CareLink-Corrections Phase 1: A Feasibility Study Inside Prisons to Improve Self-Care Upon Release

Abstract

CareLink-Corrections is an evidence-informed self-care management (SCM) program designed to provide nursing and health services students an opportunity to serve a vulnerable justice-involved population while learning to provide clinical care service. Within this program, SCM of health is the clinical focus and is conceptualized as a competency where the individual acquires the knowledge, skills, and attitudes that facilitate health maintenance, health care management, and/or health promotion. Thirty undergraduate nursing students and 47 incarcerated persons participated in this first phase of the program. This article presents the first step in building the program—a feasibility study to test implementation of the program to persons in prison.

Introduction

CareLink-Corrections (CareLink-C) is an evidence-informed program designed to provide nursing and health services students an opportunity to serve a vulnerable justice-involved population while providing a clinical care service. The aim of the CareLink-C program was to assist incarcerated individuals preparing for reentry into the community with a focus on self-care management (SCM) of their health care issues. SCM is conceptualized as a competency where the individual acquires the knowledge, skills, and attitudes that facilitate health maintenance, health care management, and/or health promotion. The program was conceptualized to serve persons transitioning from prison to community supervision and into unsupervised placements. The first step in building the program was to test implementation of the program in prison, followed by a test of implementation in community-supervised transitional care residences, and then to link the two components together.

The primary belief underlying the design of the program was that incarcerated persons would be better prepared for transition with enhanced SCM skills. The theoretical framework for SCM is the Rediscovery of Self Care (RSC) Model (Shelton, Barta, & Anderson, 2016b), an evidence-informed model based on clinical experience and an extensive review of nursing literature on SCM. SCM is defined as a process of initiating and engaging in behaviors that promote health and manage chronic conditions. SCM includes behaviors that an individual engages in to maintain their health by setting health care goals; decision-making and problem-solving; planning and taking action; evaluating goals; and managing physical, emotional, and cognitive symptoms (Shelton, Barta, & Anderson, 2016a).

The translation of the theoretical foundation for SCM drew upon work completed with individuals with chronic conditions (heart disease and diabetes) in community-based populations (Ryan & Sawin, 2009). A gap remains, however, on how SCM can be implemented for those involved with the criminal justice system.

The movement of clients across health care settings highlights vulnerabilities in the care continuum (Arbaje et al., 2014). During these transitions, clients often experience difficulties in obtaining appropriate health care and support services (Clarke et al., 2014), resulting in unintended medical errors (American Medical Association, 2014). Rehospitalization is a frequent, costly, and sometimes life-threatening event associated with gaps in follow-up care (Jencks et al., 2009; Wang et al., 2013). A similar period of heightened vulnerability occurs for incarcerated persons who struggle with transition from jail or prison to the community (Binswanger et al., 2007), often resulting in poor outcomes such as reincarceration and death.

Transitional health care (referred to as transitional care) has not been translated to criminal justice-involved individuals with complex combinations of co-occurring disorders (mental illness/substance abuse) and chronic health problems (e.g., diabetes, hypertension, and HIV). These authors (Clarke et al., 2014; Jencks et al., 2009; Wang et al., 2013) posit that the hallmarks of transitional care for individuals released from jail or prison include providing time-limited services with intermittent dosing for 1–2 years and repetition of content focused on self-care competencies with emphasis on education of clients, families, and caregivers to address the root causes of poor health outcomes and to avoid high-cost preventable service use (Emergency Room, hospitalizations, and reincarceration).

The purpose of this article is to describe a feasibility study of CareLink-C, a nursing academic–justice partnership model for transition of persons with health and mental health needs from prison to the community. This article reports findings that describe the first pilot of the CareLink-C program focused on implementation of the program inside prisons. The construct of SCM for the cohort of incarcerated patients (hereafter referred to as patients) was developed by examining (1) the biopsychosocial risk factors of the patient sample, (2) the participant's phase of self-care as determined from the implementation of the individual intervention, (3) the participant's movement toward improved mental health and problem-solving skills as outcomes, and (4) the evaluative program data. A secondary assumption was that provision of well-crafted clinical learning experiences for health students could provide a clinical service as well as student learning.

Background

CareLink-C is an adaptation of an award-winning nurse-driven partnership between the University of Connecticut, School of Nursing and the Visiting Nurses Association of Central Connecticut, Inc. (Bernal et al., 2004) and the incorporation of evidence-based principles designed for a corrections reentry population (Wolitski, 2006). With knowledge that periods of transition are times when fragmentation and lack of continuity in services occurs, SCM is viewed as critical for management of chronic health conditions. Designed for criminal-justice involved populations, CareLink-C provides student-led multisession individual interventions for participants with a focus on increasing patients' awareness of their health risk behaviors and consequences, setting goals, and providing tools and resources to reduce risks and promote health upon return to the community.

The application of CareLink-C is designed to serve those patients who do not meet criteria for established programming (such as the seriously mentally ill). In the current economic environment, strained service system resources target those in most critical need. In Connecticut (CT), these targeted patients receive a health or mental health service need score through a correctional screening procedure. Those individuals with high scores are considered most in need and prioritized for services. Individuals with moderate or low need (as an example, a person with diabetes and mild symptoms of depression) are equally in need of follow-up in the community but are left to sort this out upon transition with minimal guidance. Given what is known about the vulnerabilities of the newly released prison population, there is a high risk for failure in the community and recidivism without human support to make and sustain linkages to community services. Given the lower priority scores, these individuals were identified as a group of underserved persons within the target population of underserved persons. It was theorized that this may be the group that can achieve success in SCM with student support leading to reduced recidivism and costs over time. This academic–community supported partnership believed we could make a significant contribution to the public health needs of this population, provide training for students, and ultimately demonstrate a cost–benefit in the future for the CT justice-health care system.

Theoretical Underpinnings

The RSC Model (Shelton, Barta, & Anderson, 2016b) is evidence informed by clinical experience and an extensive review of nursing literature on SCM, supplemented by a review of psychological literature on behavior change and direct experience in behavior change interventions. The most salient principle from nursing is self-care, which is articulated in the seminal writings of Dorothea Orem and refers to the individual's capacity to participate in activities aimed at preserving optimal health either by avoiding health-compromising behaviors or adhering to medically recommended treatment regimens. Self-care is defined as “action directed by individuals to themselves or their environments to regulate their own functioning and development in the interest of sustaining life, maintaining or restoring integrated functioning under stable or changing environmental conditions, and maintaining or bringing about a condition of well-being” (Orem & Taylor, 1986, p. 52). In addition to Orem's self-care definition, the RSC Model draws on Rutter's (1987) perspective on resilience. According to Rutter, qualities that give rise to resilience include (1) a planning tendency, (2) a degree of self-reflection and self-regulation that permits an adaptive assessment of goal-attainment strategies that have succeeded or failed in the past, and (3) a sense of agency and self-confidence. Rutter's account, similar to most accounts of resilience, emphasizes personal attributes and a strengths-based approach (Zimmerman, 2013). Shelton, Barta, and Anderson (2016b) identified resilience-related factors of self-efficacy, motivation, perceived control, and the ability for planning (engaging in self-care activities) as critical for criminal justice-involved persons. RSC offers nurses and health care providers a framework for identifying processes by which individuals acquire an increased capacity for self-care. Nurses using the RSC model would seek to increase self-care by increasing resilience-related factors and reversing or preventing the de-skilling that takes place in people because of the incarceration experience. CareLink-C and other studies continue to validate the constructs of the RSC Model (Maruca, 2016; Maruca et al., in press; Reagan et al., 2016) and SCM from the perspective of persons with an incarceration experience.

Method

Study Design

A programmatic goal was to determine if student clinical training programs could impact patient care outcomes, thereby equalizing the exchange of resources between an academic partner and the clinical agency. This is critically important to demonstrate for justice systems that are difficult to access as training sites. The research question was “Could clinical nursing and health care students effect change in individual SCM capabilities to reinforce reentry success while learning their clinical skills?” For patients, it was expected that with improved SCM competency (knowledge, skills, and attitudes) individuals would feel empowered to manage their own health issues, thereby improving their reentry experience. In adherence to the RSC Model, it was expected that early stages of SCM would be evidenced through goal setting and planning activities for health, reduced levels of depression, interest in the program demonstrated by attendance, and participant satisfaction with the program.

In addition, based on a review of literature, two moderating variables were expected: problem-solving and health literacy of incarcerated persons. Studies have supported correlations between social problem-solving abilities and perceptions of health and physical symptoms (Elliott & Marmarosh, 1994), health compromising behaviors (Dreer et al., 2004), and adherence to medical regimens (Johnson et al., 2006). Additional studies report that interventions targeting social problem-solving abilities minimize subsequent psychological distress and depression for persons with chronic health conditions (Cameron et al., 2004). Although measuring social problem-solving abilities is important to identify those at risk for problems throughout rehabilitation and during transition to the community, routine assessment of social problem-solving abilities in health care is typically underutilized (Dreer et al., 2009).

Health literacy has been positively associated with self-care efficacy in a study of rural persons with hypertension (Wang et al., 2013) and SCM was reported to be lower among older adults with low health literacy (Geboers et al., 2016). In a 2003 national assessment of adult literacy conducted in prisons (National Center for Education Statistics, 2007), males and females of all adult ages had lower average literacy than adults of the same gender and age living in households. Furthermore, education moderates health literacy levels among incarcerated persons, with individuals who achieve high school education or its equivalent scoring higher on literacy assessments.

A multicase study design (Eisenhardt, 1989) was used in this study to explore the feasibility of implementing the CareLink-C inside the prison setting and to test assumptions regarding benefits of clinical education to students and patients.

Intervention

A 10-week educational intervention designed to explore SCM of chronic disease was provided through 1-hour individual sessions provided every other week. Individual sessions were guided by an evidence-based health goal-setting activity workbook (Bartholomew et al., 2006) providing 14 cognitive mapping exercises for engaging clients in identifying and setting health goals for reentry and aftercare. Use of cognitive mapping is reported to make treatment discussions more memorable (Knight et al., 1994). An increase in on-task performance in group sessions are especially helpful for clients with attentional problems (Danseraue et al., 1995). On-task performance provides ethnically diverse clients and clients with limited education greater confidence in their ability to communicate (Newbern et al., 1999). Furthermore, group session format facilitates the therapeutic alliance (Simpson et al., 1995) and resulted in better treatment outcomes (Joe et al., 1997). These cognitive mapping activities were guided by trained students on an individual basis for 1-hour per week and focused on individual chronic health issues.

Sample

Forty-seven patient participants were recruited from two state prison facilities over a 2-year period after obtaining academic institutional review board approval (IRB no. H16-149) and approval from the Department of Correction Research Advisory Committee. The research team explained the study protocol and consented those persons who willingly volunteered and met the inclusion criteria. Two individuals dropped out stating that they did not think this program was useful for them.

Student Interventionists

Fourteen nursing students participated in the CareLink-C program in the first semester and 17 nursing students in the second semester for a total of 31 students who self-selected into this clinical experience. Each semester, students were provided orientation for a 2-day period before the semester to understand the CareLink-C program protocols and how supervision would work and to conduct Department of Correction orientation required to enter the prison. Inter-rater reliability among students was assessed using the Behavior and Symptom Identification Scale (BASIS)-24 instrument for each set of students (k = 0.67). Students delivering the intervention received supervision every clinical day from the clinical faculty (2 clinical days/week) and monthly from the research faculty.

Agency Partners

The initial community–academic partnership was with three agencies for student placements: the CT Department of Correction, the CT Correctional Managed Health Care provider, and the University of Connecticut, School of Nursing. Additional community partnerships were developed as the project unfolded into the community setting (phase 2) in collaboration with the assistance of the CT Eastern AHEC.

Measures

Biopsychosocial Nursing Assessment

Students interviewed participants who reported biologic, psychological, and social health data (Boyd, 2012). Modification of the assessment had been made with work of Shelton, Barta, Trestman, et al. (2016) for incarcerated populations to account for criminogenic variables and the effects of prisonization to align with clinical application of the RSC model development (Shelton, Barta, & Anderson, 2016a). The adaptations have face validity and are supported in the literature and by pilot data (Shelton, Barta, & Anderson, 2016b) and constructs of the model were tested (Maruca, 2016; Reagan et al., 2016). The assessment identifies behavioral and health risks and is identified among the interventions of the Wheel of Public Health Interventions developed by the Minnesota Department of Health (2019). Assessments are completed over several weeks.

The Newest Vital Sign

The Newest Vital Sign (NVS) is a nutrition label comprising six questions and requires 3 minutes for administration (Weiss et al., 2005). It is reliable (Cronbach's α > 0.76 in English and 0.69 in Spanish) and correlates with the Test of Functional Health Literacy in Adults (TOFHLA; Parker et al., 1995). All patients who score greater than 4 on the NVS will have adequate literacy when measured by the TOFHLA. A score less than 4 on the NVS, in contrast, indicates the possibility of limited literacy. Clinicians should be particularly careful in their communication with patients who score less than 2 as they have a greater than 50% chance of having marginal or inadequate literacy skills.

Health Goal-Setting Activity Workbook

Health Goal-Setting Activity Workbook provides 14 cognitive mapping exercises (Bartholomew et al., 2006). These mapping exercises were purposefully focused upon health by students. As a component of mapping, patients were asked to identify personal strengths they would apply toward achieving their goals and transition. Cognitive mapping exercises were analyzed utilizing descriptive qualitative methods from Miles and Huberman (1994). This was completed during the ten 1-hour weekly individual sessions.

The Social Problem-Solving Inventory-Revised

The Social Problem-Solving Inventory-Revised (SPSI-R) yields five variables: (1) Positive Problem Orientation (5 items), (2) Negative Problem Orientation (10 items), (3) Rational Problem-Solving Style (20 items), (4) Impulsive/Careless Style (10 items), and (5) Avoidant Style (6 items) rated on a Likert-type scale ranging from 0 (not at all true of me) to 4 (extremely true of me) (D'Zurilla et al., 2002). The SPSI-R had demonstrated good internal consistency reliability. Cronbach's α in a young adult sample across subscales were between 0.76 and 0.92 and a 3-week test–retest yielded reliabilities of 0.72–0.88 (D'Zurilla et al., 2002). This instrument has an eighth-grade reading level and takes approximately 20 minutes to complete. It was administered before and after the intervention. Higher scores on Positive Problem Orientation, Rational Problem Solving, indicate constructive problem-solving, whereas higher scores on Negative Problem Orientation, Impulsive/carelessness Style, Avoidant Style indicate dysfunctional problem-solving.

Medical Records

This source of information was utilized for gaps in reported information or for clarification, particularly around medications and prerelease instruction.

Behavior and Symptom Identification Scale-24

BASIS-24 is a 24-item self-report measure of difficulty in six major symptom and functioning domains: (1) Depression and Functioning, (2) Relationships, (3) Self-Harm, (4) Emotional Lability, (5) Psychosis, and (6) Substance Abuse (Eisen et al., 2004). It is used to assess mental health outcomes. Internal consistency reliability (Cronbach's α) coefficients ranged from 0.75 to 0.89 for inpatients and from 0.77 to 0.91 for outpatients. Test-retest reliability coefficients (intraclass correlation coefficients) ranged from 0.81 to 0.96 for inpatients and from 0.89 to 0.96 for outpatients. Construct validity was demonstrated by correlations between the comorbidity index and the overall BASIS score were 0.15 (p < 0.001) for inpatients, and 0.27 (p < 0.001) for outpatients; thus, increased psychiatric comorbidity was associated with greater self-reported symptom/problem severity. The questionnaire takes 10 minutes to complete.

Program Evaluation

Each participant and cohort of students met with the research faculty to report levels of satisfaction and areas for improvement for CareLink-C. Student clinical skills evaluation was completed by the clinical faculty and is not included in this study.

Statistical Analyses

Descriptive analyses were conducted and instruments were scored to begin to explore the feasibility of translating the CareLink-C to the correctional environment. Data sets were screened for missing data with no more than 10% missing data noted. A nonresponse pattern was noted in the mapping exercise and evaluated at the end of the two semesters. De-identified data were collected in paper and pencil format with uniform numbers linking the various components and entered in the SPSS v 24 statistical package (SPSS, Armonk, NY). Random records were double data entered to monitor data entry errors.

Results

The results reported from the implementation of the CareLink-C program inside prisons begins by reporting those factors noted in this sample that align with the Biopsychosocial Vulnerability Stress Model (Shelton, Barta, Trestman, et al., 2016). Data obtained during the individual intervention sessions describe the phase of self-care (Shelton, Barta, & Anderson, 2016a) the participants were able to achieve, patient attendance, BASIS-24 scores, and satisfaction.

Demographics

Student Demographics

Thirty-one undergraduate nursing students self-selected for this clinical. Six male (19%) and 25 female (81%) nursing students between the ages of 20 and 23 years (M = 21.3, SD = 0.748). Ninety percent of students reported ethnicity as White.

Participant Demographics

In total, 47 incarcerated patients participated in two cohorts over two academic semesters. Thirty females (63.8%) and 17 males (36.2%) participated. The age of patients ranged from 25 to 51 years (M = 25.04, SD = 19.577). Nine (22%) individuals reported being employed before incarceration and 9 (22%) reported receiving disability. Students had an opportunity to work with multiracial patients and individuals with a variety of educational levels (Table 1).

Table 1.

Demographics

Participants (N = 47)	Number	Percentage
Gender
Females	30	63.80
Males	17	36.20
Age
<25 years	19	41.30
>40 years	15	32.20
Education level
Greater than high school	6	16
High school or GED completion	19	52
Less than high school	12	32
Race
American Indian or Alaskan Native	4	8.50
Black or African American	13	27.70
Asian	5	10.60
White or Caucasian	20	42.60
Native Hawaiian or other Pacific Islander	1	2.10
Multiracial	2	4.30
Medical conditions
1 or 2 chronic diseases	21	52
3–5 chronic diseases	9	23
6–10 diseases	2	5
Mental health disorder
Depressive disorder	9	23
Bipolar disorder	5	12
Substance use disorder	5	12
Post-traumatic stress disorder	3	7
Psychotic disorder	3	7
Personality disorder (cluster C)	3	7

GED, General Education Development.

Patient Biopsychosocial Vulnerability Stress Factors

Medical Conditions

Twenty-nine (72%) patients reported they had a current illness, but only 23 (57%) of these stated they were receiving treatment. Of those receiving treatments, slightly more women (n = 14, 67%) sought treatment than men (n = 9, 53%). Among the 32 individuals reporting chronic illnesses, most individuals reported one to two chronic diseases (n = 21, 52%), but 9 (23%) reported 3–5 chronic diseases and 2 others (5%) reported 6–10 diseases. Twenty-two (68%) patients also reported a mental health diagnosis (Table 1). All participants had functional assessment (Global Assessment of Functioning) scores that ranged from 22 to 88 (M = 63, SD = 19.902), indicating very low functioning (scores 22–50) for some individuals (n = 8, 25.8%), but most were assessed to have moderate scores that ranged either from 51 to 70 (n = 8, 25.8%) or minimal scores ranging from 71 to 88 (n = 17, 48.4%).

Participants accessed medications either through prescription or over-the-counter (OTC) through the commissary. Of those taking medications, 23 individuals were prescribed medications (57%), 21 were prescribed psychotropic medications (52%), and 9 (22%) also reported taking OTC medications. Fifteen (38%) patients reported side effects from their medications and 2 (5%) reported refusing their medications because of these side effects. Data were limited on OTC medications and impact on side effects.

Personal Strengths

Fifteen (38%) patients requested a cultural accommodation in relationship to care (diet, support, and medical). Twenty-three (58%) maintained contact with their families and felt they were important to their care and transition to the community. An additional five persons (12%) had this belief but did not have contact with their families. Sixteen (40%) participated in a formal religion and an additional 10 persons (25%) claimed to be “spiritual.” Of note, incarcerated patients were adamant that they had personal strengths.

Health Literacy

This is known to be a complex construct that encompasses many aspects of how individuals use health information and the health care system (Weiss et al., 2005). Students reported that some patients struggled with this assessment and were embarrassed by their inability to read or to do mathematical calculations. Twenty-six (65%) patients scored in the “adequate literacy” range (> 4), 11 patients (27%) scored less than 4 and were noted to have “a possibility of limited literacy,” and 3 (8%) scored less than 2 and have a greater than 50% chance of having marginal or inadequate literacy skills. This distribution was like that found among community-based vulnerable populations where 36% were found to have basic or below basic health literacy (Kutner et al., 2006).

Intervention Data Analysis

Those targeted for the CareLink-C program while incarcerated were near to their release date (within 1–2 years). Of the 40 patients who began the CareLink-C program, 34 (85%) remained in the program, 3 were released, and 3 dropped out. Incarcerated persons in this correctional system frequently get moved between facilities, are released at times unexpectedly, or may be moved for reasons related to management of the population. The three who dropped out reported that they did not feel the program would benefit them.

Self-Care Management

Before the intervention we assessed patient engagement in SCM. Patients were asked if they felt capable of providing self-care or if they would like assistance in providing self-care. Thirty-two patients (80%) reported that they did not need assistance with SCM of their health. Two individuals (6%) reported that they “self-treated” their illnesses and 5 (12%) said they just “ignored it.” One person refused to answer. Participants had difficulty focusing on their health needs during the program (Table 2). Their focus remained housing and employment as stressed by the prison system and less upon health maintenance activities for release. Nearly all participants perceived that health care arrangements would be “done [for them] by the social worker,” lacking insight into their role in self-care as they transitioned to the community. Frequently, participants referred to their transition status as “just waiting.”

Table 2.

Self-Care Management Strategies

Self-care management strategies for health during transition	Frequency
Health status: physically able to take care of daily needs; strength to get addictions under control, good diet, and exercise	23 (74%)
Structured activities: leisure activities, vocational activities, and activities with their family and friends would support both their health needs and their transition	29 (94%)
Personal problem-solving capabilities: ability to ask for help, self-reflection, and ability to identify resources	27 (87%)
Emotional strengths: exercising self-control, helping others, and ability to care or have feelings	29 (94%)
Values: religious or spiritual beliefs, family, and community values support achieving goals	27 (87%)
Vocational strengths: dependable work ethic, working as a volunteer, and history of full- or part-time employment	26 (84%)

Cognitive Mapping Exercises

Of the 47 participants in the program, only 9 (20%) completed all of the mapping activities in the individual sessions and 34 participants completed most (8 sessions) of the mapping exercise. Twenty-nine (84%) participants did, however, identify a realistic and achievable health goal. Sixteen (46%) patients were able to visualize through the exercises how to move that goal forward, which demonstrates planning skills. Fifteen (44%) patients identified their target goal as “simply getting a routine and achieving stability in their life.” Eight individuals (23%) targeted issues reinforced by the criminal justice system for successful transition to the community—specifically housing, employment, meeting the demands of probation, and getting a job. Six (17%) patients did identify “rehabilitation for their addictions and mental health issues”—such as symptom management, access to medications, controlling behavior, abstinence, managing stress and anxiety, and working on relationships as goals—and proceeded to work toward planning how they would handle these things. Patients who required medications after incarceration appeared to be more aware of the need to do SCM, expressing concerns about how to access medications upon release.

As a component of mapping, patients were asked to identify personal strengths they would apply toward achieving their goals and transition. Participants could identify one or more personal strengths (Table 2). Twenty-three (74%) patients identified “self-reliance upon their physical health” as their strength and explained this strength as their “ability to take care of themselves,” the “strength it takes to get their addictions under control,” and having a “good diet and exercise.” Twenty-nine (94%) patients felt their “leisure activities, vocational activities, and activities with their family and friends” would support both their health needs and their transition to the community. Twenty-seven (87%) patients felt they had “personal problem-solving capabilities” reported as an “ability to ask for help,” “self-reflection skills,” and “ability to identify resources.” Twenty-four patients (70.5%) also reported “personal values” as a source of support for achieving transition health goals. These were reported as “religious or spiritual beliefs” and “family and/or community values.” Emotional strengths for transition were identified by 29 (85%) patients, described as “exercising self-control,” “helping others,” and “an ability to care or have feelings.” Finally, vocational strengths to support transition were identified by 26 (84%) patients who described their “work ethic” as something to help in transition, described as “being dependable,” “working as a volunteer,” and “holding full- or part-time employment.”

Social Problem-Solving

Total score and subscales of the SPSI-R were examined (Table 3). Participants scored high in Impulsivity/Carelessness and Avoidant Style, suggesting dysfunctional problem-solving styles. Total social problem-solving scores did not significantly change over the 10-week intervention (t(38) = −0.254, p = 0.931, CI = −9.988 to 10.888). Hayward et al. (2008) suggest that poorly functioning people understand rational problem-solving, but that negative orientation, impulsivity, or avoidance get in the way of using these skills.

Table 3.

Pre–Post Treatment Social Problem-Solving Inventory-Revised (n = 40)

Styles	Pretest			Posttest
	M	SD	SE	M	SD	SE
Positive problem orientation	7.75	3.447	0.771	8.65	2.978	0.666
Rational problem-solving	25.40	13.228	2.958	25.20	12.211	27.31
Negative problem orientation	17.70	8.007	1.790	16.50	6.771	1.514
Impulsive/careless	11.05	3.886	0.869	10.00	3.43	0.768
Avoidant style	10.55	3.395	0.759	10.20	3.518	0.787
Total score	92.00	18.146	4.057	91.55	14.229	3.182

Behavior and Symptom Identification

Subscale scores are shown in Table 4. Forty-three participants reported some symptoms, with slightly higher scores reported for some scales at posttest. The total score change was not significant (t(26) = −0.616, p = 0.543). In comparison with a community sample of Whites, African Americans, and Latinos (Eisen et al., 2004) scores reported by this sample are higher for total and subscales.

Table 4.

Behavior and Symptom Identification Scale-24 (n = 45)

Symptom and functioning domain	Pretest			Posttest
	M	SD	SE	M	SD	SE
Relationships	11.500	5.185	1.385	14.571	2.979	0.7963
Depression/functioning	10.071	5.567	1.487	9.785	4.577	1.223
Self-harm	0.5714	2.138	0.5714	0.3571	1.081	0.2891
Emotional lability	5.571	3.435	0.9181	5.071	2.702	0.7222
Psychosis	2.642	4.749	1.269	2.928	4.698	1.255
Substance abuse	4.571	4.815	1.286	5.785	4.35	1.163
Total score	34.928	17.188	4.593	38.500	13.241	3.539

Participant Satisfaction

All incarcerated participants were surprised that they were able to evaluate the intervention and provide feedback on their student, even though this was explained during consent procedures. As one participant said, “I just didn't believe it would happen.” Patients enjoyed having “their student” 2 days each week. One male patient commented that he “could not believe that students would want to come and work with someone like me in a place like this.” Another patient commented, “I am glad that I can help to teach someone what this is like. Maybe there will be more nurses and doctors in the future.”

Student Satisfaction

Student satisfaction scores were high. Three students (9.9%) were undecided if they were adequately prepared for this clinical experience after orientation. Twenty-six students (86.6%) felt the level of faculty mentoring and supervision was adequate. All students felt that what they learned was useful for their future clinical practice and they would apply what they learned through this structured experience. One student commented, “I really like the structure of the intervention. It helped me know what to do with the patient. I wasn't so nervous about it.” Students felt this clinical experience met their personal academic social-justice goals.

Discussion

The research question was “Could clinical nursing and health care students effect change in individual self-care management capabilities to reinforce reentry success while learning their clinical skills?” It is important to demonstrate the value of clinical partnerships with departments of correction that are not customary clinical sites. Participants were provided the opportunity to evaluate their students and all were very positive about the opportunity to work one-to-one with someone, with one exception. A random number of participants were interviewed at the end of the intervention and all were positive regarding the program.

It was our expectation that with improved SCM competency patients would feel empowered to manage their own health issues, thereby improving their reentry experience (Shelton & Goodrich, 2017a, 2017b). The early stages of SCM were evidenced through participant goal setting and planning behaviors despite participant feedback indicating that they did not fully grasp the importance of mapping exercises for development of problem-solving and thinking processes. We expected postintervention depression scores to be reduced based on a review of the literature, but these scores were not statistically significant. Voluntary program attendance remained high and consistent, indicating interest in the program. A random number of participants (N = 7) were interviewed and reported satisfaction with the program.

The BASIS-24 subscale scores reported by this sample were higher than noted in a published community sample (Eisen et al., 2004). Although from a Department of Correction viewpoint these patients did not meet the cutoff to be included in the high-risk group prioritized for mental health services, they appear to need programming support for successful reentry. With refinement, academic–correctional partnerships such as CareLink-C can bring an exchange of beneficial resources and opportunities.

It was proposed that problem-solving and health literacy would moderate the effects of CareLink-C. Although there were no significant changes in problem-solving scores, this sample scored high in Impulsivity/Carelessness and Avoidant Style, suggesting dysfunctional problem-solving styles. Authors noted that these participants were very cautious about their behaviors so as not to accrue behavioral tickets that might interfere with release. What appeared to be rote responses utilized by prison staff and repeated by participants indicate programmatic challenges to be addressed. The effect of institutionalization may have been seen in this sample if they provided the expected responses taught them when questioned rather than engage in thoughtful problem-solving around their release. Approaches currently utilized by corrections agencies to prepare individuals for transition may, therefore, act as a barrier to successful transition to community living.

This type of self-care-focused intervention was further tempered by patients' beliefs that someone (a social worker) would take care of these issues upon release. The mapping workbook represents a cognitive process of planning and visualizing action. Some participants found this difficult given their problem-solving styles, suggesting that there is a need to reinforce the reason for the mapping at each session. Participants reported that they felt there was redundancy in the mapping workbook, suggesting they failed to understand the need for the cognitive process. More exploration of factors influencing this, such as literacy level, is needed. In this sample 14 (35%) patients had limited health literacy, and 65% report a General Education Development or high school education or higher level of education attained. The National Center for Education Statistics (2007) study suggested that education at a high school level or higher moderate health literacy levels. Weiss et al. (2005) calls for modification of teaching approaches to individuals with literacy challenges. Programmatic approaches seem best for increasing exposure to the intervention over time until new behaviors are learned. Inside–outside programming that supports continuity is also recommended.

It should also be noted that participants were still 1–2 years from release, and the time from release may have played a role in their ability to visualize reentry. The inflexibility of correctional systems, challenges of population management, and poor teamwork make programming appear chaotic (Kersten et al., 2016). With a change of setting to community-supervised residences, the reality of the need to be more independent may alter how patients utilize the program.

An effect of the student skill level needs to be considered as well. Students received extensive front-end and repeated supervision to understand the intervention. Yet not all students were suited for this type of intervention, despite their social-justice beliefs. Graduate students may be better prepared to learn from such an experience, and providing this type of experience postgraduation in the form of a residency as students transition to the workplace may be more suitable and act as a recruitment tool for correctional systems.

Limitations

Several limitations need to be noted. As a feasibility study and considering the small sample size, the results do not generalize beyond the inclusion and exclusion criteria of the pilot design. The moderating variables of health literacy and problem-solving ability were not investigated, although future studies will explore these variables and further investigate reentry success with this intervention.

Conclusion

Several minor modifications were made before pilot testing the intervention in community correctional settings. One mapping exercise frequently skipped by participants was removed, the health literacy exercise was modified to use objects from the commissary and/or local grocery or drug store to make them “real,” and importance of the cognitive mapping process at each session was reinforced so patients would focus on their health. The effect of a change in environment to a community correctional setting was expected to bring participants closer to understanding the need for self-care skills.

Attention to the health and wellness of persons transitioning from prison to the community is inadequate. Many prison systems do not look at what happens outside their facilities as part of their mission. Correctional agencies focus on employment and housing, which are certainly important topics, but generally ignore the skill set required for success in the community, SCM. Moving from a dependent status to one with more responsibility and independence is known to be challenging, as evidenced by the number of individuals who return to prison. An SCM approach to care could be utilized throughout incarceration to avoid erosion of self-care competencies or to build new skill sets. To do this would require a programmatic approach, incorporating components of self-care into every possible part of the incarceration experience.

It was concluded that, with further refinement, student clinical education experiences such as CareLink-C can provide clinical care programs for underserved patients in justice systems. This pilot begins to demonstrate the value of justice–academic partnerships to improve health programming.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.