Vulnerable and cultural perspectives for nursing care in correctional systems

Vulnerable and cultural perspectives for nursing care in correctional systems

Hufft, Anita

At the 2001 Surgeon General’s Conference on Youth’s Mental Health a national action agenda recommended that evaluation and mental health treatment of youth be conducted in a culturally competent manner (Scahill, 2001). Mental health services within the juvenile justice system were specifically identified as needing improvement. National priorities in health care reflect the value of diversity in the workplace, including those professionals, who care for incarcerated youth (King, Sims & Osher, 2002). The goal of culturally competent care for clients in correctional settings is to encourage appropriate exchanges and collaborations among offenders, health care providers and correctional staff. These collaborations should foster equitable health outcomes and result in the identification and provision of services that are responsive to issues of race, culture, gender, sexual orientation, and social and economic status. Being competent in cross-cultural functioning means learning new patterns of behavior and effectively applying them in appropriate settings.

The purpose of this paper is to extend the idea of cultural competency to the context of nursing in correctional settings. The culture of prisons will be described as it relates to health care of offenders and caregivers, particularly in juvenile correctional settings in Louisiana. In addition, the range of ethnic and other cultures represented in correctional settings will be described in terms of the characteristics and needs they bring to health care situations.

In his work, Cultural Literacy: What Every American Needs to Know, Hirsch (1987) writes, “to be culturally literate is to possess the basic information needed to thrive in the modern world, … and includes a descriptive list of the information actually possessed by literate Americans.” (p. XIII-XIV). Extending over the domains of human activity, cultural competency in nursing is akin to cultural literacy in that it encompasses basic information about diverse populations of clients for whom nurses provide care. Brackley (1995) estimated that fifty percent of a nurse’s caseload is composed of people from a culture different from the nurse. The American Academy of Nursing (in SREB (1999) Preparing Graduates to Meet the Needs of Diverse Populations, p. 5) defined cultural competency as ” a complex integration of knowledge, attitudes and skills that enhances cross-cultural communication and appropriate and effective interactions with others.” The American Nurses Association (ANA) has asserted culturally competent nursing care goes beyond cultural sensitivity, beyond awareness of different cultures to specific knowledge and skills upon which to change situations of oppression and avoid stereotypical assumptions (ANA, 1998). Based on the anthropological notion that all human communities develop through learned and shared information about what is acceptable and expected behavior, nursing has evolved as a scientific practice discipline rooted in our own cultural values of caring, compassion and technical competencies.

Punell and Paulanka (1998) define culture as, “the totality of socially transmitted behavioral patterns, arts, beliefs, values, customs, life ways, and all other products of human work and thought characteristics of a population of people that guide their worldview and decision making”. (p.2). The prison or correctional setting represents a challenge to nursing as offenders represent a multitude of cultures within a unique culture of the prison itself. Culture is a distinctly human capacity for adapting to circumstances and transmitting this coping skill and knowledge to future generations. The prison culture has its own attributes, forming a sense of identity, a set of expected behaviors, and distinct goals for those people, who are incarcerated and for those people, who care for them. According to anthropologist Ina Brown (in Harris & Moran, 1991), people in different cultures react emotionally and psychologically to different situations as a consequence of differing perceptions to those situations; this reaction is a function of learned culture. The culture of prison becomes a setting in which persons from various cultures and criminal backgrounds come together in a contrived culture derived from values and dictates of the criminal justice system and the participants in the operations of the institution.

Prisons mirror those characteristics of any culture through expression of values and norms, beliefs and attitudes, relationships, communication and language, sense of self and space, appearance and dress, work habits and practices, and food and eating habits. Correctional nurses who are aware of the cultural backgrounds and characteristics of offenders are in a position to adapt health care practices to meet client needs and avoid imposing their own attitudes and approaches on others.

PRISON SYSTEMS

Historically, prisons have served five major purposes in American society: retribution, deterrence, incapacitation, rehabilitation, and restoration (Wrobleski & Hess, 1997; Schmalleger, 1999). Retribution represents punishment for the sake of punishment – also referred to as revenge. Retribution focuses on the crime itself rather than on the offender’s needs or the needs of the community. Deterrence relies on incarceration as a means to prevent future criminal actions and is more proactive and functional than retribution. Incapacitation refers to making it impossible for offenders to commit other crimes and has the goal of segregating offenders from the rest of society to protect them. Rehabilitation has the goal of correcting deviant behavior. In and out of favor in the criminal justice system and dependent upon funding, rehabilitation is the focus on medical and mental health treatment for many offenders whose offense is related to their pathology. Due to critical levels of funding and questions about the effectiveness of rehabilitation in light of high recidivism rates among offenders, the prevailing approach of the criminal justice system in relation to corrections currently focuses on punishment or retribution. An evolving paradigm of justice, called restorative justice, focuses on problem solving and repair of social injuries incurred through criminal behavior (Wrobleski & Hess, 1997). Restorative justice acknowledges the relationship between the offender making retribution for injuries perpetrated in criminal offenses. This approach recognizes the ability of and the victim, the rights of the victim and the need for society to be repaired through the offender the stigma of offense to be removed through repentance and forgiveness; while implemented in probation sentencing, does not represent the current model of prison culture.

The prison culture values order and obedience, power over the weak or disenfranchised, and strict adherence to policies and procedures. Many prisons are characterized by a culture of fear (Ramsbotham, 1999), and underscored by actions by offenders and staff suggesting racism and sexism. Normative behavior often includes widespread use of drugs and physical and mental abuse among offenders. Prison culture is heavily oriented towards security, with offenders being kept powerless and forced to rely on correctional officers for the delivery of services, particularly health care (Saunders, 2002).

Prisons are overcrowded and occupied by individuals convicted of violent crimes (46%), property crimes (24%) and drug crimes (23%); the latter being the most rapidly increasing category (Schmalleger, 1999). Low levels of formal education, socially disadvantaged backgrounds, and a lack of significant vocational skills in general characterize the prison population. Most adult offenders have served considerable time in juvenile correctional facilities and evidence acculturation to the prison.

Correctional nurses must first be aware of the culture shock most offenders experience upon first entering a correctional setting. Culture shock is a psychological disorientation related to inaccurate interpretation of role expectations or cues from another culture (Caggins, In ACA, 1993). In addition to being cast into interactions with persons of diverse and often unknown cultural backgrounds, the prison itself presents an environment requiring adaptation. Offenders must adhere to sets of policies dictating every movement and event from when they eat and sleep to what they wear, when they can speak, and what work they will do each day. They are cut off from family and social support systems and subjected to lack of privacy, changes in stimulation and recreation activities and limited access to physical and emotional stress management options. Offenders in prison must learn vocabulary and postures in order to fit in. They must quickly identify the power structures among the other offenders and among the staff in order to avoid becoming a victim of abuse or ridicule. Offenders with physical problems, developmental, or mental disorders are particularly vulnerable to segregation and victimization. All offenders share common deprivations of liberty, goods and services, heterosexual relationships, autonomy, and personal security. These are the common stressors that link the offenders in bonds of the prison culture.

One approach to the study of prison culture is based on the work of Erving Goffman (1961). He described total institutions as places where the same people work, play, eat, sleep and recreate together on a daily basis. Such places include prison concentration camps and mental institutions, and seminaries. Total institutions are small societies cut off from the larger society either forcibly or willingly. They evolve their own distinctive values and styles of life.

THE PRISON SUBCULTURE

Two realities exist in prisons. One is the official structure of rules and procedures dictated by the State Department of Corrections or the Federal Government. The other is the more informal but more powerful inmate culture – the prison subculture. Offenders have to learn all the rules and regulations set by the corrections administration, but they must also learn very quickly the unwritten rules dictated by the prison subculture incorporating inmate concerns, values, roles and even language (Schmalleger, 1999). The inmate learns an unwritten code that dictates five common elements:

* Do not exploit offenders. Do not steal. Do not break your word, be right.

* Do not whine. Be a man.

* Do not interfere with the interests of other offenders. Never rat on a con.

* Do not lose your head; play it cool and do your own time.

* Do not be a sucker. Do not trust the guards or the staff.

Prison subculture is constantly changing and reflects the diversity of the inmates. Structural dimensions of prison subculture often determine the way prison culture is described. These dimensions include the degree to which the staff and the offenders are alienated, the three general categories of offense types among the offenders, how work gangs and cell houses are organized, racial groups, the power of inmate leaders, the degree of sexual abnormality presented by an inmate and personality differences existing in individuals (Schmalleger, 1999).

SPECIAL POPULATIONS IN CORRECTIONS

Since the 1960’s, a growing concern for the rights of ethnic minorities, women, the physically and mentally challenged and many other groups was extended to the issue of unfair and inequitable treatment by the criminal justice system. A special population is identified as any group of individuals who present patterns that distinguish them from other individuals and whose patterns of behavior or physical characteristics affect their health or experience of health and health care. Within the prison culture there are specific groups needing nursing assessment and intervention. Major groups identified as special prison populations upon which one can focus culturally competent nursing intervention strategies include:women, homosexuals, juveniles, gang members, ethnic and racial minorities, elderly and those with chronic illnesses.

Women

Although women represent only 10% of the country’s correctional population, the are the fastest growing group in jails nationwide (Sourcebook of criminal justice statistics, 2002). On average, female offenders are 2.5 years older than their male counterparts, are less likely to be convicted of a violent offense, and are more often than not victims of sexual or physical abuse, involved in drug use or drug trade, and have youth (Greenfeld & Snell, 1999). Women live in prison within complex social systems based on close emotional relationships with other offenders. Women find prison life harder than men, crave affection and are more vulnerable to homosexual relationships (Heidensohn, 1995).

Women are especially vulnerable to the stress of separation from family and youth. Women’s correctional facilities often suffer from lack of resources as compared to men’s, in response to lack of funding equity. Fewer women in prison results in insufficient numbers to justify many programs.

Women in prison present unique health care challenges due to poor self care, high drug use and histories of sexual and physical abuse, high-risk pregnancy, and dysfunctional family. Diets high in fat and carbohydrate are often lacking nutrients considered essential in prevention of heart disease, hypertension, anemia, and loss of bone mass. Women tend to resist a prison subculture and are more likely to have more trusting relationships with staff. Women offenders are viewed by correctional staff as complainers and whiners. Their physical and emotional complaints are often viewed as malingering or manipulation.

Women offenders tend to organize themselves into “prison families”, creating artificial relationships that mirror the outside world. Three prison types have emerged in the literature: square, cool and life. The squares identify predominantly with conventional norms and values and have had little previous experience with the criminal justice system. Cools represent those women who isolate themselves and are career offenders. Lifers are full participants in the prison culture, usually taking leadership roles. Lifers represent those offenders who have no meaningful relationships or identity outside prison and find prison culture their only source of self-concept and status. A new category of female offender, the “crack kids” exhibit a lack of respect for traditional prison values, for their elders, or even for their own youth. They are frequently involved in fights and lack even simple domestic skills estranges them.

Homosexuals

Homosexual activity in prisons is universally condemned and prohibited by formal prison policy and, at the same time, encouraged and promoted by the environmental and social structures supporting prison subculture. There are two major male types of homosexual activities in prison. One type of homosexual activity involves predatory behavior of heterosexual males reacting to the constraints of prison life that prohibit heterosexual liaisons. The other type involves those men who participated in homosexual lifestyle outside of prison. Homosexual activity among female offenders is less aggressive than males and involves needs for attention and affection.

Newly admitted offenders, who are new to the system may be sought out by older offenders looking for a sexual union. Older offenders will ingratiate themselves by offering cigarettes, money, drugs and other favors and then demand sexual favors in return. The inmate code calls for the payment of debt and the new inmate is therefore obliged to perform sexual favors or be subject to inmate “justice.”

Rape among male offenders has been reported as high as 28% (Lockwood, 1978). While most sexual aggressors do not consider themselves homosexuals and sexual release is not the primary motivation for sexual attack, many aggressors continue to participate in gang rape activity in order to avoid becoming a victim of rape. Twelve percent of all hate crimes are perpetrated against males believed by their victimizers to be homosexuals (Schmalleger, 1999). This aggression often continues into the correctional setting against homosexual offenders.

Juveniles

As juvenile drug use, gun use and gang involvement increases; the presence of juveniles in correctional settings has increased. Similar to the adult population, most juvenile offenders are male, and the female population is growing at an unprecedented rate.

Taken as a broad category of the correctional population, juveniles are characterized as “rejecting middle class values of social duty and personal restraint” (Schmalleger, 1999, p. 578). Increasing experience with problems of drug and alcohol abuse, violence, gang membership, separation from family and home, and sexual and physical abuse represent the factors affecting the growth and development of the juveniles seen in the criminal justice system. The rates of self-destructive behavior such as self-mutilation and attempted and completed suicide are on the rise among juveniles in the correctional population at higher rates than in the general population (p. 587).

Ethnic and racial diversity among juveniles is a complicating factor influencing diagnosis and implementation of responsive and appropriate health care strategies, particularly in mental health (Canino & Spurlock, 2000). Inability to focus on the subtleties of cultural variance in symptoms of illness can delay onset of treatment or selection of appropriate treatment. This inaction has been a factor in the persistent lack of resources and adequate health care for youths in detention and correctional facilities.

Gang Members

Juvenile gangs have been documented as an inner city phenomenon in the United States since the 1920’s (Schmalleger, 1999). Male gang members tend to adopt a defensive world view evidenced by a feeling of vulnerability and suspicion, a general mistrust of others, the need to maintain social distance, a proclivity towards violence as a problem solving mechanism, and an attraction to others who are defensive (Wright & Wright, 1994). School-based gang activity is accompanied by criminal acts involving violence, drug sales and carrying guns. Drugs form the focus of gang activity, with large quantities of crack cocaine produced and sold by gangs (Criminal Justice Newsletter, 1998; Esbensen, 2000; Howell, 2000; Howell & Lynch, 2000).

Gang members tend to come from dysfunctional families and less likely than non-gang members to complete high school. They are known as predators, taking advantage of and exploiting other juveniles and adults. Extreme risk-takers, gang members are frequently involved in accidents as well as altercations, making them frequent visitors to the infirmary (Howell & Lynch, 2000)

High rates of sexual exploitation and early drug use among juveniles in corrections are accompanied by delays in intellectual and emotional development. Interestingly, gang members in corrections tend to have high problem solving abilities and organizational skills. Gangs can be extremely organized, evidenced by regular meetings with a rigid set of rules and even requirements for regular payment of dues. Violence is often used as a right of passage, and up to 40% of gang members report rape of females (Schmalleger, 1999). Most gangs are ethnically diverse (70%) but few allow female membership or female leadership roles. Exclusively female gangs are increasing, particularly among the Hispanic population (Schmalleger, 1999). The one thing that most gang members have in common is a tendency to violence and delinquency before joining a gang (Esbensen, 2000). Most gang members claim that, if given a second chance, they would not have joined a gang. The correctional environment, however, with its emphasis on sustaining tightly controlled reference groups, does not promote success of programs designed to discourage gang affiliation.

Ethnic and Racial Minorities

Sixty-three percent of all hate crimes are cased by racial hatred, and 14% are motivated by religious bias. The recognition of hate crimes, offenses in which aggression is based on actual or perceived race, color, religion, national origin, ethnicity, gender or sexual orientation, emphasizes the segregated and heterogeneous nature of American society. Racial and ethnic minorities such as African Americans, Native Americans, and Hispanics are over-represented in U.S. prisons and jails, along with the white supremacist and separatist groups adhering to an “identity theology” further marginalizing and segregating ethnic and racial groups (Schmalleger, 1999). Although they are so visible in our prisons, African American males are more likely to be a victim of violent crime than any other segment of our population (Sourcebook of Criminal Justice Statistics, 1999). In contrast, the correctional staff and health care professionals caring for correctional populations are predominantly white.

African Americans account for over 50% of the correctional population while Hispanics represent 15% of the incarcerated, far exceeding their numbers across the nation. In predominantly Hispanic or African American communities, these statistics are even higher (Bureau of Justice Statistics, 1997). Correctional communities solidify segregation of racial and ethnic minorities, increasing opportunities for friction and suspicion based on racial and ethnic identity and differences.

Growing numbers of non-English speaking offenders from ethnically isolated Asian or Middle Eastern communities present special needs. Restricted financing for prisons and jails and difficulty recruiting a diverse workforce in corrections limits the ability to provide multi-lingual services.

Elderly

Growing numbers of elderly people in prisons are the result of 1) increasing crime among those people over 50 years old, 2) the gradual aging of society from which the offenders come, and 3) a trend toward longer sentences, especially for violent offenders with previous offenses, and 4) the gradual accumulation of older habitual offenders in prison. Typical elderly offenders serving life sentences or long time sentences tend to be African-American. Common characteristics among elderly offenders include physical impairments and chronic illnesses, a lack of sustained contact with family or regular visitation, and a lack of interest in rehabilitation programs.

Chronically Ill

The growth of HIV and AIDS among prison offenders is a serious health care problem. Positive HIV seroprevalence rates vary from region to region reported 2.1% to 7.6% of all men and between 2.5% and 14.7% in women (CDC, 2000). Most offenders report high-risk behaviors before entering prison, especially intravenous drug use. Most reports indicate that HIV transmission within prisons is minimal (Macalino, 2000). HIV appears to be spreading in prison through homosexual activity, intravenous drug use, and the sharing of tainted tattoo and hypodermic needles. Often offenders who are HIV positive do not have their confidentiality protected. Knowledge of their status results in avoidance by staff and offenders, denial of certain jobs, home furloughs, and visitation.

Other special populations can also include those living on death row and political offenders, who by nature of their unique circumstances and backgrounds, each provide distinct cultural characteristics and considerations. They are often grouped together, segregated by the nature of their offense and therefore bonded by collective notions of victimization or unjust treatment. The moral and social philosophies associated with the definition of crime and the associated appropriate and proportionate justice response, is integral to the understanding of individual and collective health care response to patient needs among offenders.

METHODOLOGY

Louisiana State University Health Sciences Center Juvenile Corrections Program

The Louisiana State University Health Sciences Center (LSUHSC) Juvenile Corrections Program evolved as a multidisciplinary approach to ensure all juvenile offenders in the custody of the Louisiana Department of Corrections and housed at one of the four Juvenile Correctional Facilities receive adequate medical, mental health, and dental assessment and treatment services. The program was implemented September 1, 2000 and began with extensive training for all correctional and health care staff in order that they might acquire knowledge and skills consistent with the constitutional requirements for juvenile health care in correctional facilities, including cultural competency.

The LSUHSC Juvenile Corrections Program (JCP) represents a unique collaboration between the Department of Corrections and a major university health science center. No other program of its kind exists in the United States at this time. The authors of this paper serve as nursing consultants to the JCP, providing training and leadership consultation to the correctional nursing staff. Critical to the care of the youth in the Louisiana facilities is an awareness of their characteristics and an appreciation for their problems and issues. Over 70% of youth incarcerated in Louisiana are African American. Males represent 85% of incarcerated youth, most juveniles are between the ages of 13-17 years of age (Louisiana Department of Corrections Quarterly Statistical Report, 2001).

Profiles of Louisiana Youth in Secure Facilities

Louisiana incarcerates more persons per capita than any other state and, among its predominately African American male population housed in the maximum security facility at Angola, over 85% of the offenders will serve life sentences and die in custody (Tillman, 2000). With the knowledge that most adult offenders have served time in a juvenile correctional facility, the JCP focuses on raising standards of health care and the ability of youth to participate in services and programs aimed at successful re-entry into community life after serving their sentences. Sentences of youth in Louisiana secure facilities ranges from less than one year (19.9%) to more than five years (9.0%), the majority of youth serving between 1-2 years (31%). All youth participate in basic educational programs, with most youth experiencing between one and two years grade equivalency gain in reading, math and language arts. About 50% of youth participate in vocational programs such as horticulture, sewing, barbering, welding, computer applications, woodwork and small engine repair, while only a little over half (56%) of youth participate in GED programs and only 8 GED’s were awarded in 2002 (Louisiana Department of Corrections Quarterly Statistical Report, 2001).

Youth in Louisiana Secure Facilities maintain connections with parents or surrogate parents through participation in Individualized Education Program meetings. Over half of the youth in Louisiana’s facilities are involved in Special Education Classes. The percentage of youth enrolled in substance abuse services ranges from 15-44% among the four facilities throughout the state, reflecting the differences in populations assigned to the different facilities (Louisiana Department of Corrections Quarterly Statistical Report, 2001).

Nursing Implications for Prison Diversity

The nature of correctional culture, emphasizing power and control over a disenfranchised population of offenders and focusing on a philosophy of punishment and subjugation, exacerbates existing race and class inequities. The prospects for negative socialization increase with large numbers of persons with differing personalities, life experiences, and histories of crime living together in a confined space. This negative socialization can be exploitation and victimization and the creation of a setting for teaching of crime and anti-social behavior as a means of survival, of “fitting in” and eventually, a way of life.

Language, customs, and practices should be maintained with the security restrictions of the setting. Health care staff must work with correctional staff to identify mal-adaptive or dysfunctional cultural behavior patterns. Examples are tattooing or gang raping as an initiation to a gang. These behaviors must be targeted for extinction through therapeutic and policy mechanisms.

Core symbols of culture need to be examined to verify expression within the correctional setting, Issues of collectivism, individuality, positivism, genuineness, assertiveness, orientation to time, and secrecy are common themes that are modified in this setting. Nonviolent posturing as a form of emotional expressiveness among African Americans must be distinguished from intent to act. Understanding that Hispanic male youths often act out aggressively rather than withdraw when they are depressed is essential in assessment of emotional and psychiatric their status. Among Muslims, there is no distinction between secular and religious life. Islamic edicts are the way of life; dietary and dress rituals demanded in correctional settings are intolerable and a source of violent response (American Correctional Association, 1993). The preservation of ethnic identity is a right that must be sustained within the confines and restrictions of correctional environment. Offenders must derive meaning out of confinement and loss of privacy to the degree living conditions vary to allow expression of their personal experiences and culture.

Nursing Care Strategies

Specific strategies to promote an awareness of cultural context for care begin with an assessment of the cultural groups present in the facility and an inventory of practices, beliefs and needs affecting health behavior. An understanding and respect for differences, although critical to cultural competency, is difficult to promote in an environment that emphasizes conformity. Nurses, correctional staff, and administration can work to identify appropriate opportunities for individualism of health care interventions and cultural behaviors. Nurses can provide leadership to this endeavor and informational resources to all personnel. Opportunities to substantiate outcomes of nursing intervention with scientific or data based information can be a powerful tool in enlisting support. For example, a nurse could link privacy during medication administration or treatment instructions and decreases in non-compliance problems or disruptive behavior during pill-call. Any health promotion plan of care should include acceptance of authority (particularly from female correctional officers or health care staff), ways in which stigma or shame are dealt with, and the struggle to maintain individual identity, particularly in the area of health care choices (duPont & Halasz, 1998).

Nurses can break down barriers to culturally competent care from within the profession, learning how to recognize and confront prejudice, stereotyping and discrimination. Nurses need to think about ways to apply “profiling” to groups of offenders or clients, whether it be assuming all offenders are drug dealers or rapists. “Friendly fire” must be identified in the form of biased language, grouping people as having characteristics simply because of where they were born, mislabeling groups, addressing persons in a familiar way, and using inappropriate titles and terms. Nurses must learn to apply principles of physical and psychosocial assessment in a culturally competent way, particularly in corrections where eye contact may be discouraged not only as a part of cultural heritage but as learned behavior initiated by expectations of punitive correctional staff. Recognizing when behavior is consistent with the correctional culture and when it is a product of another cultural context is a difficult and ongoing process for correctional nurses. Even nursing goals may be inconsistent with expectations of the prison culture or routine, such as promoting trust and openness during psychiatric encounters, when this behavior may actually be life-threatening in the correctional setting.

Acknowledging the importance of staff health and concerns is preliminary step to gaining their cooperation. Nurses can orchestrate comprehensive health promotion programs. This type of collaborative relationship could influence administration to make culturally sensitive decisions or actions. Hiring practices and the recruiting of new staff should be guided by a commitment to inform and educate potential staff reflective of the cultural groups represented in the institution (duPont & Halasz, 1998; American Correctional Association, 1993).

An environmental inventory of the ecological factors affecting and predominating in the correctional setting is another nursing intervention. This assessment can be asking questions that raise awareness of and appreciation for cultural competency:

[bullet] What does the dress code adopted in this setting, for staff as well as offenders, say about us?

[bullet] How do the furnishings and layout of the physical setting affect emotions, perceptions, stress and functional ability to carry out daily routines?

[bullet] What does the vocabulary we use in the setting say about our attitudes, beliefs and philosophy of nursing care? Does it matter whether we use the term, “inmate”, “patient”, “client”, “youth”, “felon”, and “perp”?

[bullet] What does the history of the institution tell you about how we nurse those in our care? What roles have nurses taken? What part of the budget has been given to nursing? At what meetings or activities have nurses been regularly included? Where and when are nurses mentioned in official documents? How often and in what context do nurses interact with administration?

Over 80% of all offenders will return to the communities from which they came. The experiences they take with them, including the type and nature of health care provided to them, can be a determinant of recidivism. Culturally competent nursing care in corrections is dependent on the incorporation of fundamental principles: inclusiveness, reflecting the diversity of the community served, valuing cultural differences, employment equity, service equity, and involving everyone in the setting.

RESULTS

Results with the Louisiana Juvenile Correctional System

A needs assessment revealed most nurses working in juvenile correctional facilities in Louisiana wanted more training in mental health issues related to juveniles and the relationship of race and ethnicity to mental health assessments. In addition to mental health content, nurses identified ethical and legal issues affecting their roles in correctional settings as the focus for development. They also cited specifically the need for mastery of the boundaries of practice and their relationships with correctional staff and the youth. In other words, their primary learning needs were centered on the correctional culture and how to reconcile the demands of the correctional setting with their professional code (Hufft, 2002). Additional instruction to strengthen nursing leadership was expressed to address the nurses’ feelings of being undervalued and neglected in major decision making related to nursing services. A series of nursing staff development modules were developed by the LSUHSC School of Nursing faculty, focusing on physical and mental health care issues of juveniles, characteristics of juveniles in corrections, and the role of the professional forensic nurse working in juvenile correctional facilities.

A major adaptation required of nurses working in JCP was their transfer from the Department of Corrections to LSU (Correctional to Education based philosophies). Consequently, expectations for professional performance changed to emphasize evidence-based practice, and individual as well as departmental accountability. Increased resources, changes in health care management and organizational linkages resulted in major cultural changes for the nursing staff:

[bullet] Policies and procedures were revised to conform to national standards, rather than focusing on specific institutional correctional preferences.

[bullet] Nursing roles were defined in terms of health care agency rather than correctional confinement or control goals.

[bullet] Relationships with correctional officers were redefined from subservient to collaborative.

[bullet] nstitutional policies were no longer an excuse for lack of professional accountability.

[bullet] Success was defined in terms of health care outcomes of youth, rather than in terms of logistical expediency or security goals.

These changes build the foundation for the transition to better health care and overall change in values. While security and confinement will always be very important factors affecting the health care delivery system, the roles delineating correctional officers and nursing staff have been clarified; freeing nurses to be responsive to individual needs of the youth.

CONCLUSION

Correctional nurses must intervene sensitively, creatively, and responsibly on the basis of scientific and evidence-based knowledge, but also extend their roles to include personal advocacy for culturally competent care for offenders in correctional facilities. Current population statistics indicate the diversity of the correctional population will only grow, intensifying the need for culturally sensitive and competent health care services. Providing care within a framework of cultural meaning increases the likelihood of sustained and relevant changes in health status for the individuals involved. Increasing the satisfaction and effectiveness of health care received in correctional facilities may provide a basis for trusting and participation in self care health promotion strategies among offenders during their incarceration and after their release.

Copyright Riley Publications, Inc. Center for the Study of Multiculturalism and Health Winter 2003

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