Special Focus: Nursing in the Correctional Milieu
Practicing nursing in a correctional setting is a bit like stepping through ‘the looking glass' — everything is the same, yet different.
— Sue Smith (2005)
Nurses, as the largest group of health professionals working with persons in the criminal justice system, have a significant role to play in the timely identification, treatment and management of complex health and psychosocial concerns experienced by this group. Throughout history, nurses have selflessly provided care to the most vulnerable populations in society; however, before the late 1960s to early 1970s, very few nurses considered working with incarcerated persons. Since then, correctional nursing has slowly and methodically emerged as a niche specialty, one that has seen nurses embrace professional role development in their pursuit of providing incarcerated persons with competent, caring, evidence-informed nursing care. Correctional nurses are highly skilled specialists whose daily practice addresses primary, secondary and tertiary intervention strategies, from health promotion to end-of-life care and everything in between (Goddard et al. 2019; Peternelj-Taylor and Woods 2020; Shelton et al. 2010). However, as a workforce they remain largely hidden and their professional contributions concealed behind prison walls, invisible to the public and the larger nursing community. Akin to the population they serve, they are quite simply "out of sight, out of mind." This old adage rings true for Goddard et al. (2019), who, in a discussion of professional identity in correctional nursing, concluded that such "physical ‘hiddenness' appears to translate into a professional ‘hiddenness'" (p. 163).
In this issue, articles that embody the complexity and diversity of nursing care in correctional environments are showcased, highlighting the contributions of nursing leaders from across Canada and the United States. The papers featured herein represent unique educational initiatives, clinical practice contexts and research perspectives. Together their contributions challenge the notions of physical and professional "hiddenness" (Goddard et al. 2019) as they unmask the strides being made in the ongoing maturation of this nursing specialty.
Given the complexity of healthcare challenges experienced by persons in the criminal justice system, secure custodial environments such as jails, prisons, correctional facilities and forensic mental health settings provide a fertile climate for educational experiences that are rich in variety and content. And although nursing students' clinical placements in such environments have increased in recent years, they typically are the exception rather than the norm, which inevitably impacts recruitment to this specialty as students are quite simply unfamiliar with the opportunities for employment within this milieu (Goddard et al. 2019; Peternelj-Taylor and Woods 2020).
In "Nursing Leadership Implications for Clinical Placements in Corrections," Terblanche and Reimer-Kirkham (2020) examine the extant literature addressing nursing education within correctional environments and present a secondary analysis of qualitative interviews conducted with undergraduate nursing students regarding their clinical placements in corrections. Emergent themes, poignantly illustrated with students' observations and insights, include caring for marginalized populations, hope and restorative justice and the expanded role of nurses in caring for this vulnerable population. Emphasizing the importance of strong administrative and faculty support, the authors provide recommendations on how to successfully actualize student learning in correctional settings and conclude that non-traditional transformative clinical experiences have the "potential to shape our future nurse leaders."
Collaborative partnerships between academia and corrections go beyond clinical placements as they have the potential to more fully contribute to professional role development within corrections, enhance the professional identity of the correctional nurse and attract "fresh blood" (Goddard et al. 2019: 168) into the specialty. The importance of partnerships between academia and corrections is further illustrated in Butler and Mallet-Boucher's article (2020), "Healthcare in Secure Environments: Leading a Collaborative for Forensic Nursing Education." A two-day Knowledge Forum, hosted by the University of New Brunswick's Faculty of Nursing, brought together experienced nurse educators and key nursing leaders responsible for the healthcare of persons in the criminal justice system. A primary goal of the Knowledge Forum was to explore contemporary nursing practice within this domain and articulate nurses' unique learning needs. It quickly became evident that a gap in nursing education existed, one particularly relevant to continuing profess-ional development of nurses currently practising within provincial correctional facilities, federal prisons and secure hospital-based forensic mental health treatment settings. Through the concerted efforts of the nursing leaders in attendance, a blueprint for an online certificate program in forensic nursing emerged. The development of the certificate program followed and will be implemented later this year.
This offering is particularly noteworthy as nurses who have chosen to work with persons in the criminal justice system, within secure custodial environments, "have often done so at the expense of professional esteem" (Peternelj-Taylor and Panosky 2013: 2). Having the certificate program hosted by the university endorses correctional nursing as a specialty vis-à-vis more mainstream nursing specialties and, perhaps more importantly, reinforces and validates the professional identity of correctional nurses within the broader nursing community.
Clinical Practice Contexts
The provision of healthcare services within these closed and professionally isolated environments has long been overshadowed by custodial and security concerns, where competing interests between custody (confinement and security) and caring (provision of healthcare) prevail and matters of security often take precedence over nursing care (Holmes 2005; Peternelj-Taylor 2019). Recent amendments to the Corrections and Conditional Release Act (Bill C-83) have strengthened the provision of correctional healthcare by supporting the professional autonomy and independence of registered healthcare professionals, "including their ability to exercise, without undue influence, their professional judgement in the care and treatment of inmates," and include a "patient advocacy function for the provision of care that advances health and well-being" (Correctional Service Canada 2019). It will be interesting to see how these amendments play out in the day-to-day practice of correctional healthcare.
In "Improving Care at Correctional Facilities: Listening, Learning and Creating Change from a Patient Care Quality Office," Simon et al. showcase the emerging role of the nurse as a patient care quality specialist (PCQS). In 2017, provincial correctional health services in British Columbia (BC) became part of the Provincial Health Services Authority (PHSA). As a result, persons incarcerated in provincial corrections in BC now have equitable access to the PHSA complaint process. This role, comprehensive in nature, involves investigating healthcare-related complaints; providing information to correctional leaders and the complainant; and highlighting complaint trends, gaps and quality improvement initiatives of relevance across multiple correctional sites. The authors discuss the challenges they initially encountered in adapting their role to a correctional environment, emphasizing the importance of being external to the correctional system and building relationships with correctional authorities, healthcare managers, stakeholders and advocacy groups. Through this unique nursing role, PCQSs are making a noteworthy contribution to competent, professional correctional healthcare.
Unlike BC, where correctional health services fall under the auspices of the PHSA, healthcare in provincial correctional facilities in Ontario is the responsibility of the Ministry of Community Safety and Correctional Services. Drawing upon their previous research conducted in Ontario provincial correctional institutions, Almost et al.'s (2020) article, "The Role of Nursing Leadership in Ensuring a Healthy Workforce in Corrections," provides readers with a cogent overview of the many challenges encountered by nurses in corrections, which often culminate in reports of emotional exhaustion and burnout among staff and managers alike. With reference to contemporary literature and the sombre realities of clinical practice, the full range leadership model is endorsed as a foundation for effective leadership in correctional environments and a means to creating, maintaining and promoting a healthy correctional nursing workforce. Although this model holds promise, the authors conclude that research is needed to explore nursing leadership in the correctional milieu in order to contribute to evidence-informed interventions, with the ultimate goal of facilitating and enabling a healthy workforce in correctional institutions across Canada.
The ongoing evolution of correctional nursing as a specialty is dependent on nursing leaders to promote and nurture the development of a nursing culture that embraces nursing research; facilitate the translation and interpretation of research relevant to practice within secure custodial environments; and engage in the collaborative identification of research questions for further study (Peternelj-Taylor and Woods 2020; Schoenly 2015). Two uniquely different papers of concern from a nursing research perspective are included in this special issue: one focuses primarily on the challenges of conducting research in a correctional environment and the other is a scoping review of mother–child programs for incarcerated women.
In "Barriers to and Strategies for Gaining Entry to Correctional Settings for Health Research," Kitt-Lewis et al. (2020) share their trials and tribulations and lessons learned on how to gain and maintain access to correctional facilities when conducting nursing research. Drawing on their experiences leading a large-scale research project designed to provide correctional personnel with education and training in older adult and end-of-life care across several prison systems in the United States, the authors offer sage advice in the form of key lessons learned, critical insights gained and strategies for success. Prisons were never designed for an aging, infirm population, yet their numbers are increasing disproportionately among correctional populations, thus underscoring the creative efforts needed to successfully embrace and enhance a research agenda in this area. As outlined by these authors, gaining access to conduct research in correctional facilities can be particularly challenging, albeit necessary, and their "lessons from the field" contribute to best practices for others to follow.
The past decade has also seen a marked increase in the number of women confined to correctional environments, many of whom are of childbearing age. In "Mother–Child Programs for Incarcerated Mothers and Children and Associated Health Outcomes: A Scoping Review," Paynter et al. (2020) explored the literature to systematically map out the characteristics of residential mother–child programs, their eligibility criteria and resulting maternal and child health outcomes. Twelve countries across five continents were represented in the mapping of existing literature. However, variations in clinical contexts, the high morbidity experienced by this population and limitations in methodological rigour made it difficult for the authors to make comparisons and draw conclusions. Interestingly, no Canadian studies were found, which was somewhat perplexing as mother–child programs within federal prisons for women have been in place for a number of years. Although this dearth of research in Canada may suggest little concern for this marginalized population, the scoping review highlights opportunities for correctional nurses to assume leadership roles in caring for the many health challenges experienced by this population. Careful consideration of innovations in interprofessional practice and research, facilitation of community reintegration and the adoption of advocacy measures addressing the injustices of incarceration are imperative to guide evidence-based practices in caring for this vulnerable population.
Correctional Nursing in the Wake of COVID-19
In the last two decades, correctional authorities have dealt with severe acute respiratory syndrome (SARS) in 2003 and the H1N1 pandemic in 2009. Correctional nurses, then and now in the wake of COVID-19, are directly involved in infection prevention and control measures, clinical assessment, case finding, management and referrals, and work collaboratively with correctional staff, as well as local, provincial and federal public health authorities. As COVID-19 begins to take hold in prisons across Canada, correctional authorities are responsible for the health and safety of their employees and those in custody, as well as the maintenance of safe and secure environments and the safety of the public at large (Correctional Service Canada 2020). However, COVID-19 infection control procedures, such as physical distancing being touted by public health professionals for community-dwelling citizens, are all but impossible in correctional environments, where overcrowded facilities with double and triple bunking are the norm. Given the devastating reality of COVID-19 and the confined architectural living spaces occupied by incarcerated persons, the oncoming tsunami is particularly frightening. Family members and prison advocates alike are pushing for de-incarceration of low-risk, non-violent, medically vulnerable and aged offenders as a humane response to the prevention of a public health disaster (Ivison 2020). In general, the public has a less than sympathetic view of persons who have come into conflict with the law, and correctional nurse leaders may find themselves developing policy and advocating for healthcare resources that promote the health and well-being of those in their charge.
It has been an honour and a privilege to serve as guest editor for this special issue dedicated to nursing in the correctional milieu. The articles featured in the pages that follow draw attention to the ways in which nursing leaders are advancing the professional identity of correctional nursing as a unique specialty. I am grateful to the authors for acknowledging the challenges common to this emergent specialty and for discussing practical solutions, innovations and opportunities for nurses to adopt a leadership role in the care of incarcerated persons. As nurses traverse the interface of the healthcare system and the criminal justice system, they may stumble. When so much of what they do is eclipsed by correctional mandates, the importance of remaining true to their professional nursing roots is critical for nurses to embrace and nurse leaders to emulate.
About the Author(s)
Cindy Peternelj-Taylor, RN, BScN, MSc, DF-IAFN, Professor, College of Nursing, University of Saskatchewan, Distinguished Fellow, International Association of Forensic Nurses, Saskatoon, SK
Almost, J., W. Gifford, L. Ogilvie and C. Miller. 2020. The Role of Nursing Leadership in Ensuring a Healthy Workforce in Corrections. Nursing Leadership 33(1): 59–70. doi:10.12927/cjnl.2020.26191.
Butler, L.J. and M. Mallett-Boucher. 2020. Healthcare in Secure Environments: Leading a Collaborative for Forensic Nursing Education. Nursing Leadership 33(1): 25–34. doi:10.12927/cjnl.2020.26194.
Correctional Service Canada. 2019. Interim Policy Bulletin 651. Retrieved April 15, 2020. <https://www.csc-scc.gc.ca/acts-and-regulations/651-ipb-en.shtml>.
Correctional Service Canada. 2020. COVID-19. Retrieved April 2, 2020. <https://www.csc-scc.gc.ca/001/006/001006-1003-en.shtml>.
Goddard, D., K. de Vries, T. McIntosh and C. Theodosius, C. 2019. Prison Nurses' Professional Identity. Journal of Forensic Nursing 15(3): 163–71. doi:10.1097/JFN.0000000000000239.
Holmes, D. 2005. Governing the Captives: Forensic Psychiatric Nursing in Corrections. Perspectives in Psychiatric Care 41(1): 3–13. doi:10.1111/j.0031-5990.2005.00007.x.
Ivison, J. 2020, March 31. COVID-19 Could Be a Get Out of Jail Card for Canada's Low-Risk Prisoners. National Post. Retrieved April 2, 2020. < https://nationalpost.com/opinion/john-ivison-covid-19-could-be-a-get-out-of-jail-card-for-canadas-low-risk-prisoners>.
Kitt-Lewis, E., S.J. Loeb, V. Myers, T. Jerrod, R.K. Wion and J.L. Murphy. 2020. Barriers to and Strategies for Gaining Entry to Correctional Settings for Health Research. Nursing Leadership 33(1): 71–80. doi:10.12927/cjnl.2020.26190.
Paynter, M., K. Jefferies, S. McKibbon, R. Martin-Meisener, A. Iftene, and G.T. Murphy. 2020. Mother–Child Programs for Incarcerated Mothers and Children and Associated Health Outcomes: A Scoping Review. Nursing Leadership 33(1): 81–99. doi:10.12927/cjnl.2020.26189.
Peternelj-Taylor, C. 2019. Care of Persons under Forensic Purview. In W. Austin, D. Kunyk, C.A. Peternelj-Taylor and M.A. Boyd, eds. Psychiatric & Mental Health Nursing for Canadian Practice (4th ed.) (pp. 919–34). Wolters Kluwer.
Peternelj-Taylor, C., and D. Panosky. 2013. Advancing Forensic Correctional Nursing. Journal of Forensic Nursing 9(1): 1–2. doi:10.1097/JFN.0b013e3182867083.
Peternelj-Taylor, C. and P. Woods. 2020. Correctional health. In L.L. Stamler, L. Yiu, A. Dosani, J. Etowa and C. van Daalen-Smith, eds., Community Health Nursing: A Canadian Perspective (5th ed.) (471–88). Pearson Canada.
Schoenly, L. 2015. Research Priorities in Correctional Nursing Practice: Results of a Three-Round Delphi Study. Journal of Correctional Health Care 21(4): 400–407. doi:10.1177/1078345815600257.
Shelton, D., C. Weiskopf and M. Nicholson. 2010. Correctional Nursing Competency Development in the Connecticut Correctional Managed Health Care Program. Journal of Correctional Health Care 16(4): 299–309. doi:10.1177/1078345810378498.
Simon, M., K. Salamat and K. Gustavson. 2020. Improving Care at Correctional Facilities: Listening, Learning and Creating Change from a Patient Care Quality Office. Nursing Leadership 33(1): 52–58. doi:10.12927/cjnl.2020.26192.
Smith, S. 2005, February. Stepping through the Looking Glass: Professional Autonomy in Correctional Nursing. Corrections Today 67(1): 54–56, 70.
Terblanche, L. and S. Reimer-Kirkham. 2020. Nursing Leadership Implications for Clinical Placements in Corrections. Nursing Leadership 33(1): 35–51. doi:10.12927/cjnl.2020.26193.
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