Nursing Behind Locked Doors

from Medscape Nurses
Posted 04/01/2003

Peggy Dryden, RN, MSN, MBA

At the end of last year, we solicited readers for comments and ideas about future topics for our eLetters: Corresponding With Nurses feature. To our surprise, we received a large number of emails from nurses working in prisons. We decided to interview 2 nurses for this feature. Both nurses take us inside a prison. Jane Doe*, MSN, RN, CS, family nurse practitioner (FNP), provides us with a snapshot of a day in her ever-changing environment. Jen Witter, RN (see sidebar), describes her role as a registered nurse (RN) in a prison setting.

Question: What do you do in your nursing role in a prison?

Answer: My role as a nurse practitioner (NP) working with the prison's medical team is to provide acute and chronic care to the prison's inmate population. I also provide medical screening services, help monitor and control infectious diseases, provide patient education, arrange for specialty referrals, and provide emergency medical care and/or stabilization for emergency medical services (EMS) transport to the emergency room.

The clinic in the unit where I work serves a population of approximately 1400 inmates. I share the clinic responsibilities with another full-time NP, as well as 2 physicians who rotate through the clinic each week to provide physician coverage for a total of 2 full days and 2 half days. Our unit is not a designated medical facility, which means we don't have a hospital ward; however, we do have a 4-room observation unit in the clinic where we house those patients who need monitoring for reasons such as suicide attempts, hunger strikes, brief periods of convalescence after a hospital discharge, suspicious abdominal pains, intravenous antibiotic administration, or other conditions requiring observation.

Two of the prison's observation rooms are negative airflow rooms, set up to hold patients needing respiratory isolation. We have a radiology room and technician, a phlebotomist (all laboratory specimens are sent out), an optometry clinic, and a dental clinic. We also have a physical therapist, a brace and limb technician, a respiratory therapist, and a dietitian; all who come in for consultations.

Although the prison clinics are open and running 24 hours/day, 7 days a week, the providers' hours are basically Monday through Friday, 8 hours per day. Outside of the regular clinic hours, there is always a provider and a physician "back-up" provider on call. The nursing staff handles much of the after-hour care themselves, whenever possible, by using established protocols.

Question: Tell the readers about yourself. What has your career been like, and what is and your educational background? Could you describe how you came to your current position?

Answer: I have been a Masters-prepared, nationally certified FNP for 9 years. Prior to this, I worked as an RN for 6 years, a licensed vocational nurse for 9 years, and a certified nurse assistant off and on for 10 years -- I have been in the nursing profession in some capacity since I was 15 years old. My NP experience includes work in emergency room/urgent care, outpatient rehabilitation, and primary care in community health centers, rural health centers, private hospitals, and private practice offices and clinics. My staff nursing background includes general medical-surgical nursing, orthopaedics, neurosurgery, and inpatient rehabilitation. My career has taken me from a well-known southern California hospital that catered to the wealthy and famous, to a Navajo reservation in the Four Corners region of New Mexico. I was employed at a Veteran's Affairs Medical Center, a large university hospital, a small clinic in a low-income, medically underserved area in Mississippi, as well as communities near the US-Mexican border.

I am currently in a prison setting for the second time in my career. Previously, I worked for 2 1/2 years as a staff nurse in a state prison hospital located on the university campus while I was attending my NP program. It was that experience that made me realize that I enjoyed working in the prison environment and was not at all intimidated or fearful of the setting or the patients.

While I was working on both my associate and bachelors degrees in nursing (prior to my prison nursing experience), I also earned a degree in cultural anthropology. I am fascinated with people, human behavior, different cultures, and societal structures -- and I try to pick positions that will expose me to different situations and populations so I can learn more about them. Prisons are a great place to study human behavior and societal structures. Faced with the prospect of yet another dissatisfying and unstable job in the private sector, I decided to look for a position that would offer steady income, good benefits, and job security. I contacted my previous employer in the correctional care business and found that they had provider openings in a number of prisons statewide -- I basically just needed to pick a location.

Question: What is an average day like for you? What kinds of activities/procedures do you perform? What kinds of cases/patients do you see?

Answer: It's hard to describe an average workday, because there really is no such thing. Emergencies are always popping up that can alter even the most carefully planned day. Ideally, my NP partner will arrive at work at about 5:30 AM and go over her charts for the day. She will start reviewing stacks of laboratory and x-ray results, sign-off charts, and begin seeing sick-call patients at around 6:00 AM. I arrive at 7:00 AM to begin either seeing the patients held in the observation rooms or reviewing labs, x-rays, and charts -- or I will help with sick call, based on whatever the priority is at the time.

The inmates sign up for sick call from 6:00 AM to 7:00 AM. We can see anywhere from 10 to 30 sick-call patients a morning in our clinic. Sick call can include anything from a simple cold or allergies to medication refills, stomach viruses, athlete's foot, jock itch, simple strain/sprains, sinus infections, vague abdominal pains, pneumonia, new cases of active tuberculosis, or other serious and more complex problems.

Ideally, our scheduled appointments start at 9:30 AM. In reality, however, we can't start taking appointments until we finish sick call. We may be scheduled for anywhere between 8 to 20 appointments a day, depending on how many Chronic Care Clinic patients we have scheduled. Patients with chronic medical problems such as hypertension, diabetes mellitus, hyperlipidemia, cardiac problems, asthma/chronic obstructive lung disease, HIV, and chronic hepatitis; those on tuberculosis prophylaxis; or anyone else on medications that need to be refilled on a regular basis are scheduled with us for Chronic Care Clinic appointments every 90 days. Chronic Care Clinic visits include a review of systems; physical examination; asking about any new problems; reviewing recent diagnostic test results; ordering new labs and/or x-rays; counseling the patients on their medications, diet, exercise, smoking cessation, weight loss, and disease process(s); and referring them to physical therapy, optometry, brace and limb, dietary counseling, or to a specialty clinic if needed.

Besides chronic care visits, we also see patients for follow-up care from prior visits and do minor procedures such as toe-nail removals, incision and drainages, cyst and mole removals, and lesion biopsies. In between seeing patients, my partner and I continue to sign off charts and review lab and x-ray results, dealing with any abnormal values, refilling medications, and signing off any verbal orders given to the nursing staff. We also work with a nurse who does sick call in the Administrative Segregation (AdSeg) unit (also known as "the hole" by the public) each day.

The AdSeg holds up to 250 inmates who are housed for both protection and disciplinary actions. The AdSeg nurse's job is to convey to us the needs and requests of the AdSeg inmates who are unable to come to the clinic for sick call. We then write orders and recommendations for them on the basis of the AdSeg nurse's assessments. One day a week, we go to the AdSeg and provide care for those who need Chronic Care Clinic visits, follow-up care, physical examinations, and initial evaluations of complaints that couldn't be handled without seeing the individual.

What I have described is an ideal day... but not a typical day. We see a fair amount of trauma (beatings and stabbings) on a frequent basis. We also deal with lacerations resulting from accidents, traumas, suicide attempts, drug overdoses, cardiac emergencies, fractures, and other problems one would expect to see in any emergency room. When an emergency comes in, clinic appointments are suspended until we deal with the crises.

The clinic nurses, both RNs and LVNs, actually go out in the compound to respond to medical emergencies. The nurses assess and stabilize the patient as much as they can at the scene. The patient will then be rushed to our "ER," where the providers are waiting. The nurses do all the documentation of injuries and the initial emergency care. Following emergency protocols, they start IVs, bandage minor wounds, etc. We do not have an actual emergency room. We do not have a crash cart and are able to perform basic life-support services only. For true emergencies, we call for outside EMS to transport patients to a local ER.

Question: Anything more you would like to add about your role?

Answer: My role in a trauma or emergency situation is to perform an advanced assessment of the patient, sew up the lacerations, cast the fractures, order and do a rough interpretation of x-rays, and decide when to treat and when to call the emergency medical services and send the patient out. In the event of a major "disturbance" on the compound, one where there may be multiple victims, the clinic is closed to appointments and sick call, as dealing with the many injuries may take the rest of the day. Frequently, these disturbances can lead to lock-downs -- keeping inmates locked in their cells until the situation has been totally assessed by prison officials -- which again disrupts our "ideal" daily schedule and prevents us from seeing our patients for anywhere from a couple of hours to a couple of weeks.

Question: Can you describe any safety concerns you have inside the prison? How are safety situations handled?

Answer: Security and safety are always the first concern. Unless the patient is an AdSeg inmate, he or she is not handcuffed except when being sent outside the unit for medical care. A correctional officer is assigned to the clinic at all times, but there is no officer in the exam room with the provider unless we request one for some reason.

I have never personally been afraid for my safety, nor have I ever had a violent confrontation with an irate inmate. However, difficult situations have been known to occur in the clinic. Many of the inmates already have hostile attitudes and come into the clinic feeling that no one cares about them. They trust no one. Inmates have to be constantly aware of what's going on around them, always watching their back. They can't let their guard down as this indicates a weakness and vulnerability, which could be ultimately detrimental to their safety and their lives.

Living inside a prison is an extremely stressful existence 24 hours a day, 7 days a week. The stress can lead to frequent explosive, violent situations. Any demeaning or disrespectful behavior exhibited toward the inmates by clinic staff members only serves to reinforce negative attitudes and may create a hostile environment that often escalates into angry and verbally abusive outbursts in the clinic. Physical attacks are, fortunately, very rare. To be treated with respect by this patient population, I believe I must first earn it by giving them respect and earning their trust.

My examination room serves as a safe haven where, for a few minutes, the inmates know that someone cares about them. They can relax, let their guard down, and be treated like real persons. Even when I deny them something they're hoping to get from me such as a low bunk, soft shoes, an undeserved day off work, drugs, etc, instead of just denying their request I always try to give a rationale for my decision and, if applicable, open up policy books to show where the situation is out of my hands in order to avoid angry confrontations. I don't know what the majority of my patients are in prison for and I don't want to know. I don't want my personal feelings about what they've been convicted of to affect the patient-provider relationship or how I treat them.

In this environment, I keep my eyes and ears open, remember my security and emergency training, have established boundaries and limits, and am ready for trouble to break out at any time. I also smile, laugh, joke, say hello, respond when someone asks me a question, and give positive feedback and reinforcement for any little achievement. Because of how I treat my patients, I feel I can walk safely across the compound unescorted, something I have had to do on occasion.

Question: What are the most difficult aspects of your position?

Answer: One of the most frustrating experiences I think I've run into so far in my job is trying to get this high-risk population to want to take care of themselves, to take their medical conditions seriously, comply with the prescribed treatment, and make positive lifestyle changes. Many of these men have a history of heavy substance abuse; many also have previous injuries from motor vehicle accidents, shootings, and stabbings which, when combined with their criminal background, shows they have a history of making poor lifestyle choices with little regard for their health, safety, or the consequences of their actions. Many of these men are serving life sentences and see no reason to take care of their health.

Also frustrating is the fact that we are a managed care organization and, as such, we have restrictions on how we can treat the patient. We are encouraged to keep patients in the facility whenever possible, which cuts down on unnecessary referrals and costly trips outside the prison compound. We also work with a very strict and limited formulary for the medications we can order which, although it saves money, also gives us much less flexibility with treatment options than providers in the "free" world have.

Another frustration in the job is the fact that medical issues and concerns are a lower priority than safety, security, and prison business. This was certainly a challenging adjustment for me to make in the beginning. And probably the biggest frustration encountered in my job is the fact that nothing is done the easy way in a government facility! There is always plenty of paperwork, a proper chain of command, and bureaucratic red tape before any decisions can be made, policies changed, or problems corrected.

Question: What have been the most rewarding aspects of your position?

Answer: My most rewarding experiences come from the inmates who try hard to help themselves maintain their health and from those who thank me for taking the time to listen to them and appreciate any of the small things I do for them. I find it rewarding when a patient trusts me enough to open up and be honest with me, as these are not individuals who trust easily.

There is a harsh fact that I have to deal with on a daily basis -- my patients are prisoners in a prison. They have virtually no freedom. I try not to communicate my excitement about upcoming weekends, holidays, and vacations when inmates are around because, to them, every day is basically the same. Many don't even keep track of the day of the week, as it doesn't mean anything to those behind prison walls. Like most people in this country, I have always taken my freedom for granted; working in a prison makes me realize what a privilege and a blessing freedom truly is.

Question: Finally, any suggestions for those readers interested in a position like yours?

Answer: The role of an NP in a correctional care environment is a combination of emergency room, urgent care, and primary care practice. An NP needs the skills of all 3 of these areas in order to meet the daily challenges. Correctional care nursing can be a very stable, long-term, and satisfying job opportunity for NPs providing an exciting, stimulating, and challenging work environment. A day in a prison is seldom boring!

*Editor's Note: The author has asked that we not use her actual name because of concerns about confidentiality.