Ethical Dilemmas of Correctional Nursing

[ashagreyjoy]

As a Correctional nurse, I am providing care for a unique population of folks who have violated our society's social or legal contract. Some of them have violated it many times. If someone has been a heroin addict and stealing cars since 1997, only that person can decide, "OK I am tired of this lifestyle, I dont want to go to jail anymore, Im going to treatment, and make a change in my life". Its not easy, its a lot of hard work, some mental illnesses are not recoverable, and there are not enough resources for mental illness in society. Corrections to a large extent sees a lot of patients whose lives have been destroyed by these factors.

Reality is, my opinion, our justice system is not for rehabilitation. Our justice system currently exists 1. for punishment 2. to separate dangerous offenders away from the rest of society. Its primary goal is not to rehabilitate people. I think it would be difficult to go to work every day inside a punishment/public safety holding facility if I fundamentally disagreed with that reality. And the justice system itself (legal system, courts, etc) which sentences people to the punishment facility is technically a legislative arrangement. Jail and prison are just the holding tank and the end result. The business end of all of this is the legal system, not the building where the individuals are kept. Legislation drives all of these policies. But I digress.

Many of your patients will be awaiting legal proceedings or already convicted of some very abhorrent behavior. Keep in mind that (in my facility) fully 10% of the inmate population are in PC (protective custody) meaning they are awaiting trial for sex offenses or have prior sex offenses which make them a target for violence from other inmates. I have taken care of many, many, many patients whose face I just saw on the news for charges/& or convicted of molesting children. Personal feelings and judgements good or bad cannot come into patient interactions. The "I think this patient is innocent/guilty" thing drives me crazy...its so unprofessional. I do not care if that person is guilty or innocent, I dont care if they are a sex offender, it has nothing to do with my job as a nurse.! I work with one nurse who gets all tangled up in her feelings about the innocence of inmates and the injustice blah blah. It is beyond aggravating. I want to tell her every time I talk to her: if you want to work in Justice, please go to law school. There is a profession for persons who are practicing the field of justice and judgement, and it is not nursing.

The Corrections officers do not want to pepper spray or tase people...any use of force means they have to do lots of paperwork, on top of it puts them at risk for injury or death. If you think Corrections was unneccessarily violent with their use of force, you could file a complaint. Its all on video and chances are there were 10 other CO's there when it happened as witnesses. All their uses of force are investigated. I have never witnessed abuse by our Corrections staff. They are professional safety officers, like I am a professional nurse, but their role is to maintain safety and order and inmates who obey the rules have no problems. They want everything to run smoothly and safely. Lots of them have been there for like 20 years + and I work hard to cultivate their respect.

A key point in Corrections health its not you vs. the system....you are the system. Its not about being in a position to be "fighting the system" for mistreated persons who "the system" has failed to properly rehabilitate. Corrections health staff are *part of* the system. When my schizophrenic patient gets sent to segregation, it is my expected job to create a whole care plan for that person to ensure their safety and proper care...and there is a whole protocol in place for it. There is plenty of room for providing nursing care with respect and compassion with the appropriate boundaries.

[Hoozdo, ADN]

**And if I speak up about abuse at work will I be punished for it? Will I be working with providers who don't care about the health and safety of my patients?**

Yes, you will be punished for it in an offhand way. The management might start looking for ways to fire you because you cause too much trouble.

As far as providers, I have spent about 3 years in corrections and I have never met a provider that didn't care about the patients. Most of them bend over backwards to provide excellent care with the resources given.

I know in my jail system, (second largest in the country), as an LPN you won't have much time to be involved in patient care. You will be busy passing out thousands of medications and that is it.

[Trampledunderfoot, LPN]

I have never run into someone wanting to sweep abuse under the rug. I have actually never run into abuse at "my" prison. My experience is that patients at nursing homes are treated more disrespectfully, and with less kindness.

Keep your eyes open, though, and learn to discern what is real. Offenders regularly feel they are/have been abused by medical staff and COs, when they have not been. They also like to pretend there was abuse for their personal gain. I'm not saying abuse between staff/offenders is impossible, I'm just saying that my experience has been that if there is abuse, it was between two offenders. Keep your eyes open and collect all the facts before jumping to conclusions.

At times you do have to fight the system to provide the right care, but this is because of staffing shortages and some unbelief from doctors etc d/t malingering and story telling on the offender's part. Be ready to display all the evidence to prove your case, make sure your assessments are thorough and your documentation is great. I have never had to fight the system because abuse was accepted. There are many laws and policies that go above and beyond to protect the offenders from mistreatment, sometimes to the detriment of the staff. Sometimes the offenders are given the benefit of the doubt.

A lot of the horrors of prison seem to be glamorized through TV. Solitary is not very solitary (again, in my experience). I work in ad seg, and they are catered to more often than not. It only takes a little whining to get your way.

And I have found that a little pepper spray can do a lot of good, and usually very little harm.?

[Overcast]

Is it difficult getting hired o to corrections as a new grad? Everywhere I read states the eligibility requires a couple years of nursing experience; in particularly in a specialty, plus certain certifications, etc.

I will be graduating with an ADN from USC/LA County nursing school (LA County Hospital) and then I will have a BSN a year later.

I would like to get my pension started. Do I need to wait to apply until I have years experience?

Did you just apply online as a random person? Did you follow up in person or over the phone?
How long did it take to hear back once applying online?

I have a 1203.4 on my record, which is a dismissal from an old case decades ago. County overlooks this. Would federal?

Thank you!

[ocean.baby]

You have been watching too many prison movies.

I have worked in corrections 25 years, and have never seen physical abuse from staff towards the inmates. I am not saying it hasn't happened, but I have not seen it. Verbal abuse - yes, but rarely, and not to the point I had to report it. Most officers are professional. They want to go to work, do their job, be safe, and go home at the end of the day to their family. Inmates treat medical staff far different than they do the officers, they want something from us and are usually nice. That is NOT how they treat security.

Medical staff give inmates what they need, not what they want. You want an extra mattress because yours is too thin? That is a security issue, they assign mattresses. You need an extra mattress because the thin one makes your back hurt, and security told you to get a medical release? Well, we are not in the mattress business. There are strict guidelines as to who gets a second mattress and they are few and far between. You do not qualify.

You need 5 packets of antibiotic ointment because you have cuts on your hands? Hmmmm, or do you really want it to masturbate with?

You have a cut on your finger and need some bandaids? Well, bandaids can be used to make shanks, the cut isn't bad, just wash it with soap and water then keep it clean and dry.

An inmate comes to pill call and looks like hell - pale, diaphoretic, weak. When questioned he says he isn't feeling good, his stomach really hurts. You have never heard him complain before in the 6 months you have seen him daily. You have the officer take him to the infirmary, or the nursing office on that unit, get his vitals and assess him. BP is low, pulse is high, can't get an O2 sat. You call the doctor and get orders to start an IV, put oxygen on him, and ship him to the ER. You might have saved his life.

The best nurses only focus on medical care and issues. You need to have a good working relationship with security and develop mutual respect. When they tell you something, listen, they know what they are talking about. They will keep you from getting killed if you pay attention to them and do not take offense when they tell you that you did something stupid or out of line.

Inmates do not receive the standard of care that a congressman with great insurance does. They have to receive the same as the community standard of care. If you are a single mom working at McDonalds, no insurance, and have a bad tooth - you can afford to get it pulled but not a crown. Same with inmates. You have a scar across your face from a car accident 5 years ago - but you can't afford to have plastic surgery. Same with inmates. You have cancer, you have a heart attack - you get the treatment you need. Same with inmates.

Go into the facility wanting to give good care, not looking for any perceived problems. Please keep your mouth shut until you learn the system unless it is a life threatening situation. Watch and learn, you will do fine.

[Orca, ADN, ASN, RN]

Your opening statements sound like someone ripe for compromise. You talk about caring about "the health and quality of life of the most marginalized and vulnerable members of our society", then you act as if you expect to find abuse and neglect before you even walk through the door. Not to say that it never happens, but I have not seen either in 19 years of working behind the fences in the medical area. What I have seen is inmates who go to great lengths selling their stories of such to the people who they believe to be the most gullible and naïve members of the staff.

There is an article tacked to the main bulletin board in our nurse station that is entitled, "You Will Be Sued for Doing the Right Thing". If you are in this business long enough, you will learn that inmates will make repeated allegations against you and your coworkers, and that 98 percent of the time, the stories are exaggerated or fabricated.

["nursy", RN]

I have worked in corrections and agree completely with all the above posters. Rehab and recidivism are huge issues in the U.S. but your job as a corrections nurse are not going to magically revolutionize the system. If you want to change the system, go back to school and become a lawyer or an activist.

All the providers I worked with were genuinely compassionate and caring. Unfortunately, some of the worst issues I encountered were from my fellow nurses. It was almost impossible to get fired from my prison, so there was drug diversion, malingering, back stabbing, and a host of other issues that eventually drove me out. But the actual job of corrections nursing, I very much enjoyed, and felt like what I did, really mattered.

[Orca, ADN, ASN, RN]

Inmates will also insist that they have all kinds of undiagnosed conditions, and that their rights are being violated because they aren't being treated. I was once sued by an inmate (I'm a DON, so I get sued every time that the medical department is named) because we weren't treating an obscure neurological condition that she claimed to have that was not diagnosed by anyone who we obtained medical records from. Our contract neurologist didn't find it either. I looked it up, and the main treatment for this condition is opioids. She is an opioid addict. She found a condition that few people knew about or understood that would feed her addiction, she claimed to have it, and she was hoping that we would treat it without verifying it. When we didn't, she sued us. She lost.

Inmates will try to convince you that they aren't getting what they need, when in fact the issue is that they are not getting what they want. I was sued by another inmate over a different medication issue. He was insistent that two medications that we removed from our formulary because they have trade value on the yard and had created an underground economy were the only medications that worked for him. Neither drug was listed by any source that I could find as a treatment for his condition. We replaced the drugs with drugs in the same classes as the ones that he was on, but he was still insistent that they "don't work". Most likely we took away his income, and he was hoping that the court would force us to give it back to him. The court didn't bite.

This is a work environment unlike any other. We have to consider issues that would never come up in a hospital setting. Our clientele is almost without exception manipulators. They weren't put here for their honesty. Behind that backdrop, we have to separate the legitimate issues from the fabricated ones, and it isn't for everyone. If you come in with the attitude that all inmates are neglected, they will eat you alive. They will have you twisted in so many different directions that you won't know which end is up.

Welcome to my world.

[lincoln77, RN]

Its almost the opposite of what you think. I agree with a lot of what others said; I really have not seen abuse of prisoners. There was one officer who yelled a lot. Other than a few that yell too much, there's nothing I've seen that comes close to abuse. In fact, it seems the whole system is really accommodating. Sometimes this becomes dangerous. Where I work they are extremely reluctant to restrain inmates in the psych section. I had one permanently damage his eye by stabbing it with his finger. Custody still will not use restraints on him, even when he asks for restraints.

[Kooky Korky, BSN, RN]

On 1/8/2020 at 5:25 AM, ashagreyjoy said:

As a Correctional nurse, I am providing care for a unique population of folks who have violated our society's social or legal contract. Some of them have violated it many times. If someone has been a heroin addict and stealing cars since 1997, only that person can decide, "OK I am tired of this lifestyle, I don't want to go to jail anymore, Im going to treatment, and make a change in my life". Its not easy, its a lot of hard work, some mental illnesses are not recoverable, and there are not enough resources for mental illness in society. Corrections to a large extent sees a lot of patients whose lives have been destroyed by these factors.

Reality is, my opinion, our justice system is not for rehabilitation. Our justice system currently exists 1. for punishment 2. to separate dangerous offenders away from the rest of society. It's primary goal is not to rehabilitate people. I think it would be difficult to go to work every day inside a punishment/public safety holding facility if I fundamentally disagreed with that reality. And the justice system itself (legal system, courts, etc) which sentences people to the punishment facility is technically a legislative arrangement. Jail and prison are just the holding tank and the end result. The business end of all of this is the legal system, not the building where the individuals are kept. Legislation drives all of these policies. But I digress.

Many of your patients will be awaiting legal proceedings or already convicted of some very abhorrent behavior. Keep in mind that (in my facility) fully 10% of the inmate population are in PC (protective custody) meaning they are awaiting trial for sex offenses or have prior sex offenses which make them a target for violence from other inmates. I have taken care of many, many, many patients whose face I just saw on the news for charges/& or convicted of molesting children. Personal feelings and judgements good or bad cannot come into patient interactions. The "I think this patient is innocent/guilty" thing drives me crazy...its so unprofessional. I do not care if that person is guilty or innocent, I don't care if they are a sex offender, it has nothing to do with my job as a nurse.! I work with one nurse who gets all tangled up in her feelings about the innocence of inmates and the injustice blah blah. It is beyond aggravating. I want to tell her every time I talk to her: if you want to work in Justice, please go to law school. There is a profession for persons who are practicing the field of justice and judgement, and it is not nursing.

The Corrections officers do not want to pepper spray or tase people...any use of force means they have to do lots of paperwork, on top of it puts them at risk for injury or death. If you think Corrections was unneccessarily violent with their use of force, you could file a complaint. It's all on video and chances are there were 10 other CO's there when it happened as witnesses. All their uses of force are investigated. I have never witnessed abuse by our Corrections staff. They are professional safety officers, like I am a professional nurse, but their role is to maintain safety and order and inmates who obey the rules have no problems. They want everything to run smoothly and safely. Lots of them have been there for like 20 years + and I work hard to cultivate their respect.

A key point in Corrections health its not you vs. the system....you are the system. It's not about being in a position to be "fighting the system" for mistreated persons who "the system" has failed to properly rehabilitate. Corrections health staff are *part of* the system. When my schizophrenic patient gets sent to segregation, it is my expected job to create a whole care plan for that person to ensure their safety and proper care...and there is a whole protocol in place for it. There is plenty of room for providing nursing care with respect and compassion with the appropriate boundaries.

Much of what you say is right on.

However, I have seen inmates "abused" by the mere fact of how many inmates there are.  For example - if there are 100 inmates per pod and there are 25 bunk beds, and each bed has 4 levels, someone has to be on the top level.  

That top level inmate tells you he is too close to the air vent and is having asthma exacerbation from that air.  The CO has told him to get the nurse to say he needs a lower level.  Unless and until the nurse says it, he will suffer from the top level air. 

And the nurse might not be able to intervene immediately.  While this inmate's situation is important, a shanking must be dealt with first.  Passing out the overwhelming number of meds, getting inmates medicated before they go to court or get transferred comes first, someone with chest pain or 278/160 BP, a glucose of 29, "someone BIB a CO post-altercation and headed for the hole and needs to be seen now", and lots of other things all come first.  

So the asthma/air vent guy says he's being neglected, ignored, discriminated against because he's gay or black or hispanic or whatever.  He makes a c/o.  The nurse has to stop and deal with the c/o while some other matter/person is delayed in getting tended to, and so it goes.  Can't win sometimes.

There are many innocent people in jail.  Some can't get good lawyers, the cases of some haven't been finalized yet, some are guilty of other crimes but not the one that got them locked up this time.

I saw/heard abuse at times but that was many moons ago.  Might be a lot different now.  Most inmates just want to do their time and get out.  Most CO's just want to go home in 1 piece.  So they generally all try to get along.  There are plenty of fights, though, mostly just inmate vs. inmate.

Some nurses try to behave like CO's.

Just do your nurse work, OP, and don't go looking for trouble.  If you keep an open mind, if you get both sides of a story, if you remember that your safety depends on not getting on the wrong side of the CO's or the wrong side of inmates, you should be alright.

If you want to get involved in a jail ministry from a church you might find that more to your liking.  You are expected to be supportive of the officers, generally speaking when you work in a jail.  Your safety is not the top priority for them, you must realize.  They will try to keep you safe but they need to be safe, too.  

Top priority is safety.  Then getting inmates to and from Court.  Then everything else.

[AutumnDraidean]

I've only had the tiniest brush with corrections nursing, but honestly OP you sound like someone ripe to be gamed. See the abuse in the prison system isn't coming from the men an women who work directly with the inmates, its coming from above. it's the way our laws work, it's institutional racism and poverty that both cause trauma which can lead to addiction and crime. You as an LPN will be in no position to touch any of these issues. When you are an RN you will have both more and less power. 

I learned something about myself in my tiny brush with it (Float nurse sent to secured unit at hospital 20 miles from a major NYS prison) I don't want to have to look at a patient and wonder if I'm being lied to. I don't want to have to mistrust my patient's description of subjective symptoms because they're trying to get some narcotics. I especially do not want harm to happen because I couldn't trust that description. Once I understood these things I knew that corrections nursing was wrong for me. 

So OP if you want to work on the things I mentioned in my first paragraph you need to get involved from a different angle. Corrections nursing isn't the right avenue. If you just want a juicy state pension go find a different state agency to work for. Corrections is probably NOT for you. 

I wish you the best. maybe your state has an agency like  NYS OPWDD that works with adults and children with developmental disabilities. You can make a lot of difference there. 

[Orca, ADN, ASN, RN]

On 1/26/2021 at 10:46 AM, AutumnDraidean said:

I've only had the tiniest brush with corrections nursing, but honestly I don't want to have to look at a patient and wonder if I'm being lied to. I don't want to have to mistrust my patient's description of subjective symptoms because they're trying to get some narcotics. I especially do not want harm to happen because I couldn't trust that description.

This is one of the biggest adjustments that hospital nurses have to make when moving into this environment. If they operate like they did in the hospital, inmates will have them tied in knots. Assessment skills must be sharp because there are so many inmates trying to game you for personal gain. Getting something that they really didn't need is a personal victory (even if it is only ibuprofen), and they will pass along their strategies to their buddies in the cell block. 

Several years ago, our warden wanted us to put together a health fair for inmates. In creating the material, we had to walk a fine line between giving inmates information that they needed to protect their health, and giving them a list of new symptoms to show up at sick call with.