The nurse’s ability to practice in the profession is largely determined by his or her educational preparation. But regardless of basic educational training, nurses generally are not prepared to perform adequately in correctional health care settings, according to the National Council of State Boards of Nurses.

How nurses practice in these settings depends upon many factors, as evidenced by the following case study, which was developed from stories by nurses practicing in correctional health care settings. There are many lawsuits with similar fact patterns that support the notion that the case study is not pure fiction.

Eight nurses provided health care coverage to 1,570 female inmates in a medium-security correctional facility in a Midwestern state. Three of the nurses were associate degree registered nurses with less than two years of correctional nursing experience. The other five were licensed vocational nurses with less than one year of correctional experience.

At the time of trial, the remaining health care staff consisted of the health services director, the nurse administrator, one full-time physician, one part-time gynecologist and two outside consultants who collectively practiced general medicine at the prison clinic three hours a day, four days a week. In addition, dermatology, neurology, podiatry and optometry clinics were held on an irregular basis several times a year. Hospital services were provided by community facilities.

During sick call, one nurse listened to requests for care and, without standing orders, protocols or a physician’s order, dispensed medications during the clinic’s one-hour session held twice daily in one of the prison’s residence halls.

The nurse’s assessments were based on cursory glances at inmates in line outside a locked and barred cashier’s window. Because of this physical barrier, there was no opportunity for a physical examination to determine the nature and extent of the patient’s ailment. The average time a nurse spent with each inmate was 15 to 20 seconds, and based on that nurse’s assessment notes of complaints, another nurse assigned priorities in scheduling appointments with physicians.

The eight nurses operated the lobby clinic; prepared the physician appointment schedules; called correctional officers to escort patients to the clinic for appointments; conducted rounds in the reception, segregation and infirmary buildings; and assisted during all physical examinations. They also responded to emergency calls from the correctional officers, handled routine health care inquiries, and conducted the initial interview and screening of new admissions.

One issue the court will address is whether physicians, nurses and correctional personnel interacted effectively to ensure that prescribed health care services were provided promptly. In undertaking this inquiry, the court will focus on nurses and the services they primarily provide.

According to one leading correctional nurse expert, nurses with at least a baccalaureate degree in nursing and who practice in correctional health care at least three years become more competent because they tend to adhere closer to their legally defined scope of practice. They also tend to question ethical and environmental issues that may adversely impact their practice.

Even if the nurses in this case had the appropriate education and training for the decision-making needed, the physical environment in which health care was administered affected the quality of care delivered. For example, the physical barriers that separated the nurse from inmates did not allow for the performance of complete physical examinations.

Performing full initial nursing assessments is a crucial role of RNs, as is the secondary nursing assessments performed by LVNs. Having no assessments, or severely restricted assessments, adversely affects the quality of interventions inmates receive for their health problems. Assessment data is the foundation upon which nursing care is planned and executed. When nurses fail to obtain this data, they severely comprise patients’ safety, violate their nursing practice act and therefore jeopardize their ability to continue in practice.

The ethical principle that underlies all nursing practice is respect for the worth, dignity and rights of patients. This principle has been codified in nursing practice acts and state laws in that failure to maintain confidentiality of patient information is considered unprofessional conduct and a tort. In this case, nurses routinely violated patients’ confidentiality during sick call and lobby clinic because nurses obtained medical information in the presence of other inmates who were in line.

Medication dispensing is a violation of state nursing practice acts and pharmacy acts. Nurses who dispense medications are subject to discipline by both state boards of nursing and pharmacy.

Nurses practicing in this environment did not have an adequate number and appropriate skill-mix of nurses to administer care that followed minimum nursing standards. They were trying to do too many things in too many areas to be effective. Patients’ well-being was at risk. Whether nurses were using any nursing judgment in continuing to multi-task in this environment is questionable and makes them susceptible to investigation by the board of nursing and the court system.

Correctional officers’ control over the movement of inmates extends to their access to health care and to nurses’ access to inmates. Correctional officers should be trained to respond appropriately to inmates’ health care complaints, and available to escort inmates from housing to clinic areas to meet scheduled health care appointments.

Additionally, nurses must be proactive in advocating for patients by participating in the development and implementation of nursing policies.

Given the demands on nurses in correctional environments, I suggest that they take the following steps:

• Seek support from nursing schools and correctional systems in obtaining, at minimum, baccalaureate degrees in nursing
• Demand adequate training so that they may function more effectively and appropriately in these settings
• Insist on receiving and participating in regularly scheduled in-service education that emphasizes issues of correctional health care, ethical standards, security and care delivery in these compromising environments

I also encourage nurses to collaborate with correctional officers to attain health care and security goals without jeopardizing the delivery of nursing care that meets at least minimum standards.

Correctional officials must take responsibility, too. I recommend that they seek input from nurses on how environmental factors, including their action or inaction, contribute to the quality of health care provided to inmates. They also must provide infrastructure that supports the goal of quality nursing care for inmates.

By pursuing this goal proactively, nurses, correctional officials and other stakeholders can modify the provision of correctional health care to improve inmates’ general health, reduce health care costs and decrease related litigation.