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Healthcare and Nursing in Corrections

PART 1

Correctional Health Care encompasses the medical, mental health and nursing care provided in Federal and State prisons, County and City jails, Juvenile Detention Centers and Department Homeland Security (Immigration and Naturalization Services). 

Historically, Health care in US Jails and Prisons has been minimal.  Care was often provided by unlicensed and untrained inmate "nurses", or, untrained correctional officers. That changed as a result of the Attica prison riot in 1971 when inmates went on a rampage to protest what they claimed was inadequate health care and lack of nutritional food (Attica State Prison in New York – events depicted in the movie “Ghosts of Attica”).  Following the tumultuous riot the landmark legal cases Newman vs. Alabama (October 1972) and Estelle vs. Gamble (1975) led to the establishment of standards of health care for incarcerated inmates.   The 1975 case established the legal standard of "deliberate indifference" to inmates "serious medical needs".  Later federal cases, including Bowring v. Godwin (1977), held that psychiatric needs were included within the meaning of "serious medical needs".   Today, regulations and standards provided by National Commission on Correctional Health Care (NCCHC), American Correctional Association (ACA) and others establish guidelines for the provision of Health Care within jails and prisons. 

The number of individuals incarcerated or secured in programs or probation exceeds 6 million.  The nation's prisons and jails held 2,078,570 men and women on June 30, 2003, an increase of 57,600 more inmates than state, local and federal officials held on the same date a year earlier. The 50 states and the federal government together held 1,380,776 prisoners. Local municipal and county jails held 691,301 inmates. (Justice Department's Bureau of Justice Statistics - BJS)

Federal and State prisons tend to be large institutions holding tried and sentenced inmates who will be incarcerated for a long term.  Jails are locally operated correctional facilities typically holding inmates sentenced to a year or less as well as people in various stages of the criminal justice system such as awaiting trial. 

Jails are the entry point for arrestees who may be held from one day to one year or more and those who will end up in prison.  Arrestees typically are assessed and stabilized for acute medical problems such as minor trauma, drug abuse/overdose or long term chronic conditions requiring varying degrees of ongoing care.  Some inmates have been severely injured before arrest and are hospitalized and stabilized till medically cleared for jail – they arrive with G tubes, urostomy/colostomy, PICC lines, ports, casts on fractures, wounds, dog and human bites, wheel chairs etc.

The population being cared for in jails and prisons has different proportions of race and medical/mental health complaints compared to the general US  population.  As an example, the population in Orange County Florida consists of 19% African American, 20% Hispanic, and 61% White.  At Orange County Corrections jail the population is 50% African American, 15% Hispanic and 35% White.  The CDC (Centers for Disease Control and Prevention) estimates that 18% of the US prison population is infected with hepatitis C compared to 1.6% of people in the general community.  The prevalence of active tuberculosis disease among prison inmates is estimated to be four times greater than it is within the total U.S. population.  The prevalence of AIDS is estimated to be five (to 20) times greater among prison inmates than among the U.S. population in general.

As states reduce funding for mental health care - from 8.8% of overall US healthcare expenditures in 1987 to 7.8% in 1997 - jails and prisons are becoming America's new mental health care delivery systems.  In 1995, there were 70,000 people with severe mental illness in public psychiatric hospitals - today there are 280,000 people with severe mental illness incarcerated in state and federal prisons with many more housed in jails.  The largest mental health institutions in America today are Cook County jail in Chicago and Los Angeles County jail.

Male inmates in federal prisons have a high incidence of mental health disorders: antisocial personality disorder (56.9%), disorders related to drug dependency (40.9%) or alcohol dependency (47.2%), anxiety disorders (44.1%), depression (21.5%), psychosexual disorders (21.1%), psychosis (7.7%). 

Incarcerated women test HIV positive at two to three times higher rates than incarcerated men and over 10 times the rate of infection in the general population.  From 1991 to 1995 the number of HIV-positive women in prison rose by 88% compared to 28% increase in male prisoners.  The rates of HIV infection among incarcerated women range from 3% to 35% depending on geographic region.  Hepatitis C rates vary from 22% to 55% of women in prison.

The Journal of Correctional Health Care, in their article "Physical health of women in prison..." reports that about 70% of incarcerated women have had long-standing addictions to drugs and/or alcohol and nearly 90% developed drug problems prior to the commission of any crime - demonstrating the strong link between addiction and crime for women.”

Nurses who have worked in other health care areas report that correctional nursing is unique and cannot be directly compared to other practice areas.  Nursing in the Correctional setting requires dedication, detective work, an increased awareness of subtle patient changes and consistency in physical assessments.  Nurses (Licensed Practical nurses and Registered nurses) work in clinics, provide medication dosing, physical assessments, assessments of drug withdrawal, wound care, post emergency room/hospital assessments, pregnancy, acute care and chronic care.

The Scope and Standards of Nursing Practice in Correctional Facilities (American Nurses Association NP-104 7.5M 6/95) describe correctional nursing practice as being characterized by a high degree of autonomy [that] requires a broad-base collection of subjective and objective data.

Correctional nurses must remain neutral and unbiased by charges against inmates; the nature of a patient's crime should have no bearing on the care that is rendered.  In the midst of responding to emergencies and triaging requests for care, these nurses must be able to discern legitimate complaints and physical findings from a sometimes highly manipulative clientele.  Correctional Nursing comes with a unique set of ethical dilemmas and issues for nurses as patient advocates.  Safeguarding the rights of convicted rapists and child molesters is always an emotional struggle. (Duddy Sloan, C. in Nursing Spectrum - Legal origins and issues behind Correctional Nursing - accessed 8/10/2004)

An example of a large local jail is Orange County Corrections located at 33rd St and John Young Parkway near Interstate 4 in Orlando Florida.  Of the 3,600 jails in the United States, Orange County Corrections was the 22nd largest jail system in the United States with more than 1,600 employees including nearly 1,000 certified corrections officers. In the U.S. there are nearly 3,300 jails. The professionalism of our officers and staff has allowed us to become one of the 124 jails to achieve national accreditation from the American Correctional Association.  The average daily population at Orange County Corrections is 3,896 inmates, the yearly intake exceeds 50,000.  Correctional Health care is provided by: 3 Physicians, 1 Psychiatrist, 2 Dentists, 5 Nurse Practitioners and more than 100 nursing staff, all employees of Orange County Government.  Information can be found on the web at www.Bestjail.com.

Within Orange County Corrections there are 8 clinics located throughout the facility.  On arrival, arrestees are brought into the Central Booking Facility where all individuals are screened for medical and mental health conditions.   In Central Booking there are a large number of arrestees withdrawing concurrently from nicotine, caffeine, sleep, drugs such as alcohol, cocaine, heroin, methadone, marijuana, GHB, ecstasy, mouth wash alcohol, and self intravenous (IV) administration of ground pill formulations such as oxycontin as well as regular IV street drugs, narcotics, stimulants, and benzodiazepines.  Medications are prescribed to reduce the complications and expected effects associated with drug withdrawal.  Arrest injuries not seen in an emergency room are normally first identified in the booking clinic - human and dog bites, tazer wounds, burns, bites, abscesses, contusions sprains and suspected fractures.  Inmates are generally held in Central Booking until they have been before a judge in one of 2 courts run daily within the booking facility.  Those who can bond out of jail, those without bond may be held for transfer to another institution or transferred out of Booking to other areas of the jail.

The clinics in the jail are in the Female Detention Center houses up to 400 females.  The clinic sees patients for drug withdrawal, pregnancy, and acute and chronic medical conditions.  For male inmates, the Horizon, Genesis, Phoenix, and Main clinics see patients for drug withdrawal, acute and chronic medical conditions; AB clinic sees juvenile inmates, inmate workers and those in protective custody while SMCU is a special medical care unit for those with more severe illness and post hospital patients.

End of part 1