A few definitions

Within the most recent penal nomenclature, the word corrections refers to the programs, services, facilities, and organizations responsible for the management of people who have been accused or convicted of criminal offenses. The words jail and prison are often incorrectly interchanged in both conversation and written historical information about corrections.

A jail is a short-term holding facility that houses pretrial detainees who have been incarcerated because bond was denied, not posted, or not yet determined. Jails also hold convicted felons and misdemeanants who have been sentenced to generally less than a year or two or who are awaiting transport to a state facility to serve a longer sentence. A prison is a long-term state or federal facility that houses convicted persons, although these definitions may vary from state to state and within the federal government.

The Eighth and the Fourteenth Amendments to the U.S. Constitution extend the right to healthcare to those incarcerated in jails and prisons. The Eighth Amendment governs the treatment of those persons who have been convicted, and the Fourteenth Amendment has a due process clause that governs the treatment of pretrial detainees. Medical autonomy is at the core of these amendments. As a pivotal principle in correctional healthcare, medical autonomy means that a nonmedical person must not overrule the professional judgment of clinicians, who provide and safeguard the care of inmates.

History of healthcare in corrections

Since the arrival of the Mayflower, offenders have been part of American society. Jails first existed to isolate and punish those who broke the law. However, the prison system changed in 1820 as a result of a religious reform movement that believed that criminals should do penance for their sins in an isolated environment called a penitentiary.² During the next century, the only goals of incarceration were punishment and penance with no plan for rehabilitation or healthcare. Inmates had no rights except those allowed by their immediate jailers. If charges of cruelty or mistreatment in health issues were made against a prison administration, the courts ignored them, believing that prison administration was beyond their scope and that they did not possess the knowledge needed to rule on such issues anyway. For example, in 1948, a case concerning mistreatment of an inmate was brought to court. The decision of the case clearly indicated that courts would not rule against correctional administration and became known as the “hands-off doctrine.”³ Thirty years would pass before sweeping changes compelled the courts to rule differently.

The prison reform movement took small progressive steps in all areas except healthcare. There was a lack of interest by professional groups, such as the American Medical Association (AMA), during those early years,⁴ and even though serious allegations and court cases exposed gross negligence, prison healthcare reform was nonexistent. As recently as 1960, a businesswoman was held for contempt of court and sent to a local jail in Cook County, Ill. Her terrified account of her week of incarceration exemplified the inhumane treatment by staff and inmates that was still present in some parts of the U.S. correctional system. Her physical exam began with a body cavity search for concealed narcotics with a vaginal tool that was not sterilized between the exams. Because she protested, the matron in charge made her the last of seven women to be examined.⁴

One of the reasons for the delay in prison healthcare reform was that no one really knew just how bad the situation was. The treatment of mentally ill inmates commonly consisted of shackles and tranquilizers, which were administered by other unsupervised inmates for weeks at a time. Prisoners with cardiac conditions were assigned to job duties that required heavy lifting. Women’s healthcare needs in general were not considered, and women prisoners were denied OB/GYN care. The presence of substandard conditions and the lack of adequate healthcare were hardly mentioned in the reports of numerous commissions appointed to study healthcare in corrections during the 1950s and 1960s. Even as inmates filed litigations charging substandard conditions and inadequate healthcare and negligence in correctional facilities, the Joint Commission on Correctional Manpower and Training, appointed by Congress in 1965, failed to obtain any useful information on healthcare services. The failure of the commission to provide the necessary data to support the need for changes in medical care delivery allowed the continuation of the hands-off doctrine that persisted throughout that decade. The courts hesitated on rulings and broad discretionary powers continued to be granted to corrections administrators in the care and treatment of inmates. Inmates were regularly used for experimental drug trials and unethical research.

Turning point for healthcare in corrections

The mid to late 1960s brought rapid social change all over the world. In the U.S., minority groups demonstrated for equality, students rebelled, and women demanded equal rights. Prisoners, too, wanted rights, but the correctional system was not yet prepared to respond. Growing tensions mounted between prisoners and corrections staff. As the turbulent 1970s arrived, inmates became more angry and militant about their treatment. On September 9, 1971, at the Attica State Prison in New York, a riot broke out and 2,200 prisoners took over the prison and held corrections officers hostage. Governor Nelson Rockefeller ordered state police to storm the facility. After four days of bloodshed and 43 deaths, order was restored. The prisoners’ list of demands revealed that they were being denied fundamental rights guaranteed under the constitution. When the list was later reviewed, the demands were found to be in line with the United Nations Standard Minimum Rule for the Treatment of Prisoners, to which all member countries, including the U.S., had agreed. The United Nations agreement included the right to adequate medical care,⁵ and in fact, it was later found that inadequate healthcare was among the reasons that sparked the prisoners’ riot. The Attica rebellion opened the floodgates to lawsuits by prisoners.

Ignoring the previous inertia of the courts, inmates brought many class action suits against correctional facilities across the country. For the first time, recognition of the sorry state of healthcare in the prison systems became unavoidable for the courts. More pressure was placed on the courts to rule on cases involving cruel and unusual punishment and civil rights violations. In 1972, Newman v. Alabama became the first case that deviated from the hands-off doctrine when the state of Alabama was found to be in violation of the Eighth and Fourteenth Amendments for not providing adequate medical care for its inmates.⁶ This case exposed a prison healthcare system riddled with questionable practices. Evidence indicated that unsupervised inmates were administering treatments, and that corrections officers were giving medications and independently performing suturing and minor surgery.⁴ No safeguards for privacy or confidentiality were in place, and medical treatment was frequently withheld as punishment. Although more court cases followed, there was still not enough judicial momentum to ensure that the situation would improve.

However, in 1976, a landmark U.S. Supreme Court decision in Estelle v. Gamble 429 U.S. defined the relationship between the Eighth Amendment and the healthcare rights of the incarcerated.¹ A Texas prisoner alleged that his constitutional rights had been violated when he was injured on prison work assignment and consistently denied care by security staff. Justice Thurgood Marshall wrote the opinion on the relationship of the Eighth Amendment prohibiting cruel and unusual punishment to healthcare issues:

“We therefore conclude that deliberate indifference to serious medical needs of the prisoners constitutes the ‘unnecessary and wanton infliction of pain,’ proscribed by the Eighth Amendment. This is true whether the indifference is manifested by prison doctors in their response to the prisoners’ needs or by prison guards in intentionally denying or delaying access to medical care or intentionally interfering with the treatment once prescribed. Regardless of how evidenced, deliberate indifference to a prisoner’s serious illness or injury states a cause of action under the Civil Rights Act.”

The presumption behind the ruling was that inmates were unable to provide their own care or access healthcare on their own. Nevertheless, they still had a right to adequate healthcare, that is, care that met community standards and was appropriate for the inmate’s serious medical condition.⁷ Estelle v. Gamble resulted in the federal court’s intervention in citing facilities that violated inmate rights. Throughout the country, courts issued consent decrees addressing food service, housing, and healthcare. However, major changes were needed in correctional facilities to deliver adequate healthcare.

Implementation of standards

Simply codifying inmates’ rights to healthcare wasn’t enough to deliver it; an infrastructure for compliance was needed. In this instance, the department of corrections in each state became responsible for implementing and maintaining a program for healthcare delivery in every facility. Standards were developed. Each facility had to reorganize and provide adequate space, supplies, and equipment to create a medical department staffed with professional physicians and nurses based on the size of the population within the facility. As more laws were passed and facilities struggled to establish comprehensive health programs, two organizations came to the forefront with basic treatment standards for correctional care facilities — the American Public Health Association (APHA) in 1986 and the National Commission on Correctional Health Care (NCCHC) in 1987 (revised in 1996). Other professional organizations also addressed correctional health with their own standards, including the American Nurses Association (ANA) (1985), the American Psychiatric Association (APA) (1989), and the American Corrections Association (ACA) (1990).⁶ In the past decade, the NCCHC has even introduced a national certification program for correctional medical department staff.

Nurses who pioneered the early implementation of standards in corrections faced an unusual workplace with few signposts to guide them. For anyone working in a correctional system, the main concern had to be security. The liability of housing a civilian department within the confines of a secure environment challenged administrators. Standard operating procedures of the facility and nursing practice had to be integrated so care could be rendered without a break in security. The possibility of a civilian in a hostage situation was a constant worry for corrections personnel, and open communication between the officers and medical staff was essential to avoid this type of occurrence.

Adequate staffing was one way to reduce risks and maintain safety. However, there was little history to establish appropriate levels. At best, what was known about the interrelationship between poor health, poverty, and crime had to guide staffing. For example, planners knew that the average inmate came to prison with a 95% chance of needing medical care, and that 60% of the time it would be the person’s first contact in his or her life with a healthcare professional. In addition, inmates arrived with a 5% chance of psychiatric issues and a 15% possibility of accompanying emotional problems.⁴

The complexities of facilities today require that adequate staffing patterns be site specific. Characteristics of inmate population, the healthcare delivery model, the size of the medical department, and the gender mix are only a few of the variables that need to be considered for configuring adequate patterns. The regulators and reviewing bodies do not prescribe staffing levels.

The inmates’ side

Once incarcerated, people need to know how to access healthcare. Inmates are informed at intake how to use confidential sick-call slips to request healthcare services. Officers do not have access to the locked box that holds sick-call requests; usually, a nurse picks them up. The confidentiality inherent in this access-to-care process protects inmates from barriers to care and requires careful follow-up to requested healthcare. Missed or refused visits for healthcare that may have an adverse effect on the inmates’ health status must be followed up diligently and documented to ensure that deliberate indifference charges are avoided. Deliberate indifference occurs when a serious medical need is intentionally ignored, or when barriers are imposed that prevent care from being given.

Although the Supreme Court guarantees the right to healthcare, the burden of proof rests with the inmate if care is intentionally withheld. Inmates do bring malpractice cases against correctional physicians, nurses, officers, and administrators. However, high-profile cases with acknowledged lapses in healthcare provision have been lost when evidence of deliberate indifference was lacking.⁷ Accurate documentation is still the best defense in any litigation case and even more so in corrections where patients are inherently available and accessible to receive care. The staff must also be alert to other possible breeches in confidentiality that may occur during the med pass, when law officers are present in the infirmary, or processing sick-call lock boxes. A Department of Corrections presence in overseeing these processes is important to avoid potential lapses or lawsuits.

Practicing behind bars

Legislation and the establishment of standards for care ensure that only qualified professionals provide care in correctional settings. Correctional nurses have freedom of practice in an otherwise restricted environment. Nurses are the advocates for inmates. When discussing cases within correctional settings, nurses refer to those under their care as patients, not inmates. They ensure that tests and exams in the correctional setting are protected by the same confidentiality and privacy laws that apply in the outside world. Consent from inmates must be obtained before release of medical records, as well as for treatment. Medical information may not be shared with the corrections staff.

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 accredited facilities, nurses do not participate in forensic information gathering, such as court-ordered body-cavity searches to uncover contraband or discussions to uncover elicit information from inmates.

Correctional nurses are pivotal in the care of inmates from intake, where chronic and acute care issues are identified, throughout their stay until release. They must be proficient in assessing the health status of the patients and work with limited resources. 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. The scope of practice can involve assignments in chronic-care clinics, sick-call clinics, medication pass, treatment procedures, and infirmary rounds.

Certain practice situations create a greater risk for correctional nurses. For example, they deal with the unknown as they screen every arriving inmate for mental illness and suicide risk, as well as physical illness and communicable diseases. All inmates are tested for tuberculosis (TB) and sexually transmitted diseases and have a physical examination before they are allowed into the general population. Refusal of a TB test results in isolation — solitary confinement — for the inmate until consent is given.

Because inmates cannot freely go to a healthcare facility, healthcare personnel must go to them. Nurses must visit inmates who request their presence and those in disciplinary segregation three times per week in an NCCHC-accredited facility to determine their health status. These visits can involve the most volatile inmates in the facility. Although in some ways the correctional health environment is safer than a local ED, the staff must remain keenly aware of where they are and of the potential for violence.

Unique set of issues

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. Death by injection to satisfy capital punishment is only the most recent ethical issue to assail medical staff. These dilemmas have intensified as the inmate population becomes older and sicker and the percentage of women behind bars increases.

Correctional settings put their own spin on situations that are straightforward in the world of the unimprisoned. For example, the simple refusal of care has become a huge issue in an environment where, until the Federal Regulations in the Protection of Human Subjects Act in 1981, inmates were unknowingly used for medical research. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) legislation established a federal standard for the privacy of an individual’s health information. Inmates are specifically excluded from the general consent and privacy practice notification requirement, both in the original rule and under the final rule as modified. However, an inmate, once paroled, regains all privacy rights. Each institution must determine how this law covers privacy. Nursing practice in an institution that has “covered entity” status must comply with HIPAA’s provisions. The Patient Self Determination Act has implications for the right to refusal as it applies to the corrections population. This legislation ensures that people can make their own healthcare decisions verbally and in writing, so that even if they are unable to speak for themselves, their wishes will be honored. Inmates have the right to informed consent and to the information necessary to make a good decision regarding their care. They also have the right to refuse care. However, the court may rule that an inmate may not have the right to refuse care if that refusal is an attempt to manipulate the system. In Commission of Correction v. Myers, the court found that the inmate’s refusal was not genuine, but rather, an attempt to manipulate the system to obtain a transfer. The court overruled his refusal of dialysis.⁷

The practical way of handling a sincere refusal of care is to have the patient meet with a group of professional staff, correction officials, and clergy to ensure that the refusal was an informed and voluntary one. However, a prudent administrator may seek a court order in cases in which a patient is refusing treatment in a correctional setting.

The sentencing law of “three strikes and you’re out,” along with mandatory minimum sentences for drug crimes, have augmented the number of inmates who will grow old in prison. They are not only older and sicker, but also living and staying longer. The caseloads of chronic-care clinics and daily sick calls reveal an increasingly aged population. The health problems from aging are more evident when screenings are conducted.

In December 2005, the number of women under the jurisdiction of state or Federal prison authorities increased 2.6% from year’s end 2004, reaching 107,518 and the number of men rose 1.9%, totaling 1,418,406.⁸ This growing population of women in the prison system brings a new set of health issues to corrections. Women need care related to gynecological conditions, pregnancy, labor and delivery, children, abortion rights, and counseling. Jail or prison administrators may violate the Fourteenth Amendment right of a woman inmate if they refuse to provide opportunities for abortion.⁷ Amnesty International has identified instances of violations of internationally guaranteed rights of incarcerated women in the U.S. The employment of men as corrections officers in women’s facilities is one example, especially if they’re present when women shower or dress, as in most states, or if they conduct pat-down searches of women inmates. Another issue is the use of restraints for women in labor, which is considered cruel and inhuman treatment by international standards, but not by federal guidelines. Although the U.S. was involved in the development of these international standards, it failed to ratify them.

Some healthcare issues unique to the correctional setting stem from conflicting responsibilities and attitudes of some officers and healthcare providers, budgetary constraints of correctional administrators, and the behavior of some inmates. Correctional health professionals need to accommodate security whenever they can without compromising their ethics or jeopardizing the health of their patients. However, when conflict occurs, medical autonomy must preside. If a practitioner perceives that an action would compromise the patient-caregiver relationship, then it should not be done. For example, because of prearranged transport schedules, correctional officers may want to change the schedules of inmates who need to be taken to a site for health testing. However, the physician’s decision regarding the timelines must be honored, and administration might have to be involved to maintain the plan of care.

Adequate healthcare is the constitutional right of all incarcerated people, but a landslide of court cases, policy changes, and a Supreme Court ruling were necessary to ensure it. Correctional nurses further ensure that this right is upheld. Although they practice in a unique setting of iron bars and uniformed officers, the role of these nurses reflects those in any field of nursing with the same checks and balances and adherence to professional standards. The standard of care in a correctional facility is no different than the standard of care in a community hospital. Nevertheless, some consider correctional healthcare to be the last frontier of modern medicine as the level of care given to those imprisoned can reflect the success of medicine, the effectiveness of legislation, the progress of nursing practice, and the advancement of society itself.