Inmates as Patients in Hospital

[4cas2]

An issue arose at my hospital during my consolidation as a student, and it had both ethical and legal concerns. I was being trained on a medical/surgical floor, and one of the nurses on the floor believed that inmates were only permitted to ambulate on the floor with their guards after visiting hours were over. Inmates are commonly put on our floor as there are a couple of prisons in the vicinity of the hospital.

The clinical educator and I looked into this in the policy manual, and could only find two items that were relevant:

1. "While attending the Hospital Inmates shall remain in restraints, except as provided by section 6.3 of this policy. Any deviation shall be a result of consultation between Hospital Security, the appropriate Program Manager/Delegate, and the appropriate Correctional Service."
2. "Inmates in restraints shall be transported by wheelchair or stretcher at all times unless ambulation is a necessary component of their health care."

After telephone calls to hospital security, the prison officials, and other managers responsible for policy, it turns out that this is an unwritten rule that the guards choose to follow, and is not formal policy by any of the agencies. Therefore there are no legal concerns for the nurse if she wishes to insist that the patient ambulates during visiting hours, although she may feel ethically concerned for the fear that may arise in the other patients on the floor. Legally, the guards may be at risk of restricting the freedom of the patient in a manner that is not part of their prison sentence. The hospital too may be taking a legal risk by not addressing the situation -- what if a patient died due to something that could have been prevented had the patient been ambulatory more often? Nurses often deal with the conflict between the rights of the individual over the greater good of the group, and this is one more example of both the ethical and legal aspects of so many of the issues that nurses face on a daily basis.

The ethical concern arises in the second statement listed above. It is absolutely necessary that a person ambulates after surgery, and therefore wheelchairs/stretchers are only necessary when arriving on or leaving the floor. To restrict a patient to a few hours in the evening is an ethical dilemma for the nurses. On the one hand, you wish to provide the best care for your patient (the inmate) and in order to do this, they must be able to ambulate as much they can whenever possible. However, the stress level of seeing an inmate flanked by two large guards walking the halls will increase significantly for the other 30+ patients on the floor. Whose needs do you consider first? What are your legal obligations to the other patients and their safety? What is your obligation to the inmate? Are the guards legally allowed to restrict the patient? How do you reconcile this issue in an equitable manner?

In the article, "Caring for the incarcerated in the intensive care unit", the author describes the many aspects of nursing care that differs in a standard hospital rather than in the infirmary of a prison. However, the theme throughout the article is summarized in the conclusion: "the nurse must respect the worth, dignity, and rights of all patients, regardless of the individual's lifestyle, values, or state of health". Adopting this as a personal policy will only benefit a nurse who must work with incarcerated and non-incarcerated patients.

Reference

Graves KE. Caring for the incarcerated in the intensive care unit, Dimensions of Critical Care Nursing. 26(3):96-100, 2007 May-Jun.

[jkelley83]

"Whether written policy or not, the correctional officer has the final say. Any effort to circumvent that is counter productive."

I dont agree entirely with that statement. I was starting an IV on a shackeled to the bed inmate and one of the two armed correctional officers pulled his weapon and pointed it at the inmate. I was on the opposite side of the officer. I asked him not to point his weapon in my direction and he continued. I stood up and TOLD him to point the weapon in another direction or he and I were going to have MAJOR problems and this inmate was not going to get an IV. The other officer stepped in and told the first to holster his weapon, which he did.

Wow, I can definitely see where that could be a bit intimidating and scary! I think I would have said exactly the same thing. Good for you, to stand up to him like that.

[pantheon7]

It seems from what I have seen that inmates always have a cop on guard at all times. It's hospital policy.

[PetuniaRN]

Just a thought...ambulation doesn't have to include roaming all the hallways. walking around their room, or a secluded piece of a hallway with the guard is sufficient. Also performing ROM and having PT come work with them in their room has many of the benefits of ambulation. I worked at a hospital with many prisoners, and while they are patients, they are also prisoners. They don't get all the same privileges as everyone else. They deserve medical care, but not special allowances. And attempting to give them the same priveleges endangers their guard, and anyone else in the hospital. One inmate/patient told me it was better not to unshackle him while I gave him the bed bath, because he was in for life without parole, and he would do anything to even get a few minutes of freedom. He then said,"and I sure don't want to have to hurt you. So let's eliminate the temptation, ok, sweetheart?" He taught me an important lesson. So just my two cents here.

[Dave the nurse]

Most inmates who are chonic offenders don't mind prison or in corificeration. To them it is as normal as the sun rissing. Prison is thier home it is what they know as normal. Where you work fortey sixtey plus hous aweek and depend on your family and your steady job. Inmates know the cop on the beat, the bang of the judges gaval, the stern instruction of the parole / pobation officer, the slalm of the the cell door the call to count up and lock down!

Prison is the only stable support system most of them know ,understand and trust. For many it as the only stable influence in thier life. Prisoners on your unit are the resonsiblity of the CO's who are charged with their custody.

All of your nursing care must work in conjuction whith the holding authority. Most of these men and women will take advantage of any oppertunity to thier advantage. Most have nothing to loose. If that means a pair of sissors in your back, or rapping you in the bath room it doesn't matter they have nothing to loose. Inmates will test you and push the envelope at every turn in the road.

Plan you nursing care in conjution with the officers,to maintain security and transfer them back to thier prison infirmaries as some as they are stable.

Remmber most prison hospitals are staffed by nurses who can work pretty much in any enviorment. we have ACLS, PICC/ Midline certs ect we just do it behind the wall.

[Patti_RN]

Common sense is important in these situations. I spent some time working in our county's jail; some inmates were difficult, couldn't be trusted and others were downright dangerous--we also had inmates who were quiet, dependable and trustworthy (they were the majority). Because we worked with the same people every day, we knew their personalities and knew who you couldn't trust (but not necessarily who you could trust--an important distinction). Hospital staff have no idea who they are dealing with. In the infirmary, we ALWAYS had a warden with us when we provided care, and the jail had cameras that monitored every corner and hallway. You simply do not want to take chances when dealing with inmates. Caution and safety (your own and other patients' safety) are paramount. That said, you do have a responsibility to provide inmates with the same medical care any other patient would enjoy. A prisoner who just had major surgery is probably not a physical threat to you or others. On the other hand, inmates are known to fake illnesses to escape--if they are not accompanied by a guard or officer they might take advantage of a relaxed situation and hurt you or others in an attempt to gain their freedom. Hospital nurses have little or no training in dealing with inmates and must walk a fine line between maintaining a safe environment and providing quality care for the inmate. There is a great potential for mistakes that would jeopardize others as well as the inmate's health. My advice is to seek clarification from your unit director. I would also offer to organize a committee that would include security, nursing and administration to establish guidelines in dealing with incarcerated patients.

[MIC!]

I'm a correctional officer and have been for the last 5 years. I'm currently in clinicals to be an RN. As a correctional officer I transport inmates to and from hospital while accompaning them during their hospital stay. So, I can give you incite on the scope of both roles correctional officer and nurse. I think the confusion comes in at just how much authority does a correctional officer have. Well, I'll tell you what many nurses in my state don't know. While an inmate is in my custody I am awarded the powers of a State Trooper. Even when I'm going to and from my post (hospital).

With that said it is the correctional officers who have the final say on how the inmate will be restrained during ambulation. Of course, advisement from medical staff is considered before a final decision is by the officers on duty. Inmates are state property no matter how you look at it. Your not going to see specific rules in your policy manual because every inmates security level is different and so are there charges. So this is why it is at the discretion of the correctional officers on duty. You as a nurse should still remain an advocate for your patient by advising correctional staff of treatments/therapy.

Correctional staff on duty at hospitals must ensure that contraband does not enter the room. That no family members of the inmate contact or attempt to visit unless the inmate is terminally ill. Family members are not even allowed to know the location of the inmate in fact. Every individual who enters the inmates room is to be identified. We are also supposed to make sure the inmate is not being discriminated upon because of his status.

You as a nurse don't know what the inmate is capable of. Nor do you know if your patient/inmate visit to the hospital is an elaborate plot to escape. We as correctional officers are not only watching the inmate but we are also watching YOU and other staff. We don't know if you as a nurse may possibly be in fact assisting the inmate in escaping. These are things we try to observe/detect as correctional officers. As correctional officers we have info on hand that describes the inmates charges, behavior, alias, last known address, social security # etc. This info enables us to make informed decisions when it comes to restraints needed. It is at the complete discretion of the officers on duty. So, if an officer insists on the inmate wearing cuffs after advisement from medical staff about ambulation. Just let the officer restrain him/her as the officers see fit. ITS FOR MY SAFETY, YOUR SAFETY AND THE PUBLICS SAFETY. Most officers have common sense and can differentiate whats good for security and in the best interest of the patient/inmates recovery. So an officer is not going to let an inmate develop a pressure ulcer on purpose. In fact many correctional officers work with staff nurses as teammates rather than against them.

This just happened three weeks ago. We had an incident involving an inmates family member who manipulated the nurse into believing she was the power of attorney. The nurse said that the family member then asked where he was located. The nurse unaware of the policy and procedures told her the inmates room number. This situation could have gotten ugly, but I informed the nurse that the inmate is a ward of the state (state property) and that power of attorney is irrelevant at this point. And this inmate was not terminally ill. We then remained on high alert on the possibility of an attempt to escape for the rest of the night. Luckily, there was no incident after that.

The moral to the story is to work with correctional officers and communicate while respecting HIPPA.

[Carliestarling]

Wow! That is very scary! What was the inmate doing that the guard felt warranted pulling his weapon? Wasn't the inmate sick and (weakened) in the first place? I notice you said he was shackled to the bed--How much damage could he have done? Officer's forget that we nurses handle unruly, sometimes violent and confused patients all the time--without any weapons! Although the Guard's intent may have been to protect you, it seems he went too far, and in fact put you in danger. I would have reported that, and I hope you did!

I am glad for the protection most Correctional Officers provide, not only for Staff, but for the safety of other patients as well. After reading the post from MIC!, I am reminded that MOST CO's have more knowledge than we, as nurses have, regarding the criminal mind, and just how far one might go for a few moments of freedom. Also, the CO's who use common sense, and cooperate with nursing staff are our best allies when handling patients who are also prisoners.

As to ambulation, I agree with someone who earlier stated that prisoners should ambulate in private areas of the hospital. None of us would want a prisoner who just had abdominal surgery to develop an ileus, and if we communicate with the guards the rationale behind ambulation, I am sure none of them would refuse.

Thanks to the OP for this enlightening article. It is definitely something that facilities should have P&P in place for.

[nursemary9, BSN, RN]

We occasionally get prisoners; We have a policy for prisoners. They MUST have a police guard 24 hrs./day. While the guard has breaks or meals, another police officer relieves them. It cannot be our staff or our security.

While they are our patients, they must have a handcuff to at least one extremety. They usually do OK with just one foot shackled.

One story I have. I worked the night shift for 35 yrs. One nite, we had a young woman who was "picked" up for prostitution & apparantly had an asthma attack in the police car. She was hospitalized on my unit & she was my pt.

She had a young, female police officer with her & was shackled to the bed when I was in the room & making my rounds & hanging a piggy-back on her. I don'[t think I was out of the room even 15 minutes when t he Respiratory therapist came to me & said the pt. was "gone" & the police "Lady" was sleeping!!!!!!!

Well, apparantly, the policewoman removed the shackle from her---said she was "OK". She then promptly fell asleep & our little girl decided to leave!! IV was laying in the bed where she had pulled it out.

Well, I immediately alerted security, but she was all ready gone. We immediately called the Police who sent MANY more police over. We were all questioned by detectives.

Several months later, we were again questioned. The upshot----The Policewoman was fired. She was young and a fairly new-hire & they didn't give her another chance.

I wonder if she ever realized that it could be VERY dangerous to fall asleep on a prisoner!!!

never heard anymore about the girl!!

[shodobe]

We get patients from the State hospital which they are accompanied by two armed guards. The prisoners from the federal prison comes with 4 armed guards! Seems overkill with our taxes but what can you do. Most of the guards are regulars and know the rules but you do get the occasional one with an attitude. We work it out though and things proceed well.

[Rick2323]

We occasionally get inmates and they are always accompanied by two guards and are shackled to the bed. The wear leg irons when ambulating. Sometimes seems insane when it's a 70-year old who just had open-heart surgery. Never had any problems with inmate patients.

On another note...ok you new grads...students... what the blazes is "consolidation"? Sound slike another nursing school whiz-bang program, but what is it exactly?

[rkitty198, BSN, RN]

We would allow the inmate to ambulate as MD prescribes, however, our policy was unclear too. So they would ambulate after visiting hours.

[Orca, ADN, ASN, RN]

I am a nursing administrator in a correctional facility, and many years ago I was a correctional officer. I have done hospital escort duty, so I know both sides of this equation. To summarize:

What is your obligation to the inmate?

To provide the best care you possibly can within the necessary restrictions placed upon the inmate as an incarcerated person.

Are the guards legally allowed to restrict the patient?

Yes, and they had better. On hospital duty you are responsible for the custody and confinement of that inmate. Within the hospital setting, you are in effect the prison itself. You are there to ensure that the inmate does not escape, that the inmate does not obtain contraband or weapons of any kind, that he or she does not harm others, and that he or she is not harmed by others. I did not want to have to explain why an inmate who ran away from me was not restrained or worse, have to draw my firearm within a crowded hospital in an attempt to halt an escape that could easily have been prevented by using proper restraints.

The reaction we got from hospital staff ran the gamut. Some were grateful we were there, some wanted nothing to do with inmates, and still others thought we were barbaric ogres just there to cause misery to the inmate and interfere with treatment.