Correctional Nursing

1. Correctional Nursing Chia-Chen Lee, MSN, RN, FNP Nurse Manager Santa Clara County Custody Health Services

2. Historical Overview • American Nurses Association recognized correctional nursing as a specialty profession in 1975 • ANA published “Scope of Nursing Practice in correctional Facilities in 1985 • ANA states that nurses practicing in correctional facilities have a minimum of BS degree

3. Correctional Medicine Moving from Isolation toward professional identity (1975-2005) Pioneering survey of medical care in U.S. jails published by American Medical Association 1972 National Commission on Correctional Health Care (NCCHC) 1981 Society of Correctional Physicians (SCP) founded 1993

4. Constitutional Rights of Inmates • Federal courts to improve conditions: • A) Lack of inmate access to medical services • B) Poor follow-up care of recognized health needs • C) Insufficient staff and funding to provide adequate care • D) Preventable negative outcomes of care, including death or permanent injury

5. Correctional School of Nursing • Idaho nine-weeks correctional nursing certificate program • Understanding inmate behavior • Managing narcotics • Self-defense • Responding to riot/hostage situations • Conducting sick call

6. Correctional School of Nursing • Medication administration • Emergency response • Infirmary care • Differences in nursing approach to men and women

7. Confidentiality and Regulation • HIPPA and confidentiality • B. Investigation and Public Health information • C. Title 15, storage and transportation of • patient records

8. NCCHC • Our MissionNational Commission on Correctional Health Care is to improve the quality of health care in jails, prisons and juvenile confinement facilities. With support from the major national organizations representing the fields of health, law and corrections, NCCHC’s leadership in setting standards for health services is widely recognized. Building on that foundation, our not-for-profit organization offers a broad array of resources to help correctional health care systems provide efficient, high quality care.

9. Correctional Staff and Health Care • Collaboration between health care and security staff • Balancing institutional movement rules and inmate access to services • Working with security to send inmate/patient off-site • Inmate turnover and the episodic approach to health services

10. The Problem • Estimated 283,800 mentally ill inmates is US (Sniffen, 1999) • 547,800 mentally ill offenders on probation every year (Sniffen, 1999) • Non compliance with psychiatric medications most significant predictor of arrest (McFarland, 1989) • 1/3 discharged from psychiatric hospitals lose contact with services within a year (Barr, 2000) • Costs California, $40,000,000 annually (MIOCRG, 2002)

11. Solutions • Increasing compliance with psychotropic medications • Improving compliance ￬relapse, ￬ hospital readmission and ￬ criminal transgression (Dubyna & Quinn,1996)

12. The Role of Nurses • Health screening and physical examinations • Assessment and treatment of health complaints (sick call) • Triage and treatment of urgent complaints • Medication administration • Health education and counseling

13. Nursing Role and Correctional Facilities • A) Lone provider versus health care team member • B) Clinical assessment and use of nursing protocols • C) Professional autonomy • D) Risk and rewards of correctional nursing

14. Santa Clara County Custody Health Services • Valley Medical Center • Elmwood-daily average population/2005=2981 • Main Jail-daily average population/2005= 1503 • Mental Health (8A) daily average population 30 approx 800-900 OPD-ELM and MJ • Juvenile Facilities-average daily population 350-400 minors

15. Research Questions • What do correctional nurses believe about medication compliance? • What information do correctional nurses collect during their assessment of inmates’ medication compliance? • What barriers do correctional nurses identify related to medication compliance after inmates are released? • What are the self care behaviors? • Do they have concerns for their safety?

16. Methodology • Exploratory mail survey • Questionnaire developed based on literature review and Scope and Standards of Forensic Nursing Practice (IAFN & ANA, 1997) • Experts utilized to develop and pilot tool • Human Subjects Protected by meeting IRB requirements, SJSU • 31 jails or prisons with population over 500 in CA were targeted

17. Final Instrument • Survey design expert formatted the final 60 questions in a four page questionnaire • Piloted by 10 correctional nurses not part of the final study

18. Procedure • Phone call made to medical directors/or directors of nursing stratified nonrandom sample of 31 CA jails or prisons with populations over 500 • 3 facilities could not obtain administrative approval • Surveys were mailed to 28 sites in CA nurses: RNs, NPs, & CNSs • Each nurse was supplied pre-stamped, pre-addressed envelope • A follow up phone call was made 1 week after mailing

19. Response & Data Analysis • 14 facilities participated (50%) • 55 nurses returned questionnaires • Question #50 asked for the exact number of nurses & based on self-report there were 86 potential participants • 64% response (55/86) • SPSS was used to compute frequencies and percentages

20. Institutional Characteristics N = 14

21. Demographic Characteristics: Gender, Age, Education

22. Ethnicity

23. Nursing Experience N = 55

24. Nursing Experience as Correctional Nurse N = 55

25. Experience With Inmates With Mental Illness N = 55

26. Medication Compliance Views (N = 55)Very Important to Important

27. Assessment of Medication Compliance

28. Medication Compliance Nurse Behaviors N = 55

29. Perceived Barriers Referrals to Outside Agencies N = 55

30. Barriers Providing Discharge Summaries to Outside Psychiatrist and/or Medical Clinic

31. Barriers When Providing Medications at Discharge

32. Barriers When Providing Prescription Prior to Release

33. Self Care Practices N = 55

34. Personal Safety N = 55

35. Limitations • Nonrandom sample • Survey tool lacked established reliability & validity • Study population in California only • Participants well educated & experienced and may not be representative of all correctional nurses • Self-report and may not match actual practice or behaviors

36. Conclusions • 55 well educated, experienced, caucasian nurses in 14 jails & prisons in CA believe that medication compliance is very important in reducing recidivism & crime • Believed that correctional nurses had the most influence over inmate’s medication compliance • Believed that the therapeutic relationship was very important to medication compliance • Identified many barriers to medication compliance after release • 58% were concerned about their personal safety • Self care behaviors are not engaged in frequently • 94% believed that debriefing services were important

37. Recommendations • Repeat study with larger random sample in multiple states • Maintain high percentage of baccalaureate and advanced practice nurses employed in jails and prisons • Increase self care practices • Increase ethnic diversity of nurses • CA specific recommendations: • Add regulation to Title 15 California Code of Regulations to include discharge plans, follow up care, medications or prescriptions upon release, visits by correctional nurses after release

38. A Vision Mandating discharge medications and ensuring follow up treatment, along with well-educated, experienced, compassionate, and dedicated forensic nurses practicing in CA jails and prisons may lower rates of crime, recidivism and reduce costs. Furthermore, ex-inmates with serious mental illness may have an opportunity for improved quality of life and increased tenure in the community