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Pacific Region

Nursing on the Inside

By Shirley Cox, Regional Accreditation Co-ordinator

I find myself smiling as I reflect on my last 10 years as a nurse in a correctional setting. In February 1993, when I walked through the prison gates, I entered a world that caused a complete shift in my thinking about the provision of health care. I soon began to learn about the culture on the inside and how it differed from the community outside.

The prison population presented to me a new way to the examine issues that I encountered each day.

Security Mandate Versus Nursing Care
Prison is a unique environment, a world of its own, that presents a number of challenges for health service staff. I was interested and pleased to learn that the Mission of the Correctional Service of Canada (CSC) supports both rehabilitation and the promotion of health. The challenge for a nurse is to manage the provision of care and treatment while maintaining the safety of the public, staff, and inmates. Because of the particular pressures in the correctional environment, even in a medical crisis the safety and security of all persons must be ensured before care and treatment delivery begins.

Concerning my personal safety, I can honestly say that I feel safe in the prison setting. I am aware that I deal with inmates' who have criminal histories and that there is a potential for assault. I believe, however, that for the most part inmates view nurses as not being a part of the correctional security organization, so their risk is lower than for some other CSC staff. Additionally, there are overt security measures in place that are designed to ensure the safety of health staff. In any event, I take no unnecessary risks. I wear a personal portable alarm and if an inmate appears to pose a risk, I do not see him without security present. I have made the effort to learn about health care delivery in prison and about the issues that concern inmates and that has helped prepare me, as a nurse, to respond in a controlled manner and manage situations effectively.

The professional standards that guide the delivery of nursing care in prison are the same standards as in the community. The nurse need not compromise his/her standards of practice while working in prison. The challenge is to consistently apply those standards while complying with CSC's security regulations.

Ethical Challenges
Certainly there have been a number of ethical challenges. How do I maintain the dignity and confidentiality of my patients when there is a need to assess and treat them in the presence of non-health personnel? How do I maintain a therapeutic relationship with a patient who may be verbally abusive? It is a balancing act to be a nurse advocate for an inmate patient while at the same time working to be a team player within the correctional system.

Specialized Knowledge
Nursing in a correctional setting requires a specialized body of knowledge. There is little written information available related to best practices in this area. Opportunities such as attendance at national and international conferences, while limited, are wonderful because they provide occasions for learning and networking with other professionals facing similar challenges. In recent years CSC has supported nursing staff to develop working groups or national committees concerning methadone, palliative care, infectious diseases and other important issues. This assistance has contributed to the sharing of knowledge among correctional nurses in Canada and has decreased the isolation of this health professional group.

Continuous Learning
More than anything, my past 10 years with CSC has reinforced my personal philosophy concerning the importance of continuous learning. I have seen an evolution in the nursing role within the correctional setting and I believe that we are managing situations of ever-increasing complexity. We are working with a vulnerable population that is aging and not well informed about health issues. Applying nursing principles for advocacy is paramount.

As the complexity and the acuity of our patients' issues increase, so too does the nurses' need for knowledge. Knowledge of medical conditions certainly, but I think that nurses in CSC must also understand that they are the conduit for access to community resources and relationships. Learning how to manage professional and non-professional multi-disciplinary teams as well as respecting the dignity and privacy of inmates is a balancing act aimed at one goal - a holistic approach to health care.

A continuous learning approach is a shared responsibility between the organization and the employee. I believe that the organization has a responsibility to make available opportunities for health professionals to obtain the knowledge required to perform their jobs competently. I also strongly believe that we nurses have individual responsibility to know where to find needed information and then to seek out that information. Working within the correctional environment means that we are often practicing alone, thus requiring that our knowledge base be solidly founded on standards of practice.

Standards of Practice
The nurse who understands standards of practice and manages their application in an ethical manner will provide the best care and always advocate for the inmates. It is imperative for any nurse working in the prison setting to continue learning in order to maintain quality and a satisfying level of practice.

In conclusion, I know that working with this vulnerable population group has been at times the most challenging part of my career. It also has been the most rewarding. I look forward to practicing my profession a few more years and continuing to learn each and every day.