Forensic Nursing: Best-Kept Secret

It is not uncommon for people to be surprised when I tell them I work in corrections, and they admit they had no idea that inmates would need medical care. Among my colleagues, we joke that correctional nursing is the biggest secret, not only to the public, but to our own nursing profession. This patient population needs medical care!

I started my introduction to correctional nursing when I was a student nurse at the LA County hospital in the 1970s. Most of our patient population were homeless, addicts, alcoholics, those with injuries sustained from stabbings and/or gunshot wounds, and incarcerated individuals requiring hospitalization. It was not unusual for inmates to be placed on a ward with six to eight patients, and their identifying characteristic was a chain around their leg attached to an old metal hospital bed to keep them from escaping. As part of our assignment and prior to starting our shift, we would go up to the floor the night before and pick our patients. Many times, I found myself choosing the inmates. In truth, I enjoyed working with these patients and found for the most part that they were polite, respectful, and appreciative of the care they received.

After graduating, I worked in a variety of settings, but when I had the opportunity to help develop an inmate program at our local hospital, I jumped at the chance! Developing both an inpatient and outpatient case management program, I worked with a medical director orchestrating all specialty referrals and providing utilization reviews for those individuals that were hospitalized. Again, I truly enjoyed the work and was surprised that not everyone was as excited about this program as I was.

The program ended partially due to concerns voiced by staff and administration surrounding patient and staff safety and the growing difficulty finding specialists willing to see inmates. However, my passion for this population remained.

Shortly after the case management program ended, there was an opening for an infection control nurse for the county jails. I seized the opportunity and for the first time, I would be in the jail setting, caring for the inmates.

Now, in the correctional setting, I could observe the amalgamation of public health issues: contagious diseases, sexually transmitted infections, addiction, homelessness, mental illness, obstetrical issues, the elderly, cognitively impaired, physically disabled, and those with chronic diseases. Upon arrest, these individuals present to intake disheveled, odiferous, infested with lice, high, psychotic, suicidal, and unable to provide a medical history. Good nursing assessment skills are paramount, as providers are not on 24-hours a day and inmates may not see a provider for days. Recidivism is a very real problem with factors of lack of alternatives for the homeless, lack of follow-up care once they have left the institution, and poor compliance with psychiatric medications, which leads to the vicious circle of frequent incarcerations for these individuals.

A day in the life of a staff nurse in a jail could include lab and treatment, assignment to the infirmary, intake, medication pass, Clinical Opiate Withdrawal Scale (COWS) and Clinical Institute Withdrawal Assessment for Alcohol (CIWA) assessments for individuals withdrawing from substances, and wound care, just to list a few. Correctional nurses have many interruptions in their day and, based on your patient population, there can be several emergencies throughout the shift. Emergencies include falls, jumps from a second tier, attempted suicides, assaults, non-responsive inmates, allergic reactions, and mental health crises. These staff nurses handle inmate complaints, family phone calls, and calls from attorneys. The work is demanding, fatiguing, and can be frustrating. Security is the job of the deputies/officers, and you don't go anywhere without someone accompanying you. I say to my colleagues, "You'll never be safer than you are in jail!"

Unlike other health care entities, the inmate population can exhibit behavior resulting in an officer being exposed to bodily fluids. Known as "gassing," it is intentionally placing, throwing, or causing to be placed or thrown upon another person any human excrement or other bodily fluids. This is a punishable crime (PC 243.9: Battery by Gassing in a Detention Facility) and requires the expertise of a forensic nurse to follow the procedures for collection of blood and clothing and ensure evidence is properly obtained for the crime committed. These gassings are usually court-ordered and relying on the expertise of the forensic nurse who is familiar with court orders ensures that protocols are properly followed.

The Prison Rape Elimination Act (PREA) was created and passed by Congress to combat sexual assaults in federal, state, and local facilities of confinement. The requirements placed on the officers and nurses when there is suspicion of a sexual assault are very strict, and the referral to a forensic nurse either onsite or in the emergency room is critical to compliance of the act.

The gold standard for health care in corrections is the National Commission of Correctional Health Care. This organization provides standards of care founded on evidence-based practices and offers an accreditation much like the accreditations in hospitals, skilled nursing facilities, and home care. Personal professional growth and certification are also provided through the Commission. There are standards of governance and administration, health promotion, safety and disease prevention, personnel and training, ancillary health care services, patient care and treatment, special needs and services, and medical/legal issues that must be met to receive an accreditation. One of the important medical/legal standards is Therapeutic Relationship: Forensic Information and Disciplinary Action, and is based on the relationship and protection of the integrity of the therapeutic partnership with our patients and, for this reason, correctional health care staff are not involved in the collection of forensic evidence.

Correctional nursing is not for everyone! It offers a variety of medical experiences, excitement, and professional autonomy while caring for the underserved.