i.e., incarcerated people, interdisciplinary staff, and information technology or training staff) for aim 1, and/or participated in face-to-face usability testing of the e-training modules for aim 2. Every potential participant who met with the researchers agreed to participate either in an FG and/or usability testing.

Aim 1

Sample and setting

A total of six FGs with a purposive sample of 27 participants were conducted in one men's and one women's SCI in a Mid-Atlantic state to determine a menu of CBL modules to address priority PC training needs. Three stakeholder groups were recruited to participate in the FGs: PCs (2 FGs; n = 12), interdisciplinary staff (2 FGs; n = 10), and information technology and training staff (2 FGs; n = 5).

Data collection process

Each participant participated in one FG session, which lasted approximately 60 minutes. FGs were conducted in 1 day at the men's facility and across 2 days in the women's facility during July and August of 2018. The PI moderated all FGs using a semistructured discussion guide (see guides below) and was assisted by a trained study team member serving as comoderator, who managed audio-recording equipment, took handwritten field notes, and occasionally took part in the discussion.

Peer Caregiver FG Discussion Guide

• Share the name you would like for us to call you and how long you have been a peer caregiver.

• Has anyone cared for an adult family member or friend before coming to prison?

• Share any formal training in health care before coming to prison.

• How was the training you received here helpful to getting you started as a peer caregiver?

• How comfortable are you with using a computer? Like best and/or like least about computer based training

• As we develop our computer based training for peer caregivers, what topics do you think are essential (why)?

• Of the topics discussed, what are the three most important areas to focus on first?

• Is there any other information that you feel would be important for us to consider?

Interdisciplinary Staff FG Discussion Guide

• Please share your name, position within the prison, and how long you have been in your role.

• How have you been involved with inmates who are serving as peer caregivers?

• What training is provided to peer caregivers?

• Duration of the initial training program?

• Methods of delivering training?

• Who delivers the teaching and where?

• Follow-up training/updates (frequency and focus)?

• What are the key content areas that are addressed in your initial peer caregiving training?

• Of the key areas that you have described, which areas lend themselves well to computer based training?

• Conversely, which (if any) areas require hands-on training?

• Where do you typically get the materials that you use to train peer caregivers?

• How current/up to date are these materials?

• Do you currently use any online or computer based training materials with inmates?

• Do you purchase any commercialized training products?

• Do you access computer based training?

• As we develop our computer based training for peer caregivers, what topics do you think are essential?

• Of the topics discussed, what are the three most important areas to focus on first in our computer based training?

• Share any challenges you have faced when training inmates to be peer caregivers.

• Are there any challenges you have experienced when overseeing peer caregivers?

• What information do you feel is important for us to consider as we develop our first three computer based training modules for inmate peer caregivers?

Training and IT Staff FG Discussion Guide

• Share your name, whether you are training or IT staff, and any involvement you have with providing or developing training materials for inmates.

• What are key considerations when developing computer based training for an inmate audience?

• What have you found are inmates' general reaction and attitude toward computer based training?

• What are challenges to using technology with inmates?

• Describe what your impressions are of inmate peer caregiver training.

• What learning strategies do you feel are important to consider?

• Do inmates currently access any computer based training?

• What safeguards are used when inmates are accessing computers/tablets?

• Do you purchase any commercialized training products? (Are materials up to date?)

• What are the key content areas that should be included?

• Which areas do you believe lend themselves well to computer based training?

• Which, if any, areas discussed require practical (i.e., hands-on) training?

• What trends do you expect to see for inmate training in the next 5 years?

• Is there any other information that is important for us to consider as we develop our first three computer based training modules for peer caregivers?

FG Analysis

Audio recordings of FG sessions were transcribed verbatim by trained research assistants and then cleaned of all identifiers and verified line by line for accuracy while listening to audio recordings. Next, first level coding was completed for each question, followed by identification of themes by the PI and a trained research assistant (authors 1 and 2). The broader team then reviewed the coding and suggested minor refinements, and the team reached consensus before finalizing the FG analysis. Engagement with an advisory board of corrections experts in the fields of nursing, medicine, and training, along with an expert in geriatric and EOL nursing, allowed for sharing of findings from FG discussions and resulted in three priority areas of attention for prototype CBL module development, identification of core values for the training, and a logo for the training.

Module development

Prototype modules were programmed by the small business members of the study team following standard production steps. Interface design ideas were created in written form and then combined with scripts, flowcharts, and storyboards. All elements were reviewed by the university investigators before creation of actual images and authoring of web elements was undertaken. Programmers then produced the e-learning program and beta tested it in house for stability and code errors, as well as tested it for usability. Inmates Care was designed with Sharable Content Object Reference Model installation compliance (i.e., a collection of standards and specifications for e-learning). Inmates Care development and design was institution-specific technology for this Phase I study and was delivered through a laptop computer to inmate and staff participants. The presentation layer of the program comprises the interactive elements, video segments, and user interface components and was developed using HTML5, Javascript, CSS/SCSS, and the React Front End Framework (React 16+).

A three-module interactive CBT was developed during the project period. As noted earlier, the program's modules consist of Standard Precautions, Loss and Grief, and the Role of Inmate Caregivers in the Final Hours. Content was developed by the study team, revised to meet the 8th grade reading level, and reviewed by the advisory board. See Figure 1 for the program's sitemap. In total, the program features 23 interactive components including videos, slideshows, drag-and-drop activities, and interactive graphics. The seat time for each module was approximately 45 minutes. This program has the capability to export training sessions to fit into many different learning management systems including those used in correctional settings.

Fig. 1.

Inmates Care program flow February 27, 2019. Color images are available online.

Aim 2

Sample and setting for face-to-face usability testing

In-person usability testing of the three interactive computer-based prototypes was conducted with two stakeholder groups. The first stakeholder group consisted of both incarcerated women (n = 5) and men (n = 5)—the targeted end users of the CBL product. The second group comprised nurses and other frontline corrections staff members (n = 10 [5 per men's and women's state prisons])—people who interact regularly with PCs through either caring for or managing people who are aged and dying in prison.

Usability testing was conducted over 2 days at each of the two SCIs. In both settings, people who were incarcerated did usability testing on one day and the interdisciplinary staff did the testing during the other day. Each usability tester met with the PI and trained research assistant for approximately 1 hour to work through the prototype modules at their own pace. One of the two investigators sat adjacent to each tester directing them to specific activities and content pages, noting when difficulties were experienced and encouraging testers to troubleshoot by themselves initially and only telling them specifically what to do in the rare instances where testers had expended their ability to troubleshoot and needed the assistance to move forward (e.g., scroll to the bottom of the page to get the button to click to move on). The other investigator logged field notes and managed the audio-recording device. Usability outcomes included testers' ratings of satisfaction with the program regarding design, appeal, and functionality using the System Usability Scale (SUS). Each concept was rated on a 5-point Likert scale. Means of the Likert response items are calculated and a score of 68 or higher is considered above average (Bangor et al., 2008, 2009; Brooke, 1996). In addition, usability testers identified barriers they perceived either as the target users who potentially could be trained through the prototype modules or that they anticipated would be experienced by target users in the case of the staff usability testers. In addition, all usability testers completed a brief demographic questionnaire within the 1-hour session with the two investigators.

Usability Testing Analysis

All data were deidentified and stored in a secured database. Established protocols for quality assurance ensured high-quality data. SAS was used for the quantitative analyses. Descriptive statistics, such as means and standard deviations (SD), were calculated on the collected demographic information (i.e., gender and age) and SUS scores for both staff and incarcerated persons.

Results

FG Participants' Demographic Characteristics

Originally 17 PCs agreed to participate in the FG phase of this study; however, 5 (2 women and 3 men) did not meet the FG inclusion criterion of having a TABE score of ≥8. Twelve PCs are among the study sample along with 15 staff members from a wide variety of disciplines: 2 each of registered nurses, human resources personnel, information technology staff, psychology staff; and 1 each of training staff, chaplain, corrections officer, certified nursing assistant, correctional health care administrator, unit manager, and utilization manager (i.e., responsible for increasing efficiencies through discharge planning, disease management, and clinical case appeals). See Table 1 for more information about the demographic characteristics of the FG participants.

Table 1.

Demographic Characteristics of the Focus Group Participants

Demographic variables	Total sample (N = 27)	Peer caregivers (n = 12)	Staff (n = 15)
Gender
Male	11	4	7
Female	16	8	8
Race
Black	3	3	0
White	24	9	15
Ethnicity
Non-Hispanic	27	12	15
Hispanic	0	0	0
Age range
18–29 years	1	0	1
30–39 years	8	7	1
40–49 years	4	1	3
50–59 years	9	3	6
≥60 years	5	1	4

FG Themes

Thematic analysis of the narrative data revealed six themes that cut across the responses of the men and women who were incarcerated as well as the staff participants. The themes were Acknowledging Death and Providing Support, Fulfilling Unmet Needs Related to Loss in the Community, Important Intrinsic Qualities/Core Values of Peer Caregivers, Overcoming Limitations in Corrections Settings for the Peer Caregiver, Diversity in Training Approaches, and Important Training. Table 2 presents exemplar quotes from incarcerated men and women (i.e., PCs) and staff that represent each theme.

Table 2.

Exemplar Quotes From Peer Caregivers and Staff

Themes	Exemplar quotes
Acknowledging death and providing support (includes positive [+] and negative [−] exemplars)	PCs  They do a memorial for them [deceased] where you can go to the chapel…You can actually go up and speak…+  The only ones that I know of they met with was the person…in the room at the time of her [patient's] passing− Staff  …on a daily basis, [I] touch base with both the terminal inmate and the inmate that is taking care of the terminal inmate. Offer them a break…+  …we need to make sure we have…follow-up treatment…to help them deal with their thoughts…. To us it's an inmate…but to them it's a peer…+
Fulfilling unmet needs related to loss in the community	PCs  I had family members who passed away…we weren't able…to sit there with them…that opportunity to be with somebody else [is important] since we couldn't be with our families.  I couldn't be there with my family to sit in…. Let me sit in with somebody else's so they don't have to be alone…  …my decision came…from the need to give back, and [pause] the pain that we feel being in here being separated from our loved ones. Staff  They volunteer. They want this. We survey the institution once a year and we are doing the 40-hour training once a year and they have to show interest, they have to write to us and say, “Yes, I'm interested…”
Important intrinsic qualities/core values of PCs	PCs  …you have to respect…to give dignity, and provide the hope for that person that you're taking care of…they are relying on you…  It has always stuck with me…the amount of compassion and intensity and passion that [Hospice Nurse] brought to that training…she holds us to make sure we care for these people tremendously  …giving comfort…the physical care which we ALL can be trained on, and…the spiritual and emotional care that comes from our heart. Staff  I think they [Peer Caregivers] should help define that. I know my group will. They won't hesitate.  I think dignity, I think dignity would be really important. Respect, dignity, I like that…
Overcoming limitations in corrections settings for the PC	PCs  …you would be amazed at some…things we come up with. One guy was gurgling and we weren't allowed to use the suction…so…just rolling him to the side and just letting it come out of him [helped]…  …we can observe…take notes. And then…just relate to the nurse…  Helping swab a guy's mouth out…putting a cool rag on his head…give little tidbits of things can help person feel more comfortable…. Staff  Role playing is difficult to do with inmates. What's the number one fear being in this space? Public speaking. But what you can do is you can get the same dynamic without having role play [with computer-based training]. That's what I would suggest with inmates.  …these guys are all different education levels. And I have some guys that have master's degrees. I have some guys that can barely read and write. That has to be taken into consideration.
Diversity in training approaches	PCs  when you train people…they pick up on things in a different way…  …a certain activity or a certain type of quiz, it might stick out with the [different] individuals.  …a one-on-one training between me and [Hospice Nurse]…might be different for another person. They might actually take her words one way. Whereas that I might take it another… Staff  Still a majority of the training that we do are instructor led as opposed to web based here.  I think the graphic [novels] would be something to think about.  [suggestion for integrating CBL with face-to-face interactions with training nurse]. Like play the video, then maybe stop. Talk about what was shown, then play some more. Like that kind of thing.
Important training	PCs  Certified Peer Support is different. We do a lot of trainings…of CEU, huge requirements, we learn mental health, we learn different diagnoses…other different health issues. That helped me. I feel like, hospice workers need to have a bit more training in that aspect because you're not only dealing with a person that's dying, but you might be dealing with someone who has Parkinson's disease….  …hospice workers should be able to sit in on some of the…trainings so they would have more and a better knowledge of certain things too. Staff  I think the role of the inmate caregivers is important.  Well, obviously infection control would be important to them.  End of life, what to expect, medical signs and symptoms, how to care for them, how to change a bed, how to offer ice chips, all of those things are part of our protocol.  I think the ones that struck me more than others is loss, grief, and bereavement.  What to expect with a vigil.  What would be good for e-learning would be body mechanics.

PCs = peer caregivers.

The specific responses that were coded into the aforementioned themes, along with post-FG advisory board consultation, resulted in the identification, selection, and development of three topical areas that were concluded to be top priorities for prototype module development: Standard Precautions; Loss and Grief; and Role of the Inmate Caregiver in the Final Hours (Fig. 2). In addition, this aim 1 research resulted in identification of core values for the training (i.e., respect, dignity, and compassion), as well as naming (i.e., Inmates Care) and logo development for the CBT (Fig. 3).

Fig. 2.

Prototype module development. Permission to reproduce the figure is granted by Klein Buendel, Inc. Color images are available online.

Fig. 3.

Logo. Color images are available online.

Usability Testers' Demographic Characteristics

Ten PCs and 10 staff members participated as usability testers for the three prototype CBL modules. As in the FG phase, staff represented a wide variety of disciplines, including two each of corrections officers, unit managers, and chaplains, along with a guidance counselor, a correctional health care administrator, and a registered nurse. One staff participant chose not to provide his or her discipline. See Table 3 for more information about the demographic characteristics of the usability testing sample.

Table 3.

Demographic Characteristics of Usability Testing Participants

Demographic variables	Total sample (N = 20)	Peer caregivers (n = 10)	Staff (n = 10)
Gender
Male	8	5	3
Female	12	5	7
Race
Black	3	3	0
White	16	6	10
Other	1	1	0
Ethnicity
Non-Hispanic	19	9	10
Hispanic	1	1	0
Age range
18–29 years	0	0	0
30–39 years	5	3	2
40–49 years	3	2	1
50–59 years	7	3	4
≥60 years	5	2	3

Usability Testing Findings

Severity of usability concerns is categorized into levels: Level 1 is the most severe and represents issues that make it impossible for the user to finish a task; Level 2 is programming issues that do not function ideally but do not impede users from finishing; and Level 3 is programming issues or tasks that do not cause a high level of concern or distraction and are often more user preferences than functionality concerns. No Level 1 severities were noted for the program. Level 2 severities included the need to increase font size, difficulty with scrolling features, and clicking through directions too quickly. Level 3 concerns included requests for more narration, simplified wording in some portions, and content being available in Spanish. Levels 2 and 3 issues can be easily addressed in future iterations of development. Figure 4 shows more detailed information on usability concerns and the severity levels of any concerns found.

Fig. 4.

Usability concerns and severity levels. Color images are available online.

Mean scores on the SUS test were consistent across the PCs (n = 10) and staff members (n = 10), at 86.5 [SD = 13.46] for each group. However, the standard deviations for the two groups were quite different: PCs [SD = 7.47] and staff members [SD = 18.07]. Among the PCs, women (n = 5) reported an SUS score of 87.5 [SD = 8.66] and men (n = 5) reported a score of 85.5 [SD = 6.94]. Among the staff, female facility staff (n = 5) reported an SUS score of 80.5 [SD = 20.19], whereas the male staff (n = 5) reported a score of 92.5 [SD = 15.41]. Although the overall score of female staff was well above the SUS target score of 68, it was relatively lower than that of the other respondents. This score may reflect a preference noted during testing for more content specific to women's health. This preference was categorized as a Level 3 severity. The overall SUS score of 86.5 among all participants suggests high acceptability of the visual design, functionality, and content of the three prototype modules. In addition to the SUS, participants were asked to respond to the statement “I am satisfied with this training.” Three-fourths (75%) of all respondents “strongly agreed” and 20% “agreed,” suggesting a high level of satisfaction with the program. Overall, users thought the program would be helpful in their training education.

Discussion

FG findings from this study identified priority areas for CBL module development, core values for the PC training for preparing them to assist with geriatric and EOL care, and a logo to brand the training product. Study findings about both limitations of training PCs and the importance of staying mindful to PCs' broad diversity of literacy levels and learning styles are congruent with characteristics found to be important when developing educational materials for juveniles in detention (Macomber et al., 2010). Specifically, materials should sustain the attention of the users, “…address the wide range of literacy skills, and respect the cultural diversity…” (Macomber et al., 2010, p. 21) of the intended audience, as well as be relevant to the context of focus. The Inmates Care core values of respect, dignity, and compassion, which were established from FGs with grassroots individuals (i.e., those who are incarcerated and providing care to their peers) in our study fit well with professional nursing, “a profession with compassionate care” as a key focus (Baumann & Todaro-Franceschi, 2017, p. 256). As well, these core values are consistent with the California-based Gold Coats model whereby specially trained healthy Inmates Care for peers with dementia (Berry et al., 2016). The following testimonial evidences the parallel value held for promoting dignity and delivering compassionate care from incarcerated people caregiving for their peers in the Gold Coats program with values held by incarcerated participants in this study: “I cleaned him up when he soiled himself, helped him shower, etc., all while trying to protect his dignity” (p. 65); and “I realized my compassion for the terminally ill was deep enough…for me to continue this work…” (Berry et al., 2016, p. 66).

Our study revealed the new principle that incarcerated people who are PCs are receptive to and excited about opportunities to enhance their knowledge and extend their e-learning experience. The innovation of developing e-training for inmate PCs is the production of a training program based on best practices in geriatric and EOL care in prisons. Usability testing revealed that the Inmates Care prototype training modules are contextually relevant and feasible to implement within the restrictive environment of corrections settings, while at the same time are usable for the target audience (i.e., men and women who provide or will provide care to their aged and dying peers). Although no previous studies were found that developed and tested e-learning for PCs, our study does provide evidence that e-learning holds promise to contribute to addressing Depner et al.s' (2018) call for PC training that is both evidence based and readily available. Therefore, we are secure in recommending that others consider using this educational delivery model to contribute to meeting other training needs of people who are incarcerated. The aforementioned insights and recommendation are integrally important to consider when academic, correctional, and nursing leaders consider ways to optimize their training endeavors through innovative, evidence-based, and potentially rehabilitative ways that are possible within the prison culture.

If CBL modules were placed on available tablets for PCs to access as readily as they can their music downloads and computer gaming, then PCs could learn more about previously unencountered patient care scenarios, as well as brush up on their learning if hiatuses occurred in their service in the caregiving role. E-learning for people who are incarcerated is an evolving area with increasing possibilities for this target audience as e-learners, so long as PC security level permits, adequate supervision is provided, and necessary controls are placed on the electronic devices.

Implications for Correctional Nurses and Other Health Care Professionals

Development and testing of e-training to help prepare incarcerated people to assist prison staff in caring for their peers who are aging in place and/or approaching EOL in prisons have implications to correctional nursing practice. Corrections nurses are both the largest group of health care professionals in correctional settings and the most likely staff to be engaging in development and delivery of training to incarcerated men and women. Well-trained PCs are positioned to provide supplemental care for their peers and support corrections staff. Peers can provide more comprehensive care in terms of giving people dignity, choice, and support to address their physical, personal, social, and spiritual needs. PCs could provide some of these aspects better than staff and PCs may be the only socialization incarcerated patients get (Morris et al., 2015; Swerissen & Duckett, 2014).

An awareness that e-training is not only feasible and acceptable for prison staff (Almost et al., 2019; Loeb et al., 2017) but also for those living in prisons can widen the views of nurses, health care administrators, and corrections executive leaders of what is possible in the restrictive environment of prisons. In addition, the availability of rigorously developed evidence-based highly interactive training programs frees up time from prison staff members' busy schedules, so that they do not need to develop home-grown training. Instead these nurses, psychologists, chaplains, and other trained professionals who are engaged in delivering geriatric and EOL care, as well as the training and oversight of PCs in corrections settings, can devote more attention to things such as loss and grief support. Another opportunity for the aforementioned staff would be to expand their role modeling for incarcerated men and women in ways such as to promote and facilitate current and future PCs that allow them to make important contributions that “add something positive to the world” (Baumann & Todaro-Franceschi, 2017, p. 256) inside of prisons. As a Gold Coat caregiver eloquently shared, “Every moment with a client is always a great moment; to connect with someone at this level is a gift they share and a lesson in life about relationships” (Berry et al., 2016, p. 66). This is important, because PCs' contributions are directed toward people who have grown old and are facing their EOL in prison—these individuals are significant people to someone, who “after all are not so different from the rest of us, beings who will also get frail and die” (Baumann & Todaro-Franceschi, 2017, p. 257)—a point that was similarly expressed by a Gold Coat caregiver, who stated, “It reminded me of how alike we all are” (Berry et al., 2016, p. 70). Finally, availing older adult or dying incarcerated people of well-trained PCs can assist in breaking cycles of sorrow and pain that have been experienced by PCs and care recipients (Baumann & Todaro-Franceschi, 2017) and is an example of an intervention that could help to mitigate what Baidawi and Trotter (2016) describe as the distress and health burdens experienced by older incarcerated people.

Policy and Research Implications

Williams et al. (2012) highlighted the need to “enhance palliative care programs” (p. 8). Inmates Care e-learning can contribute to meeting this goal. Depner et al. (2018) have noted that although regulations for the care of correctional populations vary globally, “the experience of dying while incarcerated has universal elements that could be addressed by synthesizing or cross evaluating the research that has emerged globally” (p. 970). Development of e-learning strategies holds promise to allow for more ready access to rigorously tested training materials so long as adequate financial resources and infrastructure are available to support their use. In our team's more than a decade of research on enhancing EOL care in prisons, we have regularly developed practice–research partnerships and encountered numerous practitioners and administrative leaders in correctional settings who welcome opportunities to deliver high-quality health care services for those who have grown old and are likely to spend their final days in prison. This is an important field observation because, as Secret et al. (2011) note, partnerships between practitioners and academics are critical to creating research conditions that allow programs to be evaluated.

Future Research

Next steps for this line of research are existing module refinement based upon what was learned in this Phase I study, developing and testing additional modules for the Inmates Care CBT, and large-scale usability testing of the Inmates Care product across diverse prisons to optimize the scalable unit. Such research will facilitate broader dissemination, determine training effectiveness, allow for greater generalizability of findings, and provide critical insights regarding the potential for future commercialization.

Strengths and Limitations

Key strengths of this study include the inclusion of women who are incarcerated as well as staff from a women's SCI in the research and development of the Inmates Care prototype modules. Williams et al. (2012) highlighted the need for more research attention being focused on older women who are incarcerated because their numbers are increasing and their health and social issues do not precisely mirror their male counterparts. Inclusion of iterative consultation with an advisory board of highly qualified people with diverse backgrounds and expertise also adds rigor to this multi-aim study. Finally, the innovative nature of developing CBL modules to enhance, extend, and standardize the current large home-grown training available to PCs is especially noteworthy.

However, like with any research, our study is not without limitations. The fact that some incarcerated peoples' responses were not able to be included due to a delay in the sharing of TABE scores was disappointing and impacted our ability to analyze and disseminate the full array of perspectives shared. Also, the relatively small sample of usability testers (n = 20) limits the generalizability of findings from the usability testing, although this is somewhat mitigated by the face-to-face nature of this testing, the use of the well-established SUS measure that continues to be used in technology-related health research (Reeder et al., 2019), and data suggesting that a sample of 10 usability testers is sufficient to capture the lowest severity usability problems (Sauro & Lewis, 2012; Turner et al., 2006).

Conclusions

The Inmates Care CBT holds promise for contributing to standardization of training received by PCs who are assisting staff in caring for their aged and/or dying peers and to complement the practical experience and face-to-face discussions that are typically nurse led in correctional settings. PCs who have ready access to e-learning materials can refer to Inmates Care training as an ongoing resource for refreshing knowledge when there are hiatuses between caregiving opportunities and when a less familiar situation arises, or for reinforcing knowledge for long-term retention. PCs who are well prepared and have ongoing access to evidence-based training information are positioned to make quality contributions that extend the care provided by nurses and the multidisciplinary team of corrections professionals who are charged with caring for and managing older and/or dying incarcerated people.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

U.S. Department of Health and Human Services, National Institutes of Health, National Institute on Aging R41 AG057239.