Nurse Academic-Practice Partnerships in Justice Systems: Building Upon the Evidence

Contemporary leaders have repeatedly advocated for nursing educators and clinicians to forge new collaborative bonds. This call has taken on new urgency in the wake of nursing’s efforts to promote a nursing solution to the ongoing healthcare challenges in the United States. Stimulated by the report “Future of Nursing: Leading Change, Advancing Health” (Institute of Medicine [IOM], 2011) and the development of a future vision through “Future of Nursing 2020–2030: Charting a Path to Achieve Health Equity” (National Academies of Sciences, Engineering, and Medicine [NASEM], 2021), the specialty of correctional nursing is seeking solutions and strategies for a most challenging healthcare environment and population. Building on the four key messages that structured the IOM’s discussion and recommendations in 2011, in this article we focus on the second message to transform education. The Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine suggested that “Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression” and transition into practice (IOM, 2011, Ch. 4 p. 1). A quick view of the correctional healthcare landscape revealed a glaring gap. The lack of academic preparation of nurses for work within carceral environments and preparedness for complex and seriously ill populations promotes further workforce shortages, resulting in inadequate access to nursing care for patients. In systems in which nurse turnover was already high, the recent migration of nurses out of these healthcare settings post pandemic is alarming. This leaves patients who have been marginalized being underserved to an even greater degree.

Academic-correctional practice partnerships are strategic relationships between educational institutions and correctional institutions/systems that address mutual interest related to practice, education and knowledge development, evidence-based knowledge as a basis for practice, and potential research opportunities. The presence of academic-practice partnerships (APPs) for nursing in corrections has been sporadic despite the size of the criminal justice system and the number of patients receiving care through this system. Challenges for resource strained correctional systems remain include: limited clinical access for student training, time required to establish and maintain these clinical partnerships, limited academic resources, concerns by faculty regarding the safety of clinical learning in correctional facilities, the need for faculty research and education in this specialty, and the misalignment of teaching content with correctional nursing-practice needs. The purpose of this article is to explain how a variety of academic institutions have worked to overcome these challenges to the benefit of their students and the individuals within the correctional system.

Background

In the profession of nursing, APPs are most often defined as strategic relationships between educational and clinical practice settings that are established to advance their mutual interests related to practice, education, and research (Beal et al., 2012). In 2008, a series of reports (American Association of Colleges of Nursing [AACN], 2008; Nursing Executive Center, 2008a, 2008b) highlighted limitations in the workforce-development pipeline and resultant gaps in competencies among nursing graduates resulting in a renewed call for APPs to advance the nursing workforce and the health of the public. The idea of APPs was reinforced by the “Future of Nursing” reports (IOM, 2011, NASEM, 2021) to promote the expanded role of nurses. In 2012, AACN published “Guiding Principles for Academic-Practice Partnerships” to serve as a north star for institutions seeking it establish or maintain an APP (AACN, 2021). The case examples of APPs noted below highlight the importance of experiential learning in these nontraditional carceral settings that provide opportunities to learn many types of care given the complexities of the patient population and system in which they are served (IOM, 2016; Campaign for Action, 2019). Support for these partnerships is found in a second systematic review conducted by Pedregosa et al. (2020), who reported these partnerships to be foundational in achieving educational goals. Shared resources between faculty and staff, as demonstrated below, help meet the call to increase the nursing workforce, especially when the number of nursing students is rising and clinical sites are becoming scarce.

Although priorities and perspectives on resource allocation may differ between practice and academia, intentional and formalized relationships based on mutual goals, respect, and shared knowledge provide the synergy to make the partnership effective. As noted by Bvumbwe (2020), partnerships require a deliberate effort to establish an environment conducive to the creation of an effective partnership that includes shared vision, joint planning, open communication, trust, respect, and commitment. More contemporary studies have reinforced the benefits of APPs despite the variability of their structures (Granger et al., 2012; West et al., 2014). Researchers have reported improvements in patient-care delivery and outcomes (Granger et al., 2012; Roach & Hooke, 2019), and pre-licensure students who participated in APPs found it easier to transition into their roles as nurses (Wallace, 2016). In a cross-sectional study conducted by Yi et al. (2020), professional socialization of students precepted by the clinical partner’s nurses was examined. Professional socialization into the specialty of correctional nursing is particularly challenging for reasons related to working in a secure environment and with a unique population for which many nurses are not adequately prepared (Shelton, Barta & Reagan, 2018; Shelton, Weiskopf & Nicholson, 2010). Yi et al. (2020) highlight the importance of the interaction with clinical-nurse preceptors upon the development of competence, stressing the significant role of practice partners.

It is clear that a competent nursing workforce is important for an effective healthcare system, yet there remains a well-documented academic-practice gap in nursing (Bvumbwe, 2016; Huston et al., 2018), with concerns about the quality of nursing care and competencies among nursing students. Academe is criticized for preparing registered nurses (RNs) who are insufficiently prepared to engage in providing complex care to acutely ill patients. Practice settings can have unrealistic expectations of new graduates related to meeting the demands of a rapidly evolving healthcare system (Huston et al., 2018). In 2016, the AACN published “Advancing Healthcare Transformation: A New Era for Academic Nursing,” which outlined a transformative vision for APPs (see Box 1). Collaboration between nursing schools and practice institutions is important to achieve this goal.

Box 1: Guiding Principles for Academic-Practice Partnerships.

(American Association of Colleges of Nursing & American Organization of Nurse Executives, 2012)

Collaborative relationships between academia and practice are established and sustained.

Mutual respect and trust are the cornerstones of the practice–academia relationship.

Knowledge is shared among partners.

A commitment is shared by partners to maximize the potential of each registered nurse to reach the highest level within his/her individual scope of practice.

A commitment is shared by partners to work together to determine an evidence-based transition program for students and new graduates that is both sustainable and cost effective

Few published studies exist that examine APPs for nursing in correctional environments. With this article, we seek to fill that gap and to demonstrate the benefits of translating these academic-practice partnership models to correctional environments to improve patient care and support the nursing workforce. We provide four examples of successful correctional-nursing APPs. A review across examples provides insight to those factors that promoted success.

Partnership 1: Educating the Workforce

At a north-eastern university, we recognized that clinical education is vital for building the correctional-nursing workforce and can be accomplished through several means: (a) establishment an academic-practice partnership, (b) introduction of correctional healthcare education to prelicensure students who will transition to the workforce, and (c) provision of continuing education for the existing correctional-nursing workforce.

To be responsive to the development needs of the clinical workforce, the first step taken by nurse leaders was to develop an academic-practice partnership. In this partnership, nursing faculty reached out to the practice sector to conduct a series of listening sessions over time. An understanding and acceptance of the amount of time needed to develop these relationships is critical. Early discussions focus on mutual benefits and on developing an understanding about academic and practice systems. Systems understanding permits aligning academic calendars with correctional-system processes, such as timing of preclinical clearances and institutional review board (IRB) approvals. Funding is always an issue. It must be acknowledged that having faculty and students in a correctional facility may impose additional security requirements and costs associated with clinical precepting. Even when external funding is not available, in-kind contributions by faculty and students should be explored, such as offering a nurse clinician free educational course for services provided to nursing students and nursing faculty providing support with data collection for quality-improvement studies.

An academic–public partnership between the university and the state Department of Correction (DOC) was established between 2010 and 2012 with Institutional Review Board approval from both the university and the DOC to implement CareLink-C, an evidence-informed program designed to assist incarcerated persons to “re-discover self-care management skills” (Shelton, Barta & Anderson, 2016) to improving wellness and self-care of chronic health needs. The 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. CareLink-C afforded junior and senior level baccalaureate undergraduate nursing students and graduate health-services students an opportunity to participate in a clinical and research experience designed to serve a vulnerable population and to observe the consequences of the social determinants of health. Students received a pass/fail grade based on completion of their clinical assignments. The CareLink-C program provided incarcerated individuals with personal support to address their various learning needs and to practice new skills that will assist them with self-care when transitioning to community living (Maruca et al., 2021). This program was provided both inside prison and in DOC half-way houses to extend support for development of confidence and competence in self-care (knowledge, skills, attitudes, and abilities).

Through CareLink-C, transitional support for incarcerated patients was provided by 25 nursing students and 25 health services students over four semesters as a clinical and research experience for credit. The intervention was provided as 10 weekly individual education sessions while incarcerated and again on release at the DOC half-way houses to explore Self-Care Management (SCM) for chronic disease (Shelton, Barta & Anderson, 2016). Following a health assessment, goals that are specific, measurable, achievable, realistic, and anchored within a time frame (SMART) unique to the individual’s health history and self-care needs were mutually set, guided by an evidence-based workbook developed by Bartholomew et al. (2006) and modified to focus on health. The individual 1-hour sessions offered 14 cognitive-mapping exercises for engaging clients in identifying and setting health goals for reentry and aftercare. Nursing and health sciences students provided support and encouragement to reinforce self-care behaviors of the participants following one week of orientation and training.

In addition to the intensive orientation from faculty, students received orientation by the DOC which focused primarily of safety and security. Weekly group conferences were held to help students manage the intervention, to process poor attitudes displayed by staff, and to problem-solve around clinical challenges. Student satisfaction was rated very high, and no attrition occurred over the four semesters. Faculty decided to divert one student to a different clinical activity, as this was not a good match for the student. Similar findings were noted in a nursing-student evaluation of their clinical experience in an Australian prison setting (van de Mortel et al., 2017).

Additionally, this northeastern university offered a one-credit course for nursing students and other undergraduate students in healthcare as an introduction to correctional healthcare and correctional nursing specifically. Students seeking this type of coursework tended to have strong social-justice academic goals. Providing correctional healthcare courses and correctional nursing specific courses offers undergraduate and graduate nursing students a rich environment to explore the complexities that arise at the interface between justice and healthcare is rich for student exploration and growth. Additional applied-research opportunities were made available for selected interprofessional students seeking to answer questions of importance to the practice partner.

While practice settings provide students opportunities to build skills, confidence, critical thinking, and decision-making competencies, academia can provide both pre-licensure students and experienced nurses with opportunities for advancing their education; engaging in evidence-based, practice-improvement activities; and becoming well informed of core competencies. At our school of nursing, introductory courses for a potential correctional nursing certificate are under development, with courses to be offered to prelicensure nursing students and other undergraduate students interested in the healthcare field. There is growing expressed interest in correctional nursing, so now is the time to provide these students with the guidance, encouragement, and support needed for them to embrace what correctional nursing offers. The courses will also offer experienced nurses who are new to the correctional environment an opportunity to learn about the specialty and uniqueness of the clinical environment while engaging in professional development. Both of these educational paths will lead to strengthening and building the correctional nursing workforce.

Shelton et al. (2018) identified along with two types of programming with 13 core curricula important to correctional nurses: (a) professional development for novice nurses entering correctional systems and (b) establishment of clinical competency for experienced nurses who are new to the correctional clinical environment. Supporting those already involved in or interested in correctional nursing can be accomplished with continuing-education credits, and offerings can focus on areas of greatest need, such as health and mental health assessments, substance-use disorders, withdrawal, suicide, serious mental disorders, and evidence-based interventions.

Partnership 2: University–Juvenile Justice Clinical Collaboration

Since 1999, a western-state university’s College of Nursing, in partnership with the School of Medicine Department of Pediatrics, has maintained a contract with the state’s department of human services/juvenile justice services to provide nursing, primary and mental healthcare services to the youth residing in juvenile correctional facilities. Through the years, the clinic numbers and the services provided have varied. Currently, the university provides staffing in seven pre- and post-adjudication correctional facilities. These facilities house between 10 and 70 youth depending on each facility’s mission and location. The contract is for a 3-year period and has been renewed six times since its inception in 2000. This contract has brought consistency and continuity of healthcare services to the state’s juvenile justice system.

RNs provide care between 20 and 40 hours per week. Primary care nurse practitioners (PCNPs) are on site between 4 and 12 hours per week. This range varies depending upon the number of youth living with the facility. Psychiatric mental health nurse practitioners (PMHNPs) spend between 4 and 8 hours per week in a clinic, depending on the needs of the youth in the facility. RNs and some NPs are initially hired as staff rather than faculty, allowing for an expeditious hire not belabored by the burdens of a faculty appointment; NPs and RNs with a master’s degree or higher may then opt to become faculty. As faculty member, their workload would consist of both didactic and clinical time. Conversely, qualified clinical and tenure-line faculty members may fill openings when they occur in the juvenile-justice clinics.

Both PCNPs and PMHNPs act as independent providers who assess, diagnose, prescribe, and treat patients. PCNPs take calls after hours and on holidays. During clinical-practice time, the PCNPs provide care for acute and chronic illness and precept undergraduate and graduate nursing students and medical residents. PCNP students are typically first semester and focus on interviewing, physical exam and assessment skills. PMHNPs provide medication management and therapy and precept graduate students. RNs provide care at the top of their licenses, serving as both primary care nurses and care managers; they routinely precept undergraduate students. RN students typically spend a portion of their community health rotation in the juvenile justice clinics where the focus is on mitigating the effects of poor social determinants of health on the youth. Clinical faculty and staff work closely with didactic course instructors establishing and evaluating course goals and objectives. All students learn to directly address difficult topics such as adverse childhood experiences, sexual activity, and drug use. RN and DNP students typically spend half a semester in the juvenile justice clinics. Medical residents typically spend a single day in a clinic with a Nurse Practitioner with the objective of learning about the juvenile justice system, the facility and spending time in the provider role. RNs and NPs serve on committees such as quality improvement, COVID management, and emergency preparedness, which allows them to serve as leaders and members of interdisciplinary teams as well as role models for the students whom they precept.

Safety for faculty, nurses and students is a primary concern. Rigorous and relevant processes and procedures are adhered to as a safeguard for everyone in the facility, including the youth. Strict adherence to facility rules and regulations(R&R) is followed at all times. Consistently enforcing these R&R keeps behavior disruptions to a minimum. Youth are on camera at all times except in the exam room. At minimum, exam room doors are always kept ajar. Exam room equipment is kept in locked drawers or fixed to the walls and youth are never left in exam rooms unobserved. In the most secure facilities, staff remain within shouting distance, but far enough not to hear private conversation between provider and patient. It has been our experience that when facility staff and nurses stress appropriate clinic behavior and clearly explain consequences, that youth behave appropriately. These safeguards provide conditions that support and encourage trust, learning, positive behavioral and social skills which allow for a long-term positive impact on youth and a safe working and learning environment for faculty, staff and students.

Correctional clinics offer faculty the opportunity to practice and precept, fulfill the expectation of service and advocacy, conduct university IRB-approved research, and serve as content experts for graduate/undergraduate research. Furthermore, correctional healthcare offers many opportunities to publish and present at conferences. Faculty become experts in correctional healthcare, serving as resources throughout a college of nursing. Students, faculty, and staff serve as advocates as they often reach out to those beyond the correctional setting (ex. judges, external clinics, university benefactors and legislators).

For correctional administrators, having nursing faculty as clinical providers within a correctional setting offers many benefits. Faculty are providers who are up to date on best practices, can serve as connectors to subspecialists inside an academic health-sciences campus, and have access to university resources. In addition, faculty can serve as eloquent spokespersons for the correctional system to state and federal legislators.

Key lessons learned from this collaboration include: 1. It is rewarding but often a struggle to collaborate with professionals who have priorities that don’t always include health care. This type of collaboration allows for personal and professional growth. 2. Students almost universally state correctional clinical experience is personally and professional fulfilling. 3. Nurses and nurse practitioners can be impactful in the correctional settings where they are the health care experts

Partnership 3: University and State Department of Corrections Research Partnerships

Investing in partnerships for health-related research in correctional settings is essential if we are to develop tailored strategies for better managing the health of both populations who must live in prisons and those who are responsible for the care and oversight of incarcerated populations (Butler, 2019). The following are reflections from my 17-year program of corrections-focused research, throughout which I have partnered with prison insiders to conduct studies aimed at enhancing the training received by those who provide care for people who are growing old and/or approaching their end of life in prison (Hollenbeak et al., 2015; Kitt-Lewis, Loeb, Myers et al., 2020; Kitt-Lewis et al., 2019; Kitt-Lewis, Loeb, Wion et al., 2020; Loeb et al., 2013; Loeb et al., 2021; Loeb, Penrod et al., 2011; Loeb et al., 2014; Loeb et al., 2017; Loeb & Steffensmeier, 2006; Loeb & Steffensmeier, 2011; Loeb Steffensmeier, & Kassab, 2011; Loeb et al., 2008; Loeb et al., 2007; Loeb et al., 2018; Penrod et al., 2016; Penrod et al., 2014). My team’s long-range goal is to improve the health of and health care provided to people living in prison. Based upon experiences across six completed studies and an ongoing study, strategies to cultivate, grow, and sustain successful collaborations are shared.

Across the above-mentioned studies, nursing students and health policy students (i.e., baccalaureate, Master’s, and PhD) have been engaged as members of my research team. Graduate students were typically in half-time research assistantship positions, which provided tuition and a stipend. In contrast, undergraduate students held wage-payroll positions. Only students who were interested and willing accompanied the key study team members to data collection visits to correctional facilities. No student ever indicated they did not want to join the key study team members; however, some did not have the opportunity to do so either due to the phase of the study at the time of the students’ engagement or because their class schedule did not permit travel to the study sites. All students who joined the investigators in the field were either at the Master’s or PhD level. Students were never sent to a correctional institution without a faculty investigator accompanying them and were only involved in on-site data collection in correctional settings if they expressed interest, were trained in safety precautions as well as study protocol, and were able to integrate travel into their academic schedule. None expressed safety concerns, likely because they were accompanied by faculty investigators and corrections staff who accompanied the team when moving throughout the facility. Debriefing sessions were held following egress from the correctional facility to discuss how the day went, any concerns or challenges, and strategies for the future.

Roles of student research assistants prior to the COVID-19 pandemic included such activities as: taking field notes, managing audio-recording equipment, and co-moderating investigator-led focus group sessions or individual interviews in prisons; assisting with transcription, data management, and team analysis of qualitative data; as well as assisting with administrative type duties in instances where the project budget was not sufficient to support a Project Manager. Students’ responsibilities during the COVID-19 pandemic have included: conducting literature searches; maintaining meeting minutes; assisting with development and filming of training videos for integration into our computer-based learning modules; working through early iterations of computer-based training module prototypes to identify usability challenges; and attending on-line workshops or conferences and bringing back written summaries and resources to share with the broader team.

To promote success in establishing partnerships between academic researchers and correctional settings, it is important for the principal investigator (PI) to have a cogent and compelling story of how they are well suited to engage in health-related research in corrections. This is especially true for those who have not previously worked in correctional settings. My early nursing experiences caring for incarcerated men in a small community hospital that served two state correctional institutions when the men’s healthcare needs exceeded the capacity of the prison infirmary is the key focus of my story. Through three years of direct nursing-care experiences, followed by nearly five years of supervising baccalaureate clinical nursing students who regularly were assigned to care for men from a state correctional institution who were patients in this hospital, my awareness arose to the tremendous chronic-disease burden experienced by this population and the opportunity to make a positive contribution was recognized. However, it was not until years later, when prepared with a research doctorate and experience conducting research with community-living older adults, that I was able to team with corrections colleagues to undertake research focused on enhancing the care of people who were growing old and approaching the end of life in prison.

In addition to establishing PI credibility, another important lesson is the need to demonstrate that the broader research team members (inclusive of researchers, staff, and students) have been sufficiently prepared to engage in corrections research is also essential. One of the essential first steps in preparing the team to engage in research focused on people who are incarcerated is to ensure that all are well versed in the ethics of research with this vulnerable population. Such training includes the general Collaborative Institutional review board Training Initiative (CITI), along with the supplementary module which provides specific instruction titled, Research with Prisoners (i.e., people who are incarcerated). CITI is a computer-based learning program to promote safe and ethical human subjects research (CITI; Penn State University, 2021). In addition, Good Clinical Practice (GCP) training is required for clinical trials that are funded by the National Institutes of Health (NIH, 2021). It is imperative the entire research team evidences a keen awareness of past atrocities in medical and healthcare research with people who are incarcerated. Specific training in this subject area helps to provide context for the especially stringent research guidelines when conducting research with people who are incarcerated and to ensure that such violations do not happen again.

Beyond formal university or government training programs, an additional lesson is the importance of the PI providing guidance about safety precautions, including suitable attire and demeanor, establishing appropriate boundaries with both corrections staff and people who live in correctional settings, and considerations regarding allowable research equipment and supplies. Consultation with each study site regarding permissible equipment and supplies at their facility is critical, because in correctional settings, researchers must secure advance permission for every item they wish to bring into the jail or prison.

Equally important is training one’s team in how to effectively partner with corrections colleagues in the field. Relationship building includes recognizing that the research team members are guests in the correctional facility and that expressing respect for and appreciation of correctional partners’ time and efforts in working with researchers can go a long way toward facilitating enduring collaborative relationships and conveying a spirit of “We are in this together with a goal of learning together.” One aspect of this “togetherness” is the practice of the research team visiting the correctional facilities and inviting key members of the corrections frontline staff and administrative team to visit the university setting. The latter exposes the correctional insiders to the system behind the university researchers and provides the researchers with the opportunity to show their appreciation to their correctional partners.

Identifying and teaming with corrections staff who are invested in the research project’s goals facilitates the development of insider champions who carry on the important work, thus sustaining any gains made long after the research project is concluded. Two possible roles in which collaborative partners in corrections may serve are participatory action research co-researchers or advisory board members. In my experiences, advisory board members have included administrators and staff members from research institutions where I currently conduct or previously conducted my research, content experts in geriatric and/or end-of-life care, individuals who previously worked in corrections settings and are now consultants or accreditation-site visitors in corrections, and returning citizens (i.e., previously incarcerated men and women).

Having more than one advisory board, each with a specific focus, works well. For example, in the research and development of computer-based training for enhancing care of those aging and dying in prison, establishing both a content advisory board and an implementation advisory board allows for matching members with particular board goals, keeping meeting size manageable, and preparing meeting agendas that are laser focused—qualities that are especially important during public-health emergencies, when meetings may be held only via videoconference. Across a program of research, maintaining some consistency is important for advisory boards; however, periodically adding new members to extend representation to new regions and infuse new experiences and views keeps boards vibrant.

Challenges to gaining access to conduct research in correctional settings can and likely will occur, and the frequency of the challenges can range from rarely to frequently. Investments in relationship building allow for regular dialogue between researchers and practitioners. In fact, investments in communication allow for shared strategizing on such things as how to best collect data such that methods are scientifically sound yet minimize the degree of burden placed on the corrections staff. Staying connected can occur through periodic updates on research progress via email, videoconferences, or visits to correctional facilities for brief presentations. Also, Department of Corrections statewide meetings for superintendents/wardens or correctional healthcare administrators can be opportunities for research teams to request time on the agenda to highlight partnering institutions, administrators, and frontline staff, as well as disseminate current research initiatives throughout the system, perhaps extending the research team’s reach and sphere of influence. Finally, social-media platforms, such as LinkedIn, and professional conferences also afford additional opportunities for university researchers and corrections professionals to communicate.

Research partnerships between correctional settings and academia can contribute to enhancing the care provided in correctional healthcare through varied mechanisms. First, as Kitt-Lewis, Loeb, Myers, Jerrod, Wion, and Murphy (2020) stated, “Experts in nursing research that is focused in corrections have the potential to positively shape the landscape of correctional healthcare” (p. 77). One such mechanism is instilling a sense of pride in corrections nurses through opportunities to be recognized as members of their nursing specialty. This also allows corrections nurses to convey a positive image of their specialty role (Hale et al., 2015) through affording them opportunities to share their expertise with research teams that include university faculty and students alike. As well, students who may be future corrections nurses are in a setting where they can learn, first hand, professional boundaries when working in correctional settings (Hale et al., 2015); learn the importance of social justice; witness faculty modeling the importance of upholding nursing standards of care when their care recipients are people living in prison; and emerge from their educational experience as professional nurses better equipped to be the change agents of the future. In addition, during their training in correctional settings—be that training in research or clinical practice—correctional staff have the opportunity to gain an appreciation for students’ enthusiasm, which can be contagious to the staff that they work with and the peers with whom they share their experiences (Hale et al., 2015). Finally, through Academic and Corrections Collaborative Partnerships, corrections health professionals on the front line and corrections leaders develop an appreciation for the value of research and the importance of applying relevant scholarly evidence in daily practice in prisons and jails (Drawbridge et al., 2018). Instilling corrections leaders and health care professionals with an appreciation of the value of research as well as trust in the PI and their research team can lead to greater likelihood of an academic researcher gaining access to conduct studies in this often hard-to-access setting.

Lessons learned from our collaboration are as follows: 1. Students and faculty can fill a need not often filled in this setting by providing needed educational and healthcare programming. 2. Always report how mutual goals are met and outcomes were measured. 3. Creating positive relationships with nursing and treatment staff is key to a successful collaboration.

Partnership 4: A University, a Spiritual Community, and a Jail Partner to Improve Life Skills: Labyrinth-Walking in Corrections

A collaboration between nursing faculty members at an eastern university and correctional nursing staff began in 2006. The early collaboration rotated junior nursing students (traditional and accelerated bachelors) to teach communicable disease education, develop and conduct biannual health fairs and work in the positive parenting program (Zucker & Rigali, 2008). With the introduction of the labyrinth walking program students were able to assist with the stress reduction classes, and evaluate the program’s effectiveness. Students underwent orientations by correctional and nursing staff prior to the rotation and were briefed on security measures. All students volunteered for this rotation of six hours weekly for 13 weeks as part of their Community Health Nursing practicum. The purpose of this clinical practicum was to provide students with the opportunity to plan and provide community-based nursing care and a population-based intervention.

A labyrinth is often referred to as a metaphor for life’s journey; it is a purposeful walking meditation. Participants engage in this activity by walking a designed single circuit path at their own pace. A 6-week curriculum was developed for teaching labyrinth walking, developed by both nursing and spiritual-life volunteer teachers. A certified facilitator prepared a comprehensive 6-week program focused on the following six themes: Introduction to the Labyrinth, Relaxation, Self-Esteem, Positive Thinking, Forgiveness, and Inner Peace. Each 30-minute session consisted of a didactic lesson, labyrinth walking, and the opportunity for quiet sitting and reflective writing, drawing, or thinking at the end. It became very popular with residents (i.e., people who are incarcerated), and sessions were rarely missed, despite there being no good time off (i.e., sentence reduction for good behavior) associated with the program.

In 2008 the university’s IRB and the correctional facility approved a pilot study aimed at measuring the effects of labyrinth walking on quality of life (QOL) and blood pressure (as a proxy for stress). To measure QOL, the authors used the 12-item Short-Form Health Survey Version 1 (Ware et al., 1996). Using a small sample, we were able to demonstrate clinical (decreased) changes in blood pressure after engaging in a 6-week labyrinth-walking program (Zucker & Sharma, 2012). Unfortunately, the 12 items Short-Form Health Survey used to measure QOL, did not capture the outcomes of interest. Qualitative data were gathered through journals completed at the end of each week’s session and concluded that the program encouraged positive emotions and thoughts, self-improvement, positive actions and intentions, reflective thoughts and self-awareness, and self-esteem. This information has been disseminated widely to correctional health audiences in the United States, Canada, and the United Kingdom. Across time, this program became so popular it was expanded from six to 12 weeks (Zucker, Villemaire and Cahhahan, 2013). These outcomes provided support for ongoing academic/practice partnerships in this correctional facility.

An important feature of the collaboration was for the college of nursing to apply for grant funding to provide labyrinth facilitation training for the correctional staff, to purchase a labyrinth mat and to begin to measure outcomes of using the labyrinth as a tool to reduce stress. The academic partners successfully acquired grant funding to support certification training for two key staff and the purchase of a 25-foot, indoor-use labyrinth mat. After about a year, some residents suggested creating an outdoor walking labyrinth in a remote part of the exercise yard. A proposal was developed and presented to the sheriff and academic faculty who worked with facility staff to develop a grant proposal to build a 40-foot outdoor labyrinth. The university recruited a master’s-level landscape architecture student to submit several building schemes and a building plan. This project not only broadened the labyrinth walking program but created a new opportunity for supporting landscape maintenance skills across the seasons. Five years of data provided substantial evidence that the participants found the program important and satisfying, wanted the program to be longer, and particularly appreciated the education session on forgiveness.

Discussion

As shown above, academic-practice partnerships (APPs) in correctional nursing as noted by the AACN’s Guiding Principles ( Box 1) can strengthen nursing research, education and practice as well as benefit individuals and staff within the carceral system by providing needed additional resources for care, enhancing professional development for all correctional health staff, and enhancing recruitment and retention which contribute to the growth of the workforce (AACN, 2012).

Nursing is pivotal to the correctional healthcare team and critical to ensuring access to appropriate healthcare for a population that likely has experienced considerable health and healthcare disparities (Schoenly, 2013). There has been an evolution in correctional nursing, and many correctional systems have and continue to build a stronger foundation for nursing practice. This is timely. The IOM report in 2011 and NASEM in 2021 continue to provide guidance for the future of nursing, and correctional nursing as a specialty has a responsibility to follow this blueprint.

At one point, carceral settings were viewed as an unlikely partner with academia. The trajectory has changed for schools of nursing as access to clinical sites has become more limited and greater emphasis has been placed on public-health curricular topics; taken together, these have served to increase interest in correctional health settings. While there has been a shift in attitude toward non-traditional clinical training placements (IOM, 2016; Campaign for Action, 2019), a lack of knowledge regarding the specialty and carceral settings, combined with potential personal biases may act as barriers to these learning environments (Findlow, 2012). Efforts to enhance professional practice and increase the presence of academically prepared nurse leaders, along with the development of National Commission on Correctional Health standards, American Nurses Association Correctional Nursing Scope and Standards for Practice (2021), and other national nursing certifications through the American Nurses Credentialing Center have contributed to the evolution of this nursing specialty.

APPs have existed for a few decades, but successful partnerships are limited in the literature (Kang-Yi, 2019), particularly regarding implementation and sustainability in carceral settings (Shelton, Maruca & Wright, 2020; Maruca & Shelton, 2015). What should be emphasized is the time and persistence required by nursing faculty to initiate and sustain these clinical partnerships. The challenges of instituting a clinical experience in a nontraditional environment with a priority on safety and security can be onerous making these difficult to achieve without sufficient academic support. Yet, there are true rewards for student learning and the development for the future nursing workforce.

In this article, we have built on previous work and partnerships between corrections and academia, extending the idea of providing clinical experiences for students, offering on-site clinical support through the university or dual appointments, encouraging research to build nursing science and disseminate knowledge, and highlighting the need to respond to the call from national nurse leaders to foster and promote academic partnerships with the practice setting.

Conclusion

The uniqueness of correctional nursing as a specialty, recruitment and retention challenges faced by correctional institutions, enhanced nursing leadership, and the need for more sites for academic clinical placement have created the opportunity for partnerships. We have highlighted collective opportunities for APPs that can build on the richness of the correctional health experience, assist correctional systems and schools of nursing with access to needed resources, and for improving care within corrections. Long-term sustainability is based on mutually beneficial outcomes, strong communication, and ongoing collaboration.

Efforts are needed to strengthen the bond of APPs to benefit the practice of correctional nursing and patient care. The next steps are to develop an action plan to heighten awareness of the benefits of carceral partners and the fertile ground for nursing research. A strategy to disseminate information on these benefits needs to be targeted to deans of schools of nursing, departments of corrections, and their clinical nurse leaders and funding agencies. Advocacy for these partnerships can gain momentum from the Future of Nursing movement in the United States.

Highlights:

• Including students in clinical rotations and research activities is a correctional environment is essential to meet the needs of this population, decrease stigmatization and increase compassion.

• Clinical experience in correctional settings can provide a meaningful learning experience for nursing students at all levels.

• Research partnerships between correctional settings and academia can contribute to enhancing the care provided in correctional healthcare through varied mechanisms.

• Correctional health offers opportunities for faculty to grow clinical, research, leadership and advocacy skills.