Jeffrey is a 29-year-old man charged with murder. Officers report that he allegedly murdered his girlfriend during an argument by stabbing her several times with a knife. During the booking process, officers observed Jeffrey’s eyes darting around the room, and he appeared to be in a heated conversation with “unseen others.” He would often cry out, “Leave me alone. I told you to leave me alone!” When his handcuffs were removed, he became combative. Jeffrey said the same voices that had kept him awake for several days before his argument with his girlfriend were telling him to attack the officers. When asked about substance abuse or any medical problems, Jeffrey responded, “No way. I’m not sick, never have been, and I don’t do drugs!”

Jeffrey’s case is challenging, but not unique to nurses working in correctional mental health. Similar situations occur on a daily basis. The nurse’s ability to perform mental health assessments and make critical decisions are key factors for intervening in these challenging, complex cases.

More than half of all prison and jail inmates, including 56% of state prisoners, 45% of federal prisoners, and 64% of local jail inmates were found to have a mental health problem, according to a new study published by the Justice Department's Bureau of Justice Statistics (BJS).¹ The census of jails and prisons is on the rise, increasing the number of incarcerated mentally ill. At midyear 2005, 747,529 inmates were held in the Nation's local jails, up from 713,990 at midyear 2004. And 2,193,798 prisoners were held in Federal or State prisons or in local jails — an increase of 2.7% from year-end 2004, but less than the average annual growth of 3.3% since year-end 1995.^2,3 Subsequently, many jails and prisons struggle with a multitude of issues, such as overcrowding, understaffing, a limited number of medical and psychiatric resources, and architectural and space limitations.

In jails and prisons, mental health services have been expanding to meet the needs of this growing population. This expansion provides an opportunity for psychiatric nurses to move from community-based mental health to correctional mental health. Although the two environments have similarities, there are also differences that create unique challenges. Correctional settings also try to develop intervention programs. The key to intervention programs lies in the accurate communication of relevant information regarding the past or recent behavior of suicidal inmates. The individual facts of each case suggest which method of intervention is most appropriate for the individual inmate.

The setting

Correctional mental health programs primarily focus on suicide prevention, identification and treatment of the mentally ill, and continuity of psychiatric treatment. The psychiatric nurse plays an integral role in all of these programs.

The psychiatric nurse’s role in a correctional setting is unique. The nurse may work as a staff nurse on an inpatient unit providing psychiatric nursing care to inmates on that unit or act as an outpatient nurse, providing evaluations, counseling, or crisis intervention to inmates in the general population.

Programs vary in size and scope of services in proportion to the population of the county jail, funding, and court mandates. For example, a large county jail may provide inpatient treatment on an inpatient unit within the jail or through a contract with a psychiatric hospital. Smaller county jails typically contract their acute services with a local psychiatric hospital. Outpatient-level services are usually provided 24 hours a day in a larger jail, while smaller jails may provide services only on the day shift. A smaller jail may employ mental health nurses on a part-time basis or not at all. States often designate single prisons within their prison systems to provide acute psychiatric care or use infirmary settings within each prison to stabilize and treat acutely mentally ill inmates.

An inpatient unit in a jail or prison may be a group of cells specifically designated to house psychiatric patients. Depending on the state, the county mental health department or the state department of mental health or health services may designate or license these units for acute care. The units may be merely protected or observed housing for mental health patients receiving services, but not at an inpatient level of care. The term outpatient describes inmates in the general population and a level of care similar to a community outpatient setting. The scope of outpatient services depends on the program design, court mandates, and funding. Some programs vary from basic treatment, such as medication prescriptions and medication monitoring, to more involved and lengthy treatment programs that include long-term individual and group psychotherapy. Most programs fall somewhere in between this range and include crisis intervention, counseling, medication monitoring, prerelease discharge planning, and patient teaching.

Differences in the scope of services provided at each correctional facility vary according to human and financial resources, state regulations, and court mandates. Despite differences in services, the inmate has certain rights under the Constitution and through state regulation or constitution. The most important of these rights is access to care. Therefore, screening and triage of referrals, timely response, assessment, and psychiatrist availability and accessibility are critical components in any correctional psychiatric program.

In these programs, the psychiatric nurse functions as an educator and consultant. The nurse’s work with correctional and medical staff is critical to facility operations and patient care. A psychiatric nurse may provide staff inservices or workshops on topics such as identification of the mentally ill, suicide prevention, psychotropic medications, and management of the mentally ill in the correctional environment. Daily contact with correctional staff to provide support, education, or guidance in managing mentally ill prisoners is invaluable to the day-to-day operations of the facility. Maintaining professional and collegial relationships and educating staff enables nurses to act as patient advocates and ultimately serves patients well. As emphasized by well-known suicide-prevention expert Lindsay Hayes, the key to an effective team approach in suicide prevention and crisis intervention is found in the elimination of territoriality and the maintenance of mutual respect for the each other’s professional abilities, responsibilities, and limitations. Regardless, all team members, correctional officers and medical and mental health staff alike, need to make a commitment to acknowledge that suicide prevention and related mental health services are only effective when delivered by professionals acting in unison with each other. The mental health nurse or clinician alone cannot ensure the safety and emotional wellbeing of the individual inmate.⁴

Assessment

Medical nurses, other healthcare providers, and correctional staff may refer inmates to psychiatric nurses for assessment. However, conducting a mental health assessment in a correctional facility can be challenging. For example, a lack of space for interviewing often forces nurses to be inventive, creating a semiconfidential interviewing room in a corner of a hallway out of earshot of others. When interviewing a combative or potentially dangerous person, custody staff must stand by, which often influences the amount of information the inmate is willing to provide. Nurses have to become skillful in engaging the inmate and building a trusting relationship quickly. It is also important to know the inmate’s arrest charges. However, nurses should not ask questions specific to the nature of the charges or circumstances of the crime. This is most critical in an unsentenced person, because disclosure of this information may then involve nurses in the legal system.

Throughout the assessment, the psychiatric nurse collects data through observations of verbal and nonverbal behaviors and through learned interactive and interviewing skills, based on a broad biopsychosocial knowledge base.⁵ The purpose of the assessment is to gather enough data to formulate a plan of care. A mental health assessment consists of two components — the psychosocial assessment and the mental status examination.

Components of a psychosocial assessment should include —

• Demographic information (name, birthdate, residential data, support system, arrest date, charges, and status of court proceedings, or release date)
• Presenting problem and nature of the referral (for example, whether the inmate was self-referred or referred by officers; include the reasons stated in the referral)
• Problem chronology (onset, description, duration, related events, relevant psychiatric and family histories, and past and present coping skills)
• Medical information (history of any present problems; past and present medications, especially agents with potential adverse effects; past and present medical conditions, particularly those that may affect mental status, such as diabetes; and previous psychiatric treatments, medications, and hospitalizations. Medical etiologies of any present problems need to be sorted out from potential psychiatric causes.)
• Substance abuse history (drugs used, such as alcohol, street drugs, and prescription and over-the-counter medications; route; amounts; frequency; last use; and any past withdrawal symptoms)
• Socioeconomic factors (support system; occupation; education; family history; history of physical, emotional, or sexual abuse; arrest and incarceration history. Arrest and incarceration information can give nurses a sense of criminal sophistication and whether the patient “knows the system.” The nature of the criminal charges, such as the severity of charges and notoriety of the case, may indicate the potential for violence, antisocial tendencies, or the degree of stress the person is facing.
• Assessment for suicidal and homicidal thoughts (current thoughts, plan, intent, and history)
• General level of functioning and ability to make use of food, shelter, and clothing

During the mental status examination, the nurse gathers data through observation and interview. The mental status examination consists of assessing appearance, behavior and activity, attitude, speech, mood and affect, perceptions, thoughts, sensorium and cognition, judgment, insight, and reliability.⁵

Simple, open-ended questions related to orientation, mood, memory, and thoughts often elicit a great deal of information. Questions such as, “How are you coping with being in jail?” and “How are you getting along with your cellmate?” often open up the conversation and provide ample opportunity for the nurse to assess mood, memory, and thoughts. Creating a comfortable, supportive nurse-patient relationship enhances the quality of the assessment. Many institutions use a standardized format of a mental status examination.

During the conversation, the nurse should note the patient’s appearance and hygiene, body language, movements, and facial expressions. The nurse should note any tattoos or scars. Tattoos may indicate gang affiliations, such as “AB” for a hardcore Aryan Brotherhood member, or may indicate previous incarceration, such as the presence of self-made “jailhouse tattoos.” Scarring, particularly on wrists or neck, may indicate suicide attempts, or numerous transverse scars on wrists may indicate “hesitation marks,” or a history of self-mutilation. Hesitation marks can be evidence of half-hearted or conflicted attempts at suicide. Some patients report cutting themselves to release tension.

The patient’s attitude may be defined in descriptive terms, such as friendly, guarded, angry, hostile, resistive, or cooperative. The nurse regularly listens to the patient’s speech to assess quantity and quality. Terms used to describe abnormal quantity include poverty of speech, poverty of content, or hyperverbal. Quality may be described as articulate, soft, loud, rapid, pressured, sparse, talkative, and hesitant. Use of particular jail or prison jargon may provide information about how familiar a person is with the correctional system.

The affect is the emotional reaction associated with an experience or the topic of conversation. Some descriptive words used to describe the inmate’s affect are flat, labile, blunted, angry, hostile, silly, or appropriate to the topics discussed. Mood describes the sustained emotional response presented by the patient, and may be described as sad, depressed, grandiose, happy, anxious, hostile, or angry.

The nurse also assesses the inmate’s thought form and content. Common descriptive words used to describe form are coherent, linear, disorganized, tangential (almost connected but not quite), or flight of ideas. The conversational content provides clues to thought content and perceptions. Perceptions are observations people make about their environment, situations, relationships, or actions of others.

One primary thought disturbance is the delusion, a false belief that is not based on reality, such as paranoia. An example of a delusion would be inmates who refused to eat because of a belief that their food is being poisoned. Another example would be people who are concerned that “someone is out to get them.” These thoughts may be difficult to evaluate, because many inmates do have rival gang affiliations or conflicts with other inmates that may be real and not imagined. The nurse should also differentiate between an illusion, a misperception of actual stimuli, and a hallucination, which is a visual, auditory, olfactory, gustatory, or tactile perception not based on reality.

Sensorium and cognition refer to levels of consciousness, attention span, orientation, intelligence, and the ability to process information. Judgment is the ability to assess and evaluate situations, while insight is the ability to perceive and understand the cause and nature of a person’s own or another’s situation. Although standardized testing is more effective, a nurse can ask the patient to respond to predetermined scenarios to assess their sensorium, judgment, and insight. For example, the nurse may ask a classic question for evaluating judgment, such as “What would you do if you were walking down the street and you found a letter with a stamp on it?” Another method for ascertaining an inmate’s judgment is by assessing how the person has been coping in the jail, behaving in particular situations, or relating to staff or other inmates. Examples of impaired judgment could be calling others derogatory names, flooding another inmate’s cell, or taking an aggressive stand towards a judge in court.

Obtaining reliable information

Inmates are not always reliable in the general community. Unreliability is even more common in the correctional setting where an accurate medical history is so important. An accurate history is essential for medical staff to know how to treat a person, what preexisting conditions exist, what to expect in terms of the patient’s baseline, and how to avoid being manipulated or inadvertently making changes in a treatment plan based on erroneous information. Many factors influence inmates’ reliability. It could be that they simply don’t know or recall the names of certain physicians or medications. At times, inmates may be afraid that what they say may be used against them. Other times, they may possess character traits in which dishonesty is used as a coping or survival skill.

Central to assessment is the collection of information from different sources about the inmate’s mental health and level of functioning.⁶ Obtaining collateral information from family, prior treatment agencies, officers, and medical staff is often necessary. This collection of information can sometimes detect or prevent such catastrophic events as suicide. There are essentially three stages of communication in preventing inmate suicides: (1) communication between the arresting or transporting officer, correctional staff, and family members; (2) communication among facility staff (including correctional, medical, and mental health staff); and (3) communication between facility staff and the suicidal inmate. In the case of Wilson v. Genesee County, the court concluded: “In essence, this case is about a failure to communicate and/or have policies in place for adequately accessing and communicating an individual’s suicide risk at all levels, and especially when transporting an individual from one facility to another.”⁷ The nurse can check old medical or mental health records the correctional facility has onsite and send releases for information from other agencies. Checking with family members or significant others to corroborate the patient’s history is also helpful.

An essential component of the psychiatric history is obtaining information about the inmate’s current or recent treatment. Continuing medication regimens from the community or prior treating agency is necessary to prevent decompensation and adverse effects from abrupt cessation of prescribed medications. Nurses should ask inmates for the name of their psychiatrists, clinic or treatment locations, and medications, including names, doses, duration, compliance, effectiveness, and last doses. The name of the pharmacy the inmate uses may be helpful in verifying medication. Nurses should ask inmates to sign a release of information, and then proceed with contacting psychiatrists or prior treating agencies. Some patients are unable to recall this information, and in those cases the pharmacy may be contacted for verification.

In addition to the patient interview and the determination of precipitating events and circumstances that prompted the need for an assessment, the nurse can use collateral and historical information from previous correctional medical and psychiatric records and arrest records to evaluate reliability. The nurse may also collect information on the inmate’s current behavior from officers and inmate peers. This is often helpful in determining how the inmate has been functioning and may help in identifying needs not always apparent in the interview.

Substance abuse

According to a 2002 study by the National Institute of Justice, Arrestee Drug Abuse Monitoring Program, in half of the 35 reporting sites, 64% or more of the adult male arrestees had used at least one drug, and 27% to 47% were considered to be at risk for dependence on drugs. In all but three of the sites where female arrestees were studied, more than half tested positive for use of at least one drug.⁸ In addition, data collected by the Department of Justice in 2002 shows that three out of every four convicted jail inmates were alcohol- or drugs-involved at the time of their current offense.⁹

Obtaining a history of substance abuse and recognizing the symptoms are critical to a comprehensive assessment. Abused drugs include alcohol, cocaine, methamphetamines, benzodiazepines, marijuana, hallucinogenics, and opiates. More recently, abuse of gamma-hydroxybutyrate (GHB) and 3, 4-Methylenedi- oxymethamphetamine (Ecstasy) are becoming prevalent. Withdrawal from drugs can be mistaken for mental illness. For example, psychosis is a symptom of diazepam (Valium) withdrawal and can be life-threatening. A patient exhibiting signs and symptoms of benzodiazepine withdrawal requires immediate intervention and physician notification. Psychiatric nurses in correctional settings must have a solid foundation in substance abuse and withdrawal in order to assess inmates accurately and act swiftly to obtain urgent medical intervention if withdrawal symptoms are suspected. Acute drug or alcohol withdrawal should be considered in any inmate exhibiting bizarre behavior or a change in mental status during the initial two weeks of incarceration.

IV drug abuse is often noted among the incarcerated population. IV drug abuse is a high-risk factor for hepatitis and AIDS. Impaired liver function from hepatitis and drug and alcohol abuse may significantly affect mental status. In addition, AIDS-related dementia or mood disorder should be considered when assessing patients with a history of a positive HIV test or diagnosis of AIDS.

Malingering

Malingering describes inmates who feign mental illness. It typically involves short-term or long-term secondary gain. In the correctional setting, inmates may act “crazy” because they are having problems with custody staff or peers and want to change their housing location. Sometimes, they simply want to talk to someone or want emotional support. A long-term secondary gain may be that inmates believe that a psychiatric diagnosis will somehow help their court process. Therefore, a thorough assessment is critical.

When a nurse suspects that an inmate is malingering, a judgment may be made that the inmate is “faking.” The nurse may feel that he or she is being “used,” and this arouses anger and feelings of exploitation. The nurse may lose objectivity. To maintain objectivity, the nurse should discuss such cases with colleagues or supervisors and use self-reflection to monitor emotional responses to avoid labeling. The nurse should refocus inmates on coping skills with the intended goal of assisting them to learn healthier, more appropriate ways of coping.

Malingerers frequently verbalize suicidal intent or make suicidal gestures such as scratching their wrist or tying a noose around their neck, making sure that someone observes them. The nurse’s challenge is to avoid minimizing the inmate’s threat and to remain objective despite suspicions of malingering. It is important for the nurse to remember that an inmate may be mentally ill and malingering at the same time. These are not mutually exclusive. Engaging in a power struggle with the suspected malingerer can provoke the inmate to engage in further destructive behaviors. Teamwork, consistency of interventions, continuity of psychiatric and correctional staff, and a clear, well-communicated treatment plan are essential factors in working with patients who exhibit symptoms of malingering.

Suicidal assessment and management

A 1995 study by Lindsay Hayes, found suicide rates to be —

• 12.2 suicides per 100,000 in the general public
• 20.6 suicides per 100,000 in prison population
• 107 suicides per 100,000, in the jail population⁸

Suicide risk is higher in jails and prisons than in the community. Incarcerated people often experience the correctional setting as insensitive and unresponsive to their needs. Many inmates verbalize feelings of overwhelming stress, hopelessness, and fear of the unknown. The life they knew before incarceration may be changed forever. Even if the experience may result in something positive, it is very difficult for them to imagine. Inmates with adequate coping before jail or prison will adapt, but even this group is at risk when additional stressors during or as a result of their incarceration are experienced.

Some analysts have theorized that jail inmates have an even higher rate of suicides than those in prison because of the isolating and crisis nature of the jail setting. Jail inmates often express a fear of the unknown, particularly the outcome of their court case, and may suffer from their recent loss of freedom, separation from family or friends, recent substance abuse and intoxication, and physical and psychological withdrawal from drugs.¹⁰

All suicidal threats should be taken seriously. Nurses must act with compassion as well as objectivity. An assessment provides the nurse with information needed to provide a safe environment for inmates and to determine what level of care they need. A thorough suicide assessment includes —

• Historical factors (history of psychiatric disorders or suicide attempts, family history, and views of suicide)
• Environmental and geographic factors (demographic predictors based on data, such as age or race, and environmental predictors, such as life stress and social support)
• Lethality of suicidal thinking (probability of a suicidal act resulting in a fatal outcome)
• Psychological factors (psychiatric disorders; suicidal thoughts, indicated by verbal content, cognitive style, and presence of psychosis such as command hallucinations telling the individual to kill him- or herself)
• Evaluation of risk potential (objectively classifying the client into a predefined risk category)
• Reporting of risk (documenting the assessment in a legally defensible way, developing a treatment plan, and seeking peer consultation)¹¹

The nurse should be alert to signs of severe depression and hopelessness that may be exacerbated by severe isolation, particularly in single-cell or disciplinary housing units with minimal social interaction.¹²

The nurse should also assess for warning signs that indicate the inmate has made a decision, for example, a previously depressed patient experiences an abrupt change in mood and energy or gives away prized possessions. Another example to be aware of is someone who is “normally” social, talkative and who interacts with others, then suddenly becomes withdrawn. An inmate with a plan is at high risk and requires immediate acute psychiatric hospitalization. In this case, a nurse would institute the facility’s protocol for hospitalization and immediate suicide prevention, which may include immediate notification of correctional or custody personnel and referral to a psychiatrist.

Safety interventions

The psychiatric nurse in a correctional setting must have a heightened awareness of assault potential, escape potential, contraband, and safety measures. Most agencies require a safety and security training class and education regarding suicide prevention.

Facilities should have a suicide prevention plan that includes inmate screening, observation and treatment for suicidal inmates, a humanistic approach, training for all correctional staff, and physical plant considerations. Suicide prevention plans are often incorporated into the overall facility safety measures to reduce contraband, provide safety-proof cells, limit dangerous objects carried by staff, and restrict objects possessed by inmates. The facility plan typically includes a screening program that provides questionnaires or assessments by staff to address an inmate’s suicidality. Positive responses result in referral to psychiatric staff.

Isolated housing within the jail or prison environment has been associated with suicides.¹³ Acutely suicidal inmates cannot be left alone or segregated without close monitoring. Monitoring procedures reflect varying degrees of risk and range from constant monitoring to routine 30-minute staff observations. Once determined to be suicidal, an inmate may be observed or monitored using cameras. Staff also uses frequent eye-to-eye contact or direct visual observation, which cannot be substituted for by cameras, to ensure patient safety. Observation cells or inpatient psychiatric unit cells are “safety-proofed” to reduce the patient’s risk of self-harm. For example, electrical outlets are blocked or shut off, hooks or areas to affix nooses are removed, and safety glass is used. Hospital beds with removable parts or bedrails that can be used as a point of fixation for hanging must be avoided. Items such as pencils or toiletries may be removed if the person is at risk for ingestion of foreign bodies.

]Because hanging is a major risk in correctional settings and articles of clothing, such as shoelaces, can be fashioned into a noose, many correctional facilitates now use “safety smocks” or “safety suits” for privacy when clothes are removed for safety reasons. A safety smock is made out of material that cannot be torn or easily woven into a noose or rope. When the treatment team has determined that the person is no longer at high risk for suicide, clothes are returned.

The nurse’s goal in interacting with the suicidal inmate is to provide ongoing suicide assessment and to assist that person in developing improved coping skills by teaching stress management techniques, offering support, and discussing ways to adapt to the general population. The nurse can assist the inmate in learning facility rules, following directions, adjusting to boredom or downtime in a cell, and gaining social skills to improve interactions with peers and custody personnel.

Patient rights

Inmates have many of the same rights as patients in a community mental health setting, including confidentiality, clothing, writing material, visits, privacy, and the right to treatment and the right to refuse treatment. These rights are governed by the 8th amendment to the Constitution of the United States, and by a groundbreaking case Estelle v. Gamble. These rights cannot be denied without good cause. For example, in some states, a physician’s order is required to deny a patient a right on an acute psychiatric jail unit. Each state or county has a procedure for denial of rights and reporting requirements. Inmates also have a right to refuse psychotropic medication. Inmates may, however, be given emergent medication with a physician’s order in an emergency situation. Nurses should refer to their particular state regulations regarding involuntary, emergent medication administration.

Case management

The majority of mentally ill offenders need the basic elements of case management.¹⁴ Psychiatric nurses in correctional settings often act as case managers, beginning prerelease planning upon the initial contact with inmates. Continuation of any treatment and medication from jail and transition to the community-based treatment in a swift manner is critical to success. Unfortunately, resources in this area are often lacking. Many inmates may not have predetermined release dates, thereby leading to releases at all hours of the day and night. Prerelease planning and coordination with community-based programs are necessary to promote continuity of care and prevent recidivism. Nurses are vital members of the interdisciplinary team and play significant roles in the assessment, planning, implementation, and evaluation of the case management plan to best meet the needs of patients.¹⁵

Within the confidentiality laws of a particular geographical area, psychiatric nurses in correctional settings can share information with treating agencies for purposes of continuity of care. Psychiatric nurses can enhance their knowledge of community resources by interacting with community agencies and developing networks and collaborative efforts with providers.

Correctional psychiatric nursing is a challenging field. Psychiatric nurses in correctional settings face exciting cases that require strong assessment skills, decision-making abilities, crisis-intervention acumen, and a solid psychiatric nursing foundation. These nurses play critical roles in the treatment team and often find advocating for the mentally ill in the complex world of corrections professionally satisfying and rewarding.