Compassion in Corrections: The Struggle Between Security and Health Care

Abstract

Many incarcerated individuals have chronic health conditions and mental health issues that have not been addressed by health care providers in years, if not decades. Patients in correctional settings are isolated from society and have reduced access to health care. Prison is a lonely scary place. How then do nurses impact the lives of these patients? It can be challenging given safety concerns, resource issues, and the bias of not only the nurse but also the security staff with whom they are working. Nurses have a responsibility to their patients to beneficence, justice, nonmaleficence, and autonomy. Compassion in corrections, though, is often viewed as naivete or weakness. Should these qualities be left out of corrections? By identifying one's own bias and asserting firm consistent practices, correctional nurses can set an example of unbiased care. The standards of care are the minimum required, but are they enough?

Introduction and Background

The correctional setting is filled with persons accused and or convicted of various crimes. It could be argued that most, if not all, have maladaptive behavior patterns. It can be complicated for anyone in a correctional setting, but especially nurses and health care providers, to walk the line of professional care. The purpose of this article is to share perspective and concern about the struggle of incorporating compassion into the correctional setting. Doing so provides opportunity for evaluating practice and opening avenues of discussion with the hope it will empower nurses to practice altruism and compassion within a security setting.

The American Nurses Association (ANA) provides structure and care guidelines for scope and practice in nursing (2020). These professional standards not only direct our practice but also defend it through evidence-based research and clinical expertise. As nurses, our first responsibility is to our patients, as described by the ANA standards, to the “protection, promotion, and optimization of health and abilities; prevention of illness and injury; facilitation of healing; alleviation of suffering through the diagnosis and treatment of human response; and advocacy in the care of individuals, families, groups, communities, and populations” (ANA, n.d., section 1, What). In addition, the ANA specifically recognizes our scope of practice being “whenever there is a need for nursing knowledge, compassion, and expertise” (ANA, n.d., section 1, When). While not all correctional facilities are NCCHC accredited, their resources and recommendations offer guidance in the care of persons in correctional settings. NCCHC and the ANA both support the concept of quality care, support, and advocacy for all patients. A standard of care, though, is the minimal expectation in each circumstance. All patients deserve good care, support, and advocacy from their nurses. While there may be no blatant lapse in standard of care, NCCHC accreditation aside, it could be argued that the degree of advocacy and services is lacking.

If our patients are not successful and prepared to reenter society, are we meeting a reasonable standard of care?.

NCCHC standards loosely outline required services for those with mental health needs, saying services provided can include pharmacology and a variety of counsel therapies to help attain function and reduce decline or reversion to prior state (NCCHC, 2018). The vagueness of these guidelines places no real burden of proof collectively on the institutions. Are we meeting the standards if our patients remain sick, fail, or experience recidivism?

Nursing success is based strongly on good outcomes, healing, and improvement to highest level of functionality. To improve the lives of those in corrections, trauma-informed care is imperative. For it to be effective, and not divisive, there needs to be buy-in from health services, security, and administration. Collaborative compassion is necessary to bring the correctional care team together and meet both ANA standards and NCCHC standards.

Trauma-informed care seeks to help patients identify their past, their struggles, and their triggers, and empower them to make changes for a better life. For some corrections staff, this concept is hard to swallow; a multitude of reasons likely contribute to this disconnect. All people have implicit bias. The atmosphere of corrections is one of control and compliance. It may be difficult to conceive the idea of structure, control, and compassion in the correctional arena, but it is crucial. Nearly all people have some form of trauma in their lives. However, not everyone has the same resources, opportunities, choices, or support. Each of us has a different background and levels of inherent resilience. Therefore, compassion in corrections matters and patient-centered care is important. The standard is the minimum, and what we do beyond the minimum is what leads to success or failure in our patients.

The patients in correctional settings are a vulnerable population. These patients have the unique distinction of having almost no control or autonomy over who is treating them. Although incarcerated patients can refuse care at almost every avenue, their choices are limited regarding the staff provided by the institution they are sent to. Trust and connection are important in health care, and in corrections this is hard to come by. There are many defining moments in patient care. However, few would argue that staff engagement and sincere connection or empathy contribute significantly to safer care. When patients are engaged in their care and treatment, lifestyle changes can be made.

To help rehabilitate the patients in correction settings and improve outcomes, connection is necessary. To progress beyond the minimally defined standards requires staff development of specialty competencies, including compassion and advocacy. Compassionate care takes work; it takes understanding and requires a certain level of vulnerability. A willingness to set aside bias and look beyond a person's criminal convictions while remaining vigilant is essential for these connections to occur in a safe and efficient way; compassion is required.

The nursing code of ethics guides a nurse's practice, and nurses are held to a high standard of ethical performance and bias-free care. Correctional care and the organizational politics and safety measures applied in a secure facility can complicate the trajectories and expression of care. In institutional settings, there is pressure and high demand for consistency between patients; many staff members see patients as one homogeneous group with no individual identity. This voids patient-directed care, personal identity, and emotional connection. Patients of correctional institutions often feel they are simply a number (Solell & Smith, 2019). If correctional nursing can normalize genuine compassion in corrections, then the standard will be just that. Compassion in corrections has the potential to improve the standards of care, leaving people better off than when they came.

Nursing Is a Field of Compassion and Caring

Nursing is a field of science and theory, but its basis is rooted in caring. Holistically connecting with the patient to meet all of their needs. These ideas are not only supported by the ANA scope and standards (2020) but also by nursing theorist Jean Watson's theory of caring. Watson declares, “Caring Science is the essence of nursing and the foundational disciplinary core of the profession” (Watson, 2008, p. 17). Watson's theory argues that caring empowers capabilities and self-actualization. The nurse's practice can have a significant impact on the behavior and health outcomes of patients in corrections, most notably those suffering from mental health disparities (La Cerra et al., 2017). Although there are countless fields of nursing, most envision a nurse at the bedside, holding a patient's hand, turning a patient, crying with a patient. Those images convey connection, compassion, and support. Nursing often ruminates on the recognition, diagnosis, treatment, and healing of physical acute or chronic conditions, seeking ways to individualize care for improved outcomes. This level of concern and empathy in the name of healing is why nurses continue to rate as one of the most trusted professions year after year (Reinhart, 2021).

Compassion can be defined as “sympathetic awareness” offering empathy and understanding to another person, relating to his or her pain and his or her struggle, and desire to help the person recover/heal (Merriam-Webster, n.d.). Providing this type of support and dignity is beneficial for the patient as well as the nurse and leads to trusting relationships, better outcomes, and higher job satisfaction (Zamanzadeh et al., 2018).

Many recognize compassion as a foundational cornerstone to ethical quality care; without it the healing connection between providers and patients cannot exist. In health care, compassion is viewed as an imperative quality, a responsibility, and a necessity both individually and collaboratively (Lown, 2015). All health care environments require forms of collaboration; corrections is no exception. The obligatory goal then should be viewed as collaborative compassion, collaborative compassion being a partnership and respect in resolution and distribution of health care that meets the whole person's needs.

How then do nurses deal with their own bias and the organizational constraints of a correctional setting? The ability to provide consistent compassionate care may be complicated by organizational support, structure, and buy-in. “… the American Nurses Association, correctional nurses' work is expected to respect certain ‘nursing values’, such as: restoring patients' health with compassion; preserving confidentiality; encouraging health promotion; and collaborating with health care colleagues to meet patients' holistic needs, including physical, psychosocial, and spiritual care” (Solell & Smith, 2019, para. 7).

The Correctional Setting Can Be a Dangerous Place

In 2012, the Wisconsin Department of Corrections' (DOC) Division of Adult Institutions (DAI) created a policy requiring employees to report and track assaults on staff. This policy outlined the definition of an assault, established a new reporting system, and defined a procedure for reporting assaults to law enforcement. In September 2012, the new reporting system was implemented to enhance collection, review, and analysis of staff assault data. … The status of each incident is categorized as an attempted assault or completed assault. Additionally, each incident type is categorized as battery, throwing, spitting, physical injury, or sexual (State of Wisconsin, n.d., Introduction para. 2–3).

Statistics gathered for fiscal year 2019 note 459 total incidents, of which 61 were attempts and 398 completions. Assaults vary, including spitting, throwing bodily fluids, weapon attacks, and battery. The current data did not separate the staff as security, health services, or other support staff.

Despite these potential risks, correctional nurses have an especially important job; their ability to connect with the patient in times of need sets a tone for future interactions and health outcomes. In most cases, altruism is likely a defining factor in a nurse's ability to separate her own bias from the patient's needs. This capacity is essential in corrections. Treating all patients with equal concern, respect, and dignity not only assures quality health care but also safety and security and reduces the potential for future litigation.

Security dictates many aspects of treatment, sometimes complicating the connection between a patient and the nurse. Nurses use all their senses to provide care; in most clinical care settings, touch and even embrace are part of the job, but not in corrections. For safety reasons, appearance of impropriety, and the litigious nature of correctional patients, embrace is strictly forbidden; touch is allowed only for assessment and security purposes. For some nurses, this can be a bit of a culture shock and takes some getting used to, further impacting the ease with which a nurse may typically provide care.

There are many instances wherein security and health care may compromise, when cooperation is not always easy to come by. When taking care of ill patients, nurses seldom imagine being in danger; however, in corrections, standing close during an assessment, turning your back to a patient, or squatting down to assess a patient can put a nurse in a position of risk. At times, safety and security may prevent gold standard treatment because of potential risks to staff and other inmates. Preconceptions and genuine safety concerns are often cited as reasons for preventing or intervening in health care treatment. Materials that nurses use to secure fractures or sprains or assistive devices can easily become weapons for self-harm or assault in a population that may feel they have nothing to lose. This is where collaborative compassion is key, finding a safe way to provide quality care.

The Danger of Deliberate Indifference: Understanding Your Own Bias

The correctional setting presents a host of challenges, one of the biggest being the risk of deliberate indifference. Deliberate indifference is defined as knowingly disregarding a patient's serious medical need. The factors that must be present include serious medical condition, knowledge of the condition, and failure to provide treatment, thereby causing pain suffering or harm. Because many inmates have not had quality health care, they often have legitimate chronic health issues; many have mental health issues in addition to somatic complaints. This is not to be confused with simply weeding out legitimate health concerns from malingering.

The key to avoiding the catastrophic potential of deliberate indifference is good communication with staff and patients, strong assessment skills, and thorough documentation. Understanding medication side effects and disease processes and communicating potential concerns with security can help avoid health complications and reduce adverse outcomes. Further complicating this potential is the struggle between security and health services. Security personnel are very safety minded and can be skeptical and biased. Health services are treatment focused and foundationally concerned about a person's well-being.

Advocacy and collaboration are correctional nurses' most imperative tools to communicate a patient's health care needs and potential concerns. These tools, supported by strong assessment skills and an ability to connect with the patients, are imperative in avoiding misunderstandings, inarticulation, or accusations of deliberate indifference.

Compassionate Care for All

When considering care for patients in corrections, there are often two camps of thought, typically divided between security and health services. The first struggles with the bias regarding an individual's crimes and rationalizes that the victims they have created make them undeserving of good care. Depending on level of violence, security will at times err on the side of caution, assuming patients are malingering, lying, or have ill intent. This fear, bias, and lack of compassion is a barrier to care. Some feel the idea of trauma-informed care is a way of enabling or excusing bad behavior. However, the control security has over assessments and care subjugates a nurse's autonomy to provide patient-centered care.

The percentage of people in society with an adverse childhood events (ACEs) score of 4 or greater is 25%. In a retrospective study done in a mideastern Wisconsin correctional setting, 80% of patients had an ACEs score >4 (Lehrer, 2021). Not only are ACEs scores a predictive factor for corrections, but they also are strongly correlated with chronic health conditions as well as a shortened life expectancy of as much as 20 years.

When considering these facts, the second camp focus is this: All people have a right to good quality care. Quality care necessitates consideration of past historical events, where these patients have come from, and their likely contributing traumatic upbringings. Compassionate care is provided without bias of age, gender, race, sexual orientation, or past wrongs.

It is the responsibility of all nurses to provide impartiality, beneficence, justice, nonmaleficence, and autonomy. Collaboration and perceptive communication with security can serve as a catalyst for change.

Conclusion

It is evident that strong communication skills are necessary to provide quality care in a correctional setting. Confidence in skills, knowledge, and nursing ability is essential in secure institutions that stifle typical nurse expression. Nurses who possess the ability to remain impartial are an integral part of quality health care in correctional settings. More work needs to be done to bridge the divide between security and health services. Training, understanding, and buy-in of trauma-informed care could promote better outcomes and reduce recidivism. Additional studies and educational opportunities for future and current nurses to improve the health care of this vulnerable population are also desirable.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.