The role of prison nursing: an integrative review

Abstract

Objectives

To review the scientific literature on the role of the nurse in Penitentiary Institutions through the study of care training and ethical implications when offering quality care to the prison population.

Material and method

An integrative review was carried out in Medline, SciELO and LILACS databases. The MeSH and DeCS terms used were: nurse’s role, nursing, nurse, nursing education, prison, ethics, ethical issues, job satisfaction, enfermería, penitenciaria, health professionals, nursing care. The types of studies included in this work are literature reviews, and qualitative, quantitative and mixed studies. The CASPe tool was used to assess the methodological quality of selected literature. The review period was October, November and December 2019.

Results

A total of 264 articles were obtained, of which 98 were chosen after applying filters corresponding to each database and after discarding duplicate articles. The title and abstract of these articles were read and the established selection criteria were applied, to obtain 18 studies. Finally, after critical reading, 15 articles were selected for this work.

Discussion

The role of the prison nurse is generally unknown. Nursing undergraduate training in this area is limited, exposing a specific training need, which may help these professionals to deal with ethical issues that they may find in their practice, as well as to improve the quality of care for the prison population.

Introduction

The nurses responsible for care and health in prisons have always played a secondary role. The position of Registered Prison Nurse, regulated by article 4.2 of Law 39/70, of 22 December, on the restructuring of prison professions was created in Spain in 1970¹.

Some years later, article 324 of the Royal Decree of 1981² was the first law to give greater definition to the duties of Registered Prison Nurses. Nurses continued to apply general skills to their profession under the orders of the physician.

However, a turning point for prison nursing came in 1989, when Royal Decree 148/1989 of 10 February³ established the General Sub-Directorate of Prison Health, in which prison nurses were defined as professionals.

In 2011, the official title of Prison Nurse was finally established in article 2.2 of Royal Decree-law 20/2011 on the restructuring of the prison professions⁴.

In 2019, the General Committee of the Spanish Nursing⁵ defined nurse in the field of prison healthcare as the following: “A professional working in advanced practice, with skills acquired from their training and experience, working under the parameters of bioethical practices and scientific evidence, to plan, intervene and evaluate nursing care in order to promote, maintain and improve the health of prison inmates, and to prevent the diseases and disabilities of same, with the use of nursing skills developed and regulated within the scope of prison healthcare”⁵.

Prison healthcare management in Spain is currently under the remit of the General Sub-directorate of Prison Health, governed by the General Directorate of Criminal Procedure and Social Rehabilitation as part of the General Secretariat of Prisons⁶.

In the search for a definition of prison nursing, the General Prisons Act and Law 16/2003, of 28 May, on the Cohesion and Quality of the National Health System provide helpful guidelines⁷. Both laws concur that prison healthcare should operate under the same conditions and standards of quality as those applied in public health services.

The current duties of prison nurses are regulated by the Prison Regulations of 1996 and some articles that were not revoked in 1981, such as art. 324, which establishes nursing roles⁸.

As regards specific training for nursing, according to the Spanish National Agency of Evaluation of the Quality and Accreditation (ANECA), a nursing degree responds to a healthcare personnel profile for a person responsible for the general care of people and the community⁹.

According to a number of studies on prison nurses, the difficulties they face are linked to professional development, such as: low job satisfaction, lack of training and specific skills, etc. These limitations stop nurses from providing inmates with high quality care, which leads to conflicts with the ethical principles that are an integral part of the nursing profession¹⁰.

In such a context and to better understand this ethical conflict, the concept of moral distress needs to be considered. In the medical setting, this consists of an emotional and psychological sensation that may appear when a nurse is aware of what they have to do according to what is morally appropriate, but cannot do so because of institutional and legal obstacles and limits, such as limited autonomy in a number of settings or a lack of managerial support^11,12.

In view of the above, the general objective established for this study was as follows: to review the scientific literature on the role of nurses in prisons.

The proposed specific objectives were: to determine the importance of healthcare training for nurses in prisons and explore the ethical implications for nursing of healthcare in prison settings.

In view of the introduction and the current situation in Spain, where the nurse-patient ratio is 9.09 nurses per 1,000 inmates, with 600 nurses distributed in 73 prisons throughout the country¹³, this study sets out to shed more light on the little known role played by nurses in prisons, and the implications of their situation for providing care to the prison population.

Material and Method

The following PICO (population-intervention-comparison-outcome) question was posed for the search strategy¹⁴: “Do prison nurses receive adequate training in care and ethical implications to enable them to offer good quality healthcare?”.

For this integrative review, we carried out a search of the scientific literature in the following databases: Medline, SciELO and LILACS.

Selection of the key words: nursing education, nursing, ethics and prisons, was made possible thanks to the use of the controlled language in DeCS and MeSH, thus obtaining the results shown un Table 1.

Table 1. DeCS and MeSH relevant terms and descriptors.

Relevant terms	MeSH	DeCS
		Spanish	English
Enfermería	Nursing	Enfermería	Nursing
Enfermera	Nurse	Enfermera	Nurse
Papel de enfermería	Nurse’s Role	Rol de enfermería	Nurse’s Role
Prisión	Prison	Prisiones	Prisons
Cuidados de enfermería	Nursing care	Atención de enfermería	Nursing Care
Cuestiones éticas	Ethics	Ética	Ethics
Educación enfermera	Nursing Education	Educación en enfermería	Education, Nursing
Satisfacción laboral	Job Satisfaction	Satisfacción en el trabajo	Job Satisfaction

Note. DeCS: Descriptors in Health Sciences; MeSH: Medical Subject Headings.

The MeSH and DeCS terms were united with the Boolean operators AND and OR: nurse’s role OR nursing AND prison; nursing education AND ethics OR ethical issues; prison AND nurse; job satisfaction AND nursing AND prison; enfermería AND penitenciaria; health professionals in controlled language AND prison; nursing care AND prison. Different filters belonging to the databases were also used to specify and reduce the results, as shown in Table 2.

Table 2. Search equation.

Database	Search equation	All articles	Filters	Results
Medline	(nurse’s role[MeSH Terms] OR (nurse’s[All Fields] AND role[All Fields]) OR nurse’s role[All Fields]) AND (prisons[MeSH Terms] OR prisons[All Fields] OR prison[All Fields]) AND (nursing[Subheading] OR nursing[All Fields] OR nursing[MeSH Terms]) AND full text[sb] AND 2014/11/29[PDat]: 2019/11/27[PDat] AND humans[MeSH]	118	5 years; humans; full text	16
	(education, nursing[MeSH Terms] OR (education[All Fields] AND nursing[All Fields]) OR nursing education[All Fields] OR (nursing[All Fields] AND education[All Fields])) AND (ethics[MeSH Terms] OR ethics[All Fields] OR (ethical[All Fields] AND issues[All Fields]) OR ethical issues[All Fields])) AND ((prisons[MeSH Terms] OR prisons[All Fields] OR prison[All Fields]) AND (nurses[MeSH Terms] OR nurses[All Fields] OR nurse[All Fields])) AND (full text[sb] AND 2014/12/07[PDat]: 2019/12/05[PDat])	7	5 years; full text	3
	(job satisfaction[MeSH Terms] OR (job[All Fields] AND satisfaction[All Fields]) OR job satisfaction[All Fields]) AND (nursing[Subheading] OR nursing[All Fields] OR nursing[MeSH Terms] OR nursing[All Fields]) AND (prisons[MeSH Terms] OR prisons[All Fields] OR prison[All Fields]) AND (full text[sb] AND 2014/12/05[PDat]: 2019/12/03[PDat])	35	5 years; full text; humans	5
SciELO	(enfermería) AND (penitenciaria) AND subject_area: (“Health Sciences”)	20	Health Sciences	19
	(health professionals) AND (prison) AND subject_area: ("Health Sciences")	38	Health Sciences	35
	(nursing care) AND (prison) AND subject_area: ("Health Sciences")	14	Health Sciences	14
LILACS	tw:(enfermería AND penitenciaria) AND (fulltext:(“1”) AND db:(“LILACS”) AND la:(“pt” OR “en” OR “es”)) AND (year_cluster:[2014 TO 2019])	32	Text complete; LILACS; portuguese; english; spanish; Last 5 years	15

The inclusion criteria were: articles published in the last five years, free access to the complete text, studies carried out on humans, publications in Spanish, English and Portuguese, and articles related to the role of nursing, the training received by this group and prison nurses’ ethical issues when providing care to inmates.

The exclusion criteria consisted of the following: articles that focus on the care that prison nurses give to the prison population and articles duplicated in different databases.

To evaluate the methodological quality, the CASPe critical appraisal tool was used, based on the type of studies that were collected in this study. The templates for qualitative studies¹⁵, cross-sectional studies¹⁶ and reviews¹⁷. were used to establish the types of studies contained in this article. Each item was appraised by the CASPe guide as follows: 1 point for those that complied with the criterion; 0.5 points for those studies that partially complied and 0 points for those that did not. The following categorisation was used for listing the studies as high, medium and low quality: the articles with a score below quartile 1 were classified as low quality and were rejected; the articles between quartiles 1 and 3 were classified as medium quality and those with a score above quartile 3 were defined as high quality¹⁸. After applying the inclusion and exclusion criteria to the 18 articles that were selected, 16.67% (n = 3) were rejected by applying the above mentioned classification method.

Results

The total number of articles obtained after the bibliographical search was 264. The filters of each database were used to eliminate 157 articles (n = 107).

The duplicated articles found in the searches were then removed (n = 98), and the titles and abstracts were read in order to select the articles that matched the subject of the integrative review, which left a total of 24 studies.

18 publications remained after applying the inclusion and exclusion criteria. Finally, the CASPe tool was used to apply a critical appraisal, giving a final result of 15 articles, after eliminating the ones that received a low quality evaluation, as shown in Figure 1.

Figure 1. Flowchart of selection articles.

The 15 articles selected for the integrative review consisted of the following types: 40% (n = 6) were reviews of the literature, 33.33% (n = 5) were qualitative studies, while 20% (n = 3) were quantitative ones. Finally, 6.67% (n = 1) were mixed method studies (Figure 2).

Figure 2. Classification of articles according to type of study.

Table 3 shows the characteristics of each article in terms of the type of study, the year and country of publication, and their relevance to the objectives of the study and the conclusions.

Table 3. Articles included in the selection.

Title	Author(s)	Year	Study	Origin	Objectives	Conclusion	Quality evaluation (CASPe)
Prison nursing: formation of a stable professional identity	Choudhry K, Armstrong D, Dregan A	2017	Literature review	UK	Analyses how working in prisons affects nursing staff.	Need to understand the professional identity and training of prison nurses.	Medium
Caring in Correctional Nursing: A Systematic Search and Narrative Synthesis	Dhaliwal K, Hirst S	2016	Systematic search and narrative analysis	Canada	Understand the care that nurses provide to inmates.	Need to act without prejudices and importance of creating working limits.	High
Training in service: perception of health workers in assistance in federal prison units	Brito LJS, Henriques SH, Bragança C, Leal LA	2020	Explo-ratory qualitative-descriptive study	Brazil	Analyses the training of health professional in care provision in prison.	There are errors in planning and education of health professionals in prison.	Medium
Correctional nursing in Liguria, Italy: Examining the ethical challenges	Carnevale F, Delogu B, Bagnasco A, Sasso L	2018	Empirical study	Italy	Examines the ethical conflicts that prison nurses experience.	Need to develop adequate policies, education programmes and practice for nursing staff in prisons.	Medium
Evaluation of a support and challenge framework for nursing managers in correctional and forensic health	Newman C, Patterson K, Clark G	2015	Qualitative study	Australia	Analyses the effectiveness of work done by nursing management in the prison context.	Importance of management in prisons and ongoing development of leadership skills of nursing management.	Medium
Ethical conflicts in nursing care in the prison context	González-Gálvez P, Sánchez-Roig M, Coll Cámara A, Canet Vélez O, Roca Llobet J	2018	Systematic review of narrative analysis	Spain	Analyses the ethical conflicts that can affect nurses when providing care in prisons.	Need for ethical training of health professionals in the prison context.	High
Nursing actions for liberty deprived people: a scoping review	Barbosa ML, Medeiros SG, Chiavone FBT, Atanásio LLM, Cavalcanti Costa GM, Santos VEP, et al.	2019	Scoping review	Brazil	Identifies the healthcare provided by nursing staff in the prison system.	The care provided by nurses in prison is equivalent to the care provided in other sectors.	Medium
Qualidade de vida no trabalho dos profissionais de saúde no sistema prisional	Barbosa ML, Menezes TN, dos Santos SRD, Olinda RA, Costa GMC	2018	Cross-sectional descriptive study	Brazil	Evaluates the quality of working life for nurses in prison units.	Importance of management of the prison system and of quality of care.	Medium
The relationship between the quality of work and organizational commitment of prison nurses	Karaaslan A, Aslan M	2019	Descriptive research study	Turkey	Evaluates the quality of life of nurses in terms of job satisfaction and organisation of work in prisons.	The difficulties of prison nurses need to be understood, since the safety of workers increases job satisfaction.	Medium
Moral distress in correctional nurses: A national survey	Lazzari T, Terzoni S, Destrebecq A, Meani L, Bonetti L, Ferrara P	2020	Cross-sectional study	Italy	Investigates the moral distress that may be experiences by nurses in the prison context.	Need for specific education to prevent moral conflicts in prison nursing from developing.	Medium
Ethical issues of prison nursing: a qualitative study in Northern Italy	Sasso L, Delogu B, Carrozzino R, Aleo G, Bagnasco A	2018	Qualitative descriptive study	Italia	Describes the working experiences and the problems of prison nurses.	Need for specific educational interventions that can help nurses to resolve ethical and moral problems.	Medium
Prison nursing and its training	Sánchez-Roig M, Coll-Cámara A	2016	Literature review	España	Determines the role of nursing and training of nurses in the prison context.	Need for specific training to work in prison	Medium
Enfermería penitenciaria: marco legal y realidad asistencial	Carrasco-Baún H	2017	Narrative biblio- graphical review	Spain	Compares the legal functions that nurse need to fulfil in real nursing situations in prisons.	Equality needs to be ensured in caring for inmates and in the obligations of nursing staff.	Medium
Atenção básica à saúde de apenados no sistema penitenciário: subsídios para a atuação da enfermagem	Barbosa ML, Celino SDM, Oliveira LV, Pedraza DF, Costa GMC	2014	Descriptive study	Brazil	Describes healthcare in prisons and supports the work done by nursing staff in this context.	A commitment at national government level is needed to leave behind the stigmas of health in the prison setting.	Medium
Percepção da equipe de enfermagem acerca da assistência à saúde no sistema prisional	Santana J, Reis FCA	2019	Qualitative study	Brazil	Determines the perceptions of nursing professionals with regard to healthcare in the prison system.	Importance of a basic administrative organisation that can improve resources and train nurses to provide inmates with good quality care.	Medium

Note. CASPe: Critical Appraisal Skills Programme España.

Discussion

Firstly, when considering the importance of the role played by nursing in the prison setting, the study by Barbosa et al.¹⁹ showed that prison nursing plays a decisive and comprehensive role that matches the care provided in other healthcare sectors, while the authors of the study by Santana et al.²⁰ consider that nurses working in these settings should have a more humanised role than in other medical sectors, since they have to provide quality care without letting themselves be guided by any prejudices.

In line with Santana et al.²⁰, Dhaliwal et al.²¹ mentioned a series of recommendations to improve nursing work in the prison setting. These include: the need to know more about the work of prison nurses, create committees that operate between prison management and the medical team, and create support groups to deal with the challenges faced by prison nurses in the workplace.

On the other hand, Carrasco-Baún²² focuses on the major difference that exists between the role fulfilled by nursing in caring for inmates and the legislation that regulates the provision of healthcare in prisons, given that the law is now obsolete and far removed from the current realities of prison nursing. The author of the study considers that a series of guidelines is needed, including guarantees of equality in caring for the prison population and in the obligations of the prison nurse, to ensure that nurses can provide inmates with quality healthcare.

Likewise, the importance of the role of nursing in prisons also depends on how the prisons themselves are managed, as in the study by Newman et al.²³, which shows the need to study the level of satisfaction amongst nursing managers in the prison setting, so as to improve how such institutions are organised, and to ensure that they have the skills and abilities necessary to carry our their work in prisons.

Finally, Barbosa et al.²⁴ and Carnevale et al.²⁵ comment on the need to improve the organisational aspects of the prison system, in order to adequately develop the functions of nurses when dealing with the most common problems in the prison population, such as drug addiction and communicable diseases. Furthermore, both authors agree with Newman et al.²³ on the fact that it is essential to bring about improvements in the organisation and policies of prison institutions to enable prison nurses to progress towards a better standard of healthcare.

As regards the training of prison nurses, an interesting point on which most of the studies appear to agree is the need for specialization in this type of setting. Studies such as the one by Sánchez-Roig et al.²⁶ show the complex nature of the care that inmates need for communicable diseases, drug abuse and for mental disorders, alongside other health problems, making it necessary for nurses to receive specialised training in prison healthcare. Likewise, Lazzari et al.²⁷ and Carnevale et al.²⁵ came to the conclusion that specialised, up to date and ongoing training for nurses is necessary to work in prisons, to ensure that the inmate population receives good quality care.

Barbosa et al.¹⁹ and Brito et al.²⁸ also state that it is essential to reinforce nurses’ skills and abilities to enable them to adequately care for prisoners, through continuous training adapted to the prison setting, just like any other area of medical practice. Choudhry et al.²⁹ came to the same conclusion and stated that a more accurate notion of the professional identity of prison nursing is necessary to enable better understanding of the skills required in such an institution and to be better able to apply improvements to their training, to make it continuous and specific, and so ensure that it is appropriate to needs in prison settings.

Barbosa et al.¹⁹ and Brito et al.²⁸ differ with Sánchez-Roig et al.²⁶ in stating that professionals showed adequate skills in caring for inmates and adapting to the prison environment, the reason being that the nursing staff considered the inmates to be like any other patient, with their own health problems, and were not felt to be a unique population.

Brito et al.²⁸ and Santana et al.²⁰ came to similar conclusions in that the lack of specific training for nurses in the prison setting is partly due to the shortage of work experience in such environments, the physical and psychological insecurity of work carried out there, the difficulties faced by healthcare personnel and the social stigma felt towards the prison population.

The ethical implications of prison nursing that prison nurses face in their day to day activities were also considered. Dhaliwal et al.²¹ discussed the difficulties that nurses face when providing care to inmates, such as ethical conflicts and the effort involved in not letting prejudices guide their work with inmates, and the need to provide safety and protection to nurses.

In line with the previous study, Karaaslan et al.³⁰ and González-Gálvez et al.³¹ comment on the need to investigate the working and ethical problems faced by prison nurses, such as those mentioned by Dhaliwal et al.²¹, and the need to improve the quality of healthcare and nurses’ safety in the prison setting and so increase job satisfaction in this type of environment. Likewise, González-Gálvez et al.³¹ and Santana et al.²⁰ not only highlight the importance of ethical problems faced by nurses, but also the need to know more about the health needs of the prison population in order to provide prisoners with more humanised healthcare based on health issues, without allowing prejudices to intervene.

Sasso et al.³² focus on ethical education, with examples of nurses’ opinions on the issue. The study comments on the need for specific ethical training to help nurses to resolve moral conflicts, such as being unable to provide healthcare to prisoners because of prejudices and the tendency to judge inmates for being in prison as a result of the crimes that they have committed.

Likewise, Barbosa et al.²⁴ also suggest that the safety of medical personnel is a priority, as is maintaining ethical conduct and the principles that govern the nursing profession, such as the duty to care for inmates.

By way of contrast, Menezes et al.³³ shows that the levels of job satisfaction amongst prison nurses are higher in the psychological and behavioural areas than in the environmental and organisational ones. Their conclusion is that the problems do not come from nurses’ ethics, but rather from the management of the prison system itself.

Finally, the conclusions drawn by Lazzari et al.²⁷ match those of the previous study in highlighting the moral distress of nurses in the prison setting caused by the problems of staff in their work as a result of ethical issues, and the fragility of the prison system in managing medical responsibilities in prisons.

Conclusions

The analysis of the literature in this study shows that the role of the nurse in prisons is similar to that in other healthcare settings in terms of overall responsibilities. What comes to light is the need to determine the role played by nursing staff in this context in order to increase the quality of care that they provide and their own job satisfaction.

This will not be possible without updating current legislation on this sector, and this once again underlines the need for laws that regulate aspects of the nursing profession in prisons, given that current laws are obsolete and far removed from the realities of healthcare.

Secondly, the importance of specific healthcare training for prison nurses should be highlighted. The current Spanish nursing diploma only covers the training of nurses in general skills. This means that recently graduated nurses lack the skills and abilities to work in the prison setting, as a result of poor training and a lack of familiarity with such specific working environments.

Finally, one aspect of the ethical implications for nurses working in prisons merits special attention: the difficulties that they face in offering adequate care to inmates. In such cases, ethical conflicts and prejudices can arise in the care that they provide. It is therefore necessary to highlight the need to further investigate this type of ethical issue so as to increase the quality of care and the job satisfaction of nurses, evaluating the skills required to resolve moral conflicts and the need for psychological support in this group. The efficiency of prison management also needs to be determined so as to improve and bring about an adequate working environment.