Prison nursing and its training

Prison nursing and its training

M Sánchez-Roig1, A Coll-Cámara2

1Quatre Camins Prison Primary Healthcare Team
2Catalan Health Institute



The main task of nurses is to take care of sick and healthy people and evaluate changes in their health conditions. The goal is to take the appropriate measures to help their recovery or guarantee a dignified death, and if possible, help them regain autonomy and independence.

Nursing is present in different areas: primary health, mental health, accident and emergencies, intensive and coronary care, surgical care, paediatrics, geriatrics, public health, occupational health, teaching, etc. In our case, prison nursing, one of the least known branches of the profession, we wanted to investigate more deeply the work of nurses in prisons, which aspect of health care they are responsible for and to what type of population they are geared towards, as well as the necessary training to be able to work in such a particular environment.

To conclude, we have seen that university degrees in general nursing do not include knowledge in this area, and that authors from different countries support the specialization of prison nursing and the need for nurses to be trained according to the health conditions of inmates and the characteristics of prisons.

Keywords: nursing; prisons; prisoners; education, continuing; competency-based education; nursing care; primary health care; mental health; substance-related disorders; communicable diseases; emergencies.



For many years prison health care has remained the great unknown within the public health system. In correctional facilities, staff was scarce and remained within the remit of minimum standards included in Prison Regulations (RP 190/1996): a physician with skills in psychiatry and a nurse, and resources were simply insufficient. In the 1980s, with the emergence of new pathologies, mainly as a consequence of injecting drug use: infection by human immunodeficiency virus (HIV/AIDS) or by Hepatitis B virus (HBV), the situation changed dramatically. In fact, prison health care stakeholders were concerned that infirmaries in prison would become real units for terminally ill patients. The need for providing care for a new type of patient entailed that medical and nursing staff became the key figures in keeping an optimum state of health among the imprisoned population. From this moment on, nursing staff began playing a new role, a substitution one. Later, when the first antiretroviral therapies arose and mainly in 1996 when the first protease inhibitors were launched, the management of HIV/AIDS infection underwent profound changes and since then the effectiveness of this treatment greatly depends on nurses’ communication and social skills to encourage patients’ adherence1.

Nowadays, the increase of mental pathologies2 and foreign population3 entails new challenges for nurses who need new knowledge and skills to provide health care with versatility and specificity1,4.

Moreover, it is worth noting that the role of prison nurses significantly differs from that of their external counterparts due to the special nature of the correctional environment mainly characterized by the deprivation of liberty of convicts and the legal influence within these facilities5. On the other hand, prison health care entails a series of specific features which requires that nurses be specially trained in areas such as: infectious diseases, mental health, drug abuse, emergencies, primary health care, public health as well as regulatory and legal aspects1,4.

This article aims to bring readers closer to the culture of health care provided by prison nursing staff, the population targeted and the special nature of this environment as well as making them familiar with what type of training is required in such a particular context. The terms "convict" and "nurse" will be used indistinctly to refer to female and male individuals.




Different authors describe how the imprisoned population gathers a series of conditioning factors of health which are clearly overrepresented in comparison with the general population6,7 such as: drug abuse, infectious diseases (HIV/AIDS, tuberculosis, hepatitis B and C, sexually transmitted infections), mental disorders and factors derived from extreme situations (self-harm, foreign body ingestion, body packer/ body stuffer, hunger strike, riots and uprisings, etc.) These factors do not differ between countries: both in Europe and America the same factors have been described as defining features of prison health care6. 8-13. Furthermore, there are other circumstances which have an influence on convicts’ welfare such as the correctional environment itself, deprivation of liberty and regulatory and legal influences.



The correctional context implies a space for communication, action and regulations which determine the relationships established between individuals who live (inmates) and cohabite (staff) within the facility1. Within this context we find constructs of prisonization and prison subculture. Some authors14-17 define prisonization as the process of accepting habits, uses and the culture of prison society entailing a decreased repertoire of human behavior as a consequence of an extended stay in a "total institution"16. Within this process a informal inmate code is formed which leads to the so called prison subculture14, 18-20 as a code of conduct which arises from the inmates themselves to ensure certain degree of resistance against the total institution. This code is based on the principle of loyalty, solidarity and no tipping-off.



Deprivation of liberty implies a substantial change in someone’s life. From the moment of imprisonment one loses important values such as privacy, since inmates live together21, liberty, which is limited in decision making and acting, the fulfillment of internal regulations and the presence of public officers during everyday activities22. Individuals assume prison subculture values and attitudes in an attempt to compensate personal deficiencies. Inmates’ self-esteem can be challenged due to criminal stigmatization and self-stigmatization. The loss of self-esteem implies the construction of social stereotypes which turns stigma into self-stigma, leading to inmate’s situational regression, a decreased self-efficacy and a lack of motivation to participate in society23. Moreover, serving a sentence entails dissociation from one’s family, friends and the social context the individual is more familiar with. This break-up implies a series of changes in their emotional state which can lead to disorders such as anxiety, depression, a lack of trust in professionals and their mates24. These changes can seriously hinder their action fluency and thus, their health too.

Although women only represent a minority of the imprisoned population (approximately 7%3) we must note that particularly them, suffer from a sense of culpability, distress and uncertainty upon imprisonment regarding their families: children and parents, the loss of a home, relationship instability, feelings of helplessness in foresight of irreversible consequences for their families, and above all, their absence in their children’s diseases and their adolescence. Women are considered transgressors by the culture itself and suffer from a triple discrimination: as women, victims and foreigners25.



Another factor we must consider is that of regulatory and legal influence, since inmates claim their rights by using their bodies as an instrument of protest26,27. To achieve their purposes, inmates call for attention by means of self-harm, hunger and thirst strikes, foreign body ingestion, refusing to take their treatment, etc. The Mental Health in Prison Workgroup28 describes that it is very important to know how to differentiate between claims and concealed requests for help. This is why nurses must have the knowledge and skills to determine the nature of the problem and provide personalized care1.



According to the American Nurses Association (ANA) correctional nursing is a unique specialty. It is a compendium of public health, emergencies, community health, occupational health, delivery primary healthcare and nursing school. This Association believes that correctional nursing implies caring for people with very complex health problems and it includes activities such as patient assessment, the delivery of medication, treatment, the assessment of its effects, crisis management, education and delivery of patient care29. In Canada they consider that the health complexity of inmates calls for highly specialized nurses able of delivering care to potentially manipulative and aggressive patients30,31.

In France, the scope of correctional nurses includes prevention, healing, health education and a relational dimension which is key in attenuating the prisonization syndrome32.

In the United Kingdom, pathologies do not differ from other European countries and thus, mental health issues, infectious diseases, drug abuse, primary care, women and children aid and people with disabilities prevail33.

In Italy, the scope of correctional nursing is based on a process of assessment of the needs of the imprisoned, assistance in general medicine and specialties, drug abuse, mental health, infectious diseases, mother and children area, emergencies and meeting cultural diversity34.

In Spain as in other countries, the health of inmates requires specially trained nurses in the most prevalent diseases, which do not differ from those aforementioned, as well as in personal and social skills to be able to meet cultural diversity.

Several governmental institutions such as the National Commission on Correctional Health Care (NCCHC)35, the American Nurse Association (ANA)36, the Royal College of Nursing of UK (RCN)37 and the International Council of Nurses (ICN)38 have drawn up documents where the special nature of the correctional context is established together with the health problems of the imprisoned population, thus describing the role and scope of action of correctional nurses, therefore establishing their level of competency.

It is worth noting that in Spain, the Ministry of the Interior periodically convenes selective tests by means of the national competition system to enter the Correctional Nursing Department (BOE Official State Gazette N. 226, as of December 21st 2015, Section IIB). This process has two stages: first an exam and second a practical training period. The program includes issues regarding the health of inmates such as: prevalent pathologies, primary healthcare, emergencies, mental health, public health, research, information system, environmental health, bioethics, health education, etc. as well as legal, administrative and correctional law issues. After several studies, among which it is worth highlighting that presented in the 4th National Congress on Prison Health (2002) held in Salamanca (Spain) under the title "Study on the profile of correctional nurses in Cataluña" in 2005 the tenets of correctional nursing were described according to the role of nurses in Cataluña39 (see Table1).


AUniversity training of nurses provides them with the necessary skills to value, identify, act and assess the health needs and provide the appropriate care to individuals, families and communities with a scientific training in critical, reflexive and humanistic attitude. Their basic training includes providing care to healthy or ill individuals and assessing the response of their health states implementing those activities which will encourage healing or a dignified death and, if possible, recovering their autonomy and independence. According to the National Agency for Assessment and Accreditation (ANECA in Spanish)40, the nursing degree answers to a nursing profile responsible for the general care of individuals and the community.

The current reality of the Degree in Nursing in Spain is that it only covers the training of general nurses. Therefore, new graduates lack the training and skills necessary to work in specific areas, such as the area of correctional nursing1, as well as the social skills which set up the socialization41, 42 of nurses in this area: being familiar with the setting, the population served, knowing how to interact with inmates and different groups working within a correctional facility (surveillance and treatment teams) and being familiar with regulations and rules1, 4.

There are several factors included in the specific nature of the care that correctional nurses must provide. On one hand, health care provided to immigrant population (43.82%)3 entails a series of events and realities that the health provider should be aware of to be able to address the specific health issues in permanent accordance with the social and cultural reality of this population as well as their original customs, values and beliefs. Several factors such as the language, religion, a lack of structural, familiar and affective references imply difficulties and conflict when dealing with these individuals43. Often they are original from developing countries with impaired healthcare structures, where migratory inflows import parasitic and tropical diseases with a low prevalence in our country44. These features imply that nurses have to be trained in healthcare skills (imported and tropical diseases and other prevalent health issues), as well as cultural and anthropology skills to face the needs of immigrant populations1, 45.

Another specific feature of the imprisoned population is the use of psychoactive substances (drugs and/or psychotropic substances). Drug abuse is one of the main problems of those who are admitted to prison, due to both the number of inmates who suffer this problem and the severity of the complications derived from this abuse: psychophysical health, disintegration of personality and familiar and social breakdown6. Being familiar with the offer of harm reduction programs both inside and outside prison enables continuous treatment follow-up as well as biopsychosocial support for inmates with a problem of drug dependency. Correctional nurses must have the skills to plan, supervise and encourage adherence of patients to treatment according to the objectives established by the program and the individual features of each user, as well as practical skills to identify urgent situations quickly and safely in case of intoxication or overdose1.

On the other hand, the high prevalence of mental disorders and the complex organization of everyday activities within correctional facilities, restrictions of every type, forced cohabitation, rigid schedules, monotony, emotional isolation and frustration make the construction of appropriate therapeutical spaces very difficult for determined mental patients28 and it impais the prevention of isolation and discrimination of these particularly vulnerable individuals due to their disabilities46. Prisons need professionals capable of providing appropriate and quality care to mental patients. It is simply ineffective to implement action guidelines if providers lack the appropriate training in a series of areas28. Moreover, it is necessary to grant the training of professionals with regard to warning signs and management of risk factors to reduce suicide rates47. It is also worth noting the importance of health providers preparing and supervising the administration of psychiatric drugs since it enables the adherence to treatment, the early detection of interruption of treatment and it avoids the manipulation by inmates48.

Another specific feature of correctional health implies healthcare actions aimed at preventing, promoting and caring for patients with infectious diseases (HIV, hepatits B and C, tuberculosis, sexually transmitted diseases, etc.) The prevalence of theses diseases is the basis for the guidelines that healthcare programs should take into account in the correctional setting. The provision of healthcare in prison is carried out by public health professionals. These professionals count upon a high level of specialization in a series of pathologies which are more prevalent within prisons and which have to be treated in a specific setting. These health problems lead to rehabilitation programs for drug users, their integration in society, or the prevention of communicable diseases such as HIV49. There are different strategies to improve adherence to antiretroviral treatment, including actions based on recall techniques, counselling, psychological support and/ or cognitive-behavioral therapies59. The adherence of inmates to treatment must take into account certain features mainly based with the particularities of the correctional setting and the population hosted within: injecting drug users (IDUs) with a high prevalence of mental disorders and social uprooting51-53. As for the skills necessary for the control of tuberculosis in prison, these are mainly based on activities of a formative or educational nature carried out by nurses as well as cooperating in the diagnosis of suspicious cases, controling adherence to treatment and carrying out research and control activities regarding the study of potential contacts54. Inmates are particularly vulnerable to tuberculosis, a fact which highlights the need for early detection of cases and appropriate measures to control this disease21, 55-60.

Hepatitis B management requires that nurses acquire and keep updated knowledges on the indicated therapies and its correct management regarding education, counselling, treatment adherence and identification of secondary effects61.

Nursing professionals are key elements in the treatment and management of diseases such as Hepatitis C. Counselling and educational skills as well as an ability to serve as a liason between patients and healthcare providers are necessary to improve the communication on monitoring and the treatment of this disease62. Therapeutic education provided by expert nurses increase the response of patients in the treatment of hepatitis C63. In order to ensure these assistance performances nurses need continuing education on the disease to improve their knowledge and limit the doubts concerning the management and control of the infection64.

Another particular situation that correctional nurses face is the causes of aggressive episodes, which are widespread and due to varied reasons concerning the prison regimen, legal, clinical and/or social factors26. These are the so called borderline situations: "The final state a person encounters at a certain point of impulsivity, mental disorder and/or demand that should not be met since doing so would endanger his/her life or that of others"1. These include the following: selfharm, hunger thirst or medication strike, body-packer/ body-stuffer, riots and upsrisings, which call for urgent health actions, planned and decisive where active communication between surveillance and healthcare teams is needed1.

Providing assistance to patients deprived of their liberty, who suffer from communicable diseases, mental disorders, disabilities, drug abuse and borderline situations is an activity which calls for a series of knowledges, skills and procedures included in everyday’s routine of correctional nurses. Clearly nursing assistance in correctional facilities includes a wide range of pathologies, wider than that of primary healthcare. Thus, professionals developing their tasks in this context must have the appropriate knowledge on primary healthcare65 (chronic diseases such as diabetes, hypertension, coronary heart disease, heart failure and pulmonary disease) and further need to be trained in the appropriate knowledge, tools and resources to do so in a singular setting1.

Although the university degree in nursing does not include the areas needed for correctional nursing1 it is worth noting that several authors agree that correctional nursing faces a series of challenges that do not benefit from a specific training in conflict, legal system terminology and criminogenic factors66 all of which are specially relevant in this context. Nursing is based on the aim to negotiate the frontiers between the cultures of custody and care. This attitude implies complexe challenges and a series of limitations regarding the patient- nurse relationship67. Several authors12, 68 describe how providing care in correctional facilities requires specific knowledges, skills and experience.

Coll1 describes how there is no country that includes specific contents for correctional nurses in the training of general nurses and how there is only specifically regulated trining for correctional nurses only in two countries: USA and Spain. The American NCCHC issues since 1991 the Certified Correctional Healt Professional Registered Nurse (CCHP-RN). This broadens and looks into the areas and knowledges needed for nurses to be able to face the challenges of correctional healthcare. In Spain, the Facultat de Ciències de la Salut Blanquerna — Universitat Ramon Llull offers a qualification "University Expert in Correctional Nursing" since 2013. This aims at preparing nurses to provide comprehensive care to inmates and acquire the skills to detect, plan, intervene and assess the health needs of inmates in the following areas: mental health, communicable diseases, drug abuse, borderline situation, multiculturalism, correctional context, regulations and law.

In other countries such as the United Kingdom, France or Canada, nurses who want to develop their tasks in prisons need to be trained in Mental Health, like in the UK or Canada, or either receive a specific training like in France, where reference hospitals provide specific training to UCSA teams responsible of providing health care in correctional settings. UCSA are hospital functional units established in prisons and dependent clinics. The teams include general physicians, specialists, dentists, pharmacists, nurses, physiotherapists and administrative staff. The role of correctional nurses includes areas of: prevention, healing, health education and a relational dimension. The relational dimension is crucial and relevant in a context where people suffer from the prisonization syndrome. Reference hospitals are responsible for providing specific training for this kind of staff32.



Correctional nursing is a unique specialty29 which includes a wide spread of aspects regarding not only the dimension of health but also that regarding the correctional context, placing professionals between custody and care. Correctional nurses develop their tasks with patients in a state of utter helplessness, complex health problems and boderline situations1, all of which takes place in a hostile setting under legal or regulatory influences and other circumstances which have an impact in the welfare of inmates: the correctional context and the deprivation of liberty.

Several authors consider that the complexity of health among inmates calls for highly specialized nursing care1, 30, 31, 69. The aim should be a symbiosis of the person deprived of liberty and the healthcare provider, who should be able of revitalizing the profession by recalling which are its legitimate purposes and what habits need to be enhanced to achieve the first70.

On the other hand, the skills of correctional nurses are nor acquired by simply studying the degree in Nursing since they are not included in its curriculum, thus a specifically designed training based on knowledges, skills and procedures in the areas of mental health, drug abuse, communicable diseases, primary healthcare, borderline situations, immigration and the phenomenon of the correctional context, including its regulation and law1 is needed. On the other hand, several authors agree that nurses should be included in healthcare teams to develop their professional skills regarding: education strategies to promote health and prevent diseases, treatment adherence and optimal therapeutic patient-provider relationship aimed at specific objectives in cases such as: infectious diseases (HIV50, TBC54, HBV61, HCV62, 63, mental health28, 47, primary healthcare65, borderline situations1, 26, tropical and parasitic diseases44, multiculturalism1, 43, 45, disabilities46, drug abuse1, 6 and the correctional context12, 68.

Currently there are two institutions which offer specific degrees in terms of correctional nursing aimed at meeting these training needs: the American NCCHC since 1991 and the Facultat de Ciències de la Salut Blanquerna of the University Ramon Llull since 2013 by means of postgraduate education. In countries such as the United Kingdom and Canada, in addition to general training, specific training in mental health is needed and in France UCSA teams providing healthcare in correctional facilities are specifically trained before taking up their job.

Therefore, nurses providing care in correctional facilities need a specific training in specialized knowledge, skills and awareness on the context unlike in external health centers1, 4, 12, 67, 68.



Montserrat Sánchez Roig



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