Healthcare in the Prison System

Healthcare in the Prison System Today

Today, the United States shares the dubious distinction with many totalitarian nations around the world in incarcerating an inordinate percentage of its population. Over the past two decades, the nation's prison population has skyrocketed and it continues to increase at alarming rates. While policymakers across the country are calling for stricter laws and lengthier prison sentences, the system has become stretched to its limit and many institutions have been reduced to little more than secure warehouses for people (Buck, 2000). In this environment, it is not surprising that the delivery of quality healthcare services would suffer, and this in fact has been the case. The purpose of this paper is to provide an analysis of qualitative research reports concerning healthcare in the United States prison system to identify evidence of scientific merit. To this end, a review of the peer-reviewed literature in general concerning healthcare in U.S. prisons is accompanied by a critical analysis of a qualitative study by John Doyle (1999) concerning the factors that tend to influence psychiatric nursing practice in prisons. A summary of the research and salient findings are presented in the conclusion.

Review and Discussion

Problem.

What is the problem the study was conducted to resolve? According to a recent report from the Bureau of Justice Statistics, in spite of a general decline in crime across the country, the United States continues to incarcerate more of its citizens than any other developed nation in the world. In fact, the nation's prison population increases by 900 inmates each week, and between mid-2003 and mid-2004, the nation's prisons and jails held 2.1 million people, or approximately one in every 138 U.S. residents (McDonough, 2006). By June 30, 2005, there were 48,000 more inmates, or 2.3%, more than 2004, according to the latest figures from the Bureau of Justice Statistics.

The executive director of the Sentencing Project, which advocates alternatives to prison, characterized the problem thusly: "We're working under the burden of laws and practices that have developed over 30 years that have focused on punishment and prison as our primary response to crime" (McDonough, 2006, p. 3).

Why is the problem an important one for nursing to study? In his study, "Managed Health Care in Prisons as Cruel and Unusual Punishment," Robbins (1999) reports that, "The goal of managed health care is to have a health care system that operates more cost-effectively than the traditional fee-for-service system. In managed health care systems, however, this goal is often achieved through cost-cutting measures" (p. 195). As a result, managed health care in such environments can result in inadequate treatment for patients. In this regard, Robbins adds that, "Concerns regarding inadequate health care are magnified in a prison setting, in which inmates have no choice about health care and cannot seek outside advice" (p. 195). In fact, providing inmates with quality healthcare services has been considered a "luxury" that they somehow do not deserve.

According to Sudbury (2004), "The new generation of prisons was designed to offer a harsh environment that would act as a deterrent to those considering 'a life of crime.' Prisons providing educational programs, recreation activities, a decent diet, and adequate healthcare were considered to be 'hotels' that did little to scare the inmate straight. Instead, the new prisons were to be austere environments with 'no frills'" (p. 10). Not surprisingly, then, those confined in the nation's correctional facilities continue to lack adequate health care services (Droes, 1994).Furthermore, not only is the nation's prison population growing older and requiring geriatric healthcare services (Beger & Erger, 2002, a disproportionate percentage of those serving time in the nation's prisons tend to suffer from a wide range of mental health issues which can reasonably be expected to become further exacerbated in such conditions (Doyle, 1999). Complicating the problem for prison healthcare practitioners is the fact that some inmates may attempt to conceal the fact that they have a serious mental health problem as, for example, in the case of the highly encapsulated delusional system of the morbidly jealous or psychotically deluded individual; in fact, the results of a study published in 1991 found a small number of inmates whose psychotic delusions appeared to be quite unknown to the prison staff (Prins, 2005). In this regard, Daly (2000) reports that, "The sheer demand in the correctional field over recent decades for professional psychologists has caused some 'give' in the established rigidity of employment standards" (p. 469).

Consequently, the delivery of healthcare services in a prison setting represents a unique type of challenge to the nursing profession: "A prison is identified by forensic nurses as a place where violence and manipulation are inherent. In prisons, failure to muster the ability to endure and triumph is, for the nurse, to fall by the wayside as a victim, or to become an accomplice. This occurs in a milieu identified as perverse, where caring, the core value of nursing, is expressly denied" (emphasis added) (Doyle, 1999, p. 29). In addition, Beger and Erger caution that, "Prisons are dangerous places and training must focus on ensuring the personal safety of nurses and maintaining institutional security in the context of providing health care" (p. 123). Likewise, Doyle emphasizes that "Constant harassment of nursing staff by prisoners for sedatives or analgesia for complaints of headache, anxiety, depression, insomnia, substance withdrawal, or other somatic distresses often results in a climate of tension and exasperation. Failure to respond in a salutary fashion to clients' vague, generalized, or poorly communicated complaints of somatic distress can lead patients to perceive nurses' clinical judgment as partisan and aligned with the custodial staff" (p. 29.

Study Purpose.

What is the purpose of the study? The purpose of the study by Doyle (1999) was to identify factors that influenced the practice of psychiatric nursing in prisons.

Research Question.

What is the research question? If it is not stated, what would you say the research question is? The research question is summed up in the author's topic, which was, "Factors influencing the practice of psychiatric nursing in prisons" (p. 29).

Would you say that the question is stated broadly enough for a qualitative study? Yes.

Study Design

What qualitative method is used? According to Doyle, "The research design used a preliminary focus group of 10 psychiatric mental health nurses to identify and explore issues of concern to the subjects. Themes identified in the focus group were explored through in-depth interviews using open-ended questioning and nondirective language techniques" (p. 29). Thereafter, 20 psychiatric nurses were interviewed (those who had participated in the focus group and another 10 nurses who expressed an interest in the research); the one-on-one interviews were tape-recorded and transcribed and the transcripts were subjected to qualitative thematic textual analysis, clusters of themes were completed under overarching attachments of meaning and the emergent understandings were returned to the subjects for clarification and comment. "The resultant narrative identified and explored a range of problems identified by the subjects" (Doyle, 1999, p. 29).

In what way is the method used an appropriate one for this study? Neuman (2003) advises that interviews are a valid source of collecting qualitative data.

Subjects and Setting.

In what way is the method of obtaining subjects appropriate? Doyle reports that the qualitative study specifically involved 30 psychiatric nurses who were employed in a prison: "The subjects (N = 30) were registered psychiatric mental health (PMH) nurses employed to deliver care to imprisoned and remanded male and female offenders in a large, metropolitan, central industrial prison. Nurses who participated in the study delivered 24-hour care in a walled, secure, 120-bed unit for assessment and acute and rehabilitation services" (p. 29).

In what way is the size of the sample used adequate? While quantitative analyses require larger samples to ensure reliability and validity (Neuman, 2003), a qualitative study of this nature can draw important insights from a representative sampling of 30 psychiatric nurses specifically employed in a prison setting.

In what way was the setting in which data were collected an appropriate one for this study? The author's reliance on psychiatric nursing staff strictly employed within the same prison could have been improved, perhaps, by a comparison with similarly situated nursing staff at comparable facilities elsewhere.

Data Collection Methods

In what way were the data collection procedures used consistent with the purpose of the qualitative approach selected? The structured interviews used by Doyle are consistent with the qualitative research approach selected for this purpose (Neuman, 2003).

In what way are the data collection procedures appropriate for this study? The author suggests that the data collection procedures used for this study were highly appropriate based on the unique manner in which mental health nurses view their practice and practice arrangements.

In what way were the steps taken to protect the rights of subjects adequate? There is no indication of informed consent provisions being made, but their anonymity was assured by the researcher.

What evidence is there that data saturation was achieved? While 30 psychiatric nurses may appear to represent a viable population sample for this profession, the author does not provide any comparison figures of overall employment so it is impossible to discern the adequacy of the sample used.