Ethical issues of prison nursing: A qualitative study in Northern Italy

Prison organization in Europe

International reformers recommend that the provision of healthcare to prisoners should be part of the public health service, ¹ and the World Health Organization Regional Office Europe calls for acceptance of ‘internationally recommended standards for prison health; providing professional care with the same adherence to professional ethics as in other health services, and … promoting the health and wellbeing of those in custody’. ²

In some European countries, such as the United Kingdom, the ‘integration of prison health care between custody and the community is moving fast, but has been an aspiration for other countries’. ³ In Italy, Penitentiary Medicine affairs were transferred to the National Health Service in June 2008, giving rise to a discipline that constitutes a very specific branch of Public Health and has important social and healthcare implications for the public. Although this discipline does not involve many healthcare workers, it does involve large numbers of prisoners and overcrowding is a serious problem in many European countries. ⁴ In fact, across Europe in 2013 there were 1,679,217 prisoners, with an average prison population rate of 140 inmates per 100,000 inhabitants; overcrowding was critical in 21 out of 50 European prison administrations. With regard to spending per inmate, European prisons spent on average €97 per inmate per day. ⁴ In Italy, there are 52,636 prisoners in 197 penitentiaries, where the regular number of places available is 49,605; of the total number of prisoners in Italy, about one-third (n = 17,387) are not Italian. ⁵

Healthcare in European prisons

Health issues for prisoners are substantially related to communicable diseases, substance abuse and mental health. ⁶ According to the Report of the WHO Regional Office for Europe, in most European countries, rates of HIV infection are higher among prisoners than the outside population. Due to overcrowding and poor nutrition, especially in many Eastern European countries, tuberculosis in prisons has been reported since the 1990s with rates up to 81 times higher than in the outside population. ⁷ Another serious health problem in prisons is the high rate of illicit drug use between 16% in Romania and 79% in the Netherlands and the United Kingdom, entailing a high risk of transmitting HIV and hepatitis.

Women constitute a very small proportion of the prison population. In Europe, women in prison range between 3.20% in Poland and 7.62% in Spain, ⁸ but these numbers are rapidly increasing. Most incarcerated women in Europe have mental problems due to traumatic experiences in their childhood, and at least 75% have problems with drug and alcohol use. Consequently, women prisoners are more likely to commit suicide than male prisoners.

According to the provisions of the Council of Europe regarding the number of healthcare personnel in prisons, this ‘should be such as to enable regular pharmacological, psychotherapeutic and occupational therapy programmes to be carried out’. ⁹ Despite the provisions of the European Prison Rules, according to the European Prison Observatory, healthcare services in prisons are scarce in all European countries and demand often exceeds the capacity to deliver care, even in France, Italy and UK where national Ministries of Health are responsible for the delivery of care in prisons. ⁸ Similar conditions are described in Canada ¹⁰ and in the United States. ¹¹

This study

In the Liguria Region, where this study was conducted, there are seven penitentiaries and 1349 prisoners (regular places available n = 1159), and of these over 50% (729) are not Italian. The majority are from Morocco, followed by Romania, Albania and South America. Prisoners in Liguria are mainly men. ⁵ Women prisoners are present only in the prison of Pontedecimo. Marassi Prison was the only one that had a dedicated clinical ward where patients could be appropriately treated. With regard to the prisoners’ most common health conditions in the prisons included in this study, 88% were affected by psychiatric disorders and 30% were drug addicted.

Problems linked to the setting were mainly overcrowding, the lack of dedicated clinical wards, high turnover rates, high numbers of foreign prisoners affected by diseases that had never been treated, cultural differences and language barriers. Due to the latter, the names and identities of non-Italian prisoners were easily mistaken by our nurses, who reported that all these aspects raised not only practical but also ethical issues in nurses making it even more difficult for them to provide care appropriately in an already difficult context like prisons, as confirmed in the literature. ^{3,12 –18}

In our experience, the difficulties experienced by the correctional nurses were linked to important issues such high nursing staff turnover rates, poor job satisfaction, the lack of specific education and competences, which did not enable them to provide equal and high-quality care to prisoners, with the potential to raise ethical issues. In addition, this difficult situation, where prison security is considered to be more important than healthcare, ³ was exacerbated by the conflict between the concept of punishment and that of caring, as also widely described in the literature. ^{13,16,19 –34}

Ethically speaking, any type of patient problem in prison is important, but those particularly needful of nursing were drug addicts, who require specific pharmacological treatment, and psychiatric patients, who require special assistance and monitoring, even by prison officers due to the high risk of self-harm and suicide. ^{12,31 –35}

Every single contact with a prisoner should be considered as a good occasion to observe and assess the prisoner’s problems, even when the patient does not openly express them; therefore, also prison officers’ reports should be taken into account. ^{23,29,32,35,36}

Despite this evidence, in our study, correctional nurses reported that key nursing activities like ‘observing’ and ‘talking’ to their patients in prison were considered as a ‘waste’ of time by prison officers, who did not see this sort of activity as essential for nurses as health professionals. Therefore, this study was needed to analyse nurses’ experience in prisons and identify the most critical factors that generate ethical issues. This will form an evidence base for future interventions designed to resolve the most critical factors of correctional nursing and consequently also the ethical issues associated with them.

Design

This study consists of two parts: (1) a quantitative part, which used the questionnaire developed by Doran and Almost, ¹⁷ and the Measure of Job Satisfaction by Traynor and Wade, ³⁷ to explore correctional nurses’ work-life issues and measure their level of job satisfaction, and (2) qualitative part consisting of five focus groups, to explore the prison nurses’ daily experience when caring for patients in prison.

The quantitative part of the study substantially confirmed the correctional nurses’ work-life issues linked to the difficulties in prison mentioned above and their intention to leave due to the low levels of job satisfaction, therefore justifying the need to conduct the second part of the study, based on more in-depth analysis using a qualitative methodology.

The focus groups

This article reports only on the qualitative part of this study, which uses a qualitative descriptive design, also referred as generic qualitative research, ^{38 –40} because this was also the part that produced the most interesting results in terms of ethical issues. The focus group methodology was chosen for this study because it enables to conduct a ‘planned series of discussions to obtain perceptions in a defined area of interest in a permissive and non-threatening environment’. ⁴¹ In addition, focus groups enable to collect reliable and valid data that take participants’ values and needs into consideration, with the potential to reduce conflicts and provide leadership to decision-makers. ⁴² In fact, in this study, we needed correctional nurses to share and talk about their perceptions regarding their experience in prisons to address any issues and collect data to help decision-makers to implement actions that would resolve the identified conflicts and issues.

Participants and context

The sample of this study consisted of 31 correctional nurses who freely volunteered and gave their consent to participate in this study following a brief presentation and a question and answer session. The participants included nurses and some of their coordinators working in the Penitentiary Medicine Units of the Liguria Health Agencies and a few nurses who had previously worked in these facilities. With regard to the characteristics of our sample, it was interesting to note that in general 77% had worked in prisons for less than 5 years. On the other hand, the nurses having a longer forensic experience and who used to work for the Ministry of Justice were only two. Instead, with regard to those working in the current prison, 83.8% had worked there for less than 5 years, and of these the great majority had been working there only for a few months (Table 1).

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Table 1.

Characteristics of the 31 correctional nurses who participated in the five focus groups.

Age	25–30 years	31.4%
	31–35 years and 41–45 years	15.3%
	36–40 years	10.4%
	46–50 years	32.4%
	56–60 years	6.0%
	51–55 years	4.5%
Education	Regional diploma	40.5%
	University diploma	4.0%
	Bachelor’s degree	40.5%
	Master’s degree	15.0%
Experience as registered nurses	<5 years	29.4%
	5–10 years	16.2%
	16–20 years	14.7%
	10–15 years	10.3%
	>20 years	29.4%
Type of working contract	Full time	83.8%
	Part-time	16.2%
Years of experience in prisons	<5 years	77.0%
	5–10 years	16.2%
	11–15 years	1.4%
	16–20 years	1.4%
	>20 years	4.0%
Years of experience in current prison	<5 years	83.0%
	5–10 years	12.2%
	11–15 years	1.6%
	16–20 years	1.4%
	>20 years	1.0%

To recruit participants, we adopted a purposive sampling strategy. Since this was a qualitative research, the significance of the data is not related to the size of the sample but to saturation, which means that researchers have collected all the possible available data to gain a clear idea of a phenomenon. ^43,44 The inclusion criteria were having professional experience in prisons, being aware of healthcare issues in prisons and voluntary participation in the study. No fixed time was set because participants were free to discuss and compare their own views with the other focus group participants as long as they needed; however, on average, each focus group was attended by six participants and lasted approximately 90 min. All the focus groups were conducted in a relaxed atmosphere in the meeting rooms of five penitentiaries in Liguria: La Spezia, Savona, Genova Marassi and Pontedecimo, and Sanremo. All the focus groups were conducted in the month of March 2014. The focus group moderators were experienced members of the research team and authors of this study.

Data collection

The moderator prompted and guided the semi-structured discussion within each focus group by asking the following open-ended questions, which were previously identified by our research team following a narrative review of the literature: (1) How do you identify the prisoners’ health needs and which prisoners do you think are mostly in need of care? (2) How would you describe the difference between working in a hospital and working in your setting? (3) What do you think is needed to do your work? (4) Which aspects of your work give you satisfaction? and (5) What are the barriers that prevent you from providing a good service?

After identifying the questions, the focus group was successfully piloted with five correctional nurses who did not participate in the subsequent phases of this study.

Following a brief introduction by the moderator, each question was projected on a large screen so that all participants could clearly see the question while they talked and in this way it was easier both for participants and the moderator to guide the discussions. All the focus group discussions were audio recorded and another member of the research team took notes, and summarized the main points on a flip board at the end of the discussion of each question, so that also the participants could confirm that what they had said had been clearly understood.

At the end of each focus group, another member of the research team who had not taken part in the focus group discussions verbatim transcribed the audio recordings. At the end of the five focus groups, a total of 500 significant statements were collected.

Thematic analysis

In conformity to the qualitative data analysis methodology, ⁴⁵ and bearing in mind the research question of this study (i.e. ‘How do correctional nurses describe their working experience in prisons? What issues emerged?’), two members of our research team independently conducted a thematic analysis. They started by carefully reading and analysing line-by-line the verbatim transcripts underlining the most significant words and sentences and coded them. Then according to the common patterns that emerged from the codes, the two researchers independently grouped the codes and identified potential themes. NVivo (Version 10) software was employed to facilitate data management. The codes and the potential themes independently identified by the two researchers were then compared and analysed again with the rest of the research team members until consensus was reached on the codes and the respective themes. At the end of the data analysis, the transcriptions, the final codes and themes were then shared with the focus group participants to see if they agreed and add scientific rigour to the final results. ^40,46

Validity and reliability

To ensure validity and reliability of the qualitative data, we adopted Lincoln and Guba’s ⁴⁷ four criteria: credibility, confirmability, transferability and dependability.

Credibility was ensured through the length and number of the codes representing the opinions of the correctional nurses, which ensure data completeness, and through independent analysis. ⁴⁸ At the end of the qualitative data analysis, the researchers offered participants the possibility to revise the transcriptions, codes and themes that emerged from their discussions.

Sampling variation, which included nurses from all the prisons in the Liguria Region, ensured the confirmability of the conclusions.

Reliability was confirmed by the code and theme negotiation process conducted by the two researchers.

Finally, the themes that emerged from the transcripts were discussed with other members of the research team who did not attend the focus group and shared with the participants, enabling to confirm the transferability of the results.

Ethical considerations

The scientific merit of this study was recognized by the Academic Scientific Committee of the University of Genoa. Approval to conduct the study was obtained on 21 February 2014 from the Liguria Regional Government that funded this study (Approval number: DGR 193) and from the Local Health Authority that was the prison nurses’ employer. All participants were informed about the purpose of the study, that discussions during the focus groups would be recorded and notes taken and that they could withdraw at any time. In addition, we informed participants that their names would not be revealed in any phase of the study and that all the recorded and written data would be stored in a safe place to ensure confidentiality. Formal consent was obtained from all the participants.

Theme 1: prisoners’ healthcare needs

Compared to patients who are not in prison, prisoners’ healthcare needs are different due to their detention in prison. Therefore, correctional nurses have to adapt their practice to the specific needs of prisoners (box 1).

In prison, the therapeutic relationship between nurses and patients is essential because most of the patients suffer from mental health disorders and drug addiction and are non-European immigrants. However, in prisons, the physical and virtual iron bars between prisoners and nurses do not permit nurses to establish an appropriate therapeutic relationship with their patients, giving rise to ethical issues (box 2).

The prison setting in our study presented issues that are not found in hospitals outside prisons, including as manipulation. This was found to impede the development of therapeutic relationships, which ultimately affect every aspect of healthcare in prison (box 3). ²⁴

Manipulation also compromises effective communication, the passage of correct information, listening to patients needs and generates a condition of ‘othering’ that produces alienation, marginalization and stigmatization (box 4). ²⁴

Some nurses reported that prisoners’ requests for their healthcare needs are related to the type of behaviour and attitude a health professional exhibits. In addition, nurses must learn to listen without judging their patients, but this requires time and very often nurses reported that they do not have enough time for everyone, giving rise to the ethical issue of being unable to provide equal care to everyone (box 5).

Therefore, participants reported that advanced competencies are needed to correctly assess healthcare needs of prisoners because some prisoners may not be honest when they express their needs and ask to be seen by specialists exhibiting fake symptoms. Most of our participants reported that the majority of their patients in prison were affected by mental health disorders. In some prisons, our nurses were particularly concerned and morally distressed ⁴⁹ about the fact that they could not address all mental health cases, as they should due to the lack of time and understaffing.

Theme 2: negotiation between custody and care

Nurses working in prisons described their work environment as being completely different from other healthcare settings because of the great number of prisoners to care for and the priority of security over patient safety. Indeed, these nurses had more patients to take care of, and timetables seemed to be dictated more by security demands than by healthcare priorities (box 6).

From the focus groups emerged that nurses perceived professional autonomy and consequently responsibility as being greater in prisons than in the usual hospital setting, but in prisons, nurses’ major autonomy is limited by a culture of security based on order, control and discipline that takes precedence over patient safety and nurses’ authority and therefore nurses’ professional autonomy (box 7).

Nurses’ feelings of powerlessness to care for their patients are a major cause of frustration and moral distress, ^21,49,50 and this was confirmed also in our study, especially when it came to dealing with complicated issues such as manipulation, which require nurses to act in full autonomy to attend to these prisoners’ special need for attention (box 8).

Theme 3: satisfaction of working in prisons

Job satisfaction is very important, especially in correctional nurses, because this has direct impact on their intention to leave and turnover rates. ¹⁵ Aspects of satisfaction are related not only to the human and professional enrichment provided by the multidisciplinary nature of the work and the multicultural nature of the setting but also to the relationship of trust that can be built over time. Indeed, some participants stated that building a relationship of trust between prisoners and nurses, whether it was the result of convenience or true mutual respect, was a reason for satisfaction (box 9).

A factor linked to non-satisfaction was ‘marginalization’. This is an important finding because the lack of job satisfaction, in addition to affecting turnover rates, raises ethical issues related to poor working conditions and interprofessional collaboration that do not enable correctional nurses to provide the best possible care in abidance to their code of conduct (box 10). ⁵¹

In prisons, the role of the nurse is also that of an outside professional who can provide support and reassurance. Nevertheless, some respondents expressed their awareness that the friendliness exhibited by some prisoners was often actually aimed at obtaining favours (box 11).

Theme 4: obstacles to quality care

The professional autonomy of correctional nurses is limited by the fact that they have to abide by rules dictated by security requirements rather than healthcare needs and patient safety. Obstacles to the provision of high-quality care raise ethical issues related to nurses’ impossibility to provide optimal care.

Another limiting factor is related to the image of the nurse that prison administrators have traditionally had. Indeed, nurses have been seen as mere administrators of medication, with no independent thought, professional autonomy, skills or competences (box 12).

Consequently, prison administrators tend to view physicians as the only recognized health professionals. Therefore, nurses’ relationship with the prison officers can sometimes be conflicting and lead to moral distress. ²¹ Prison officers are mostly very young and are often disinclined to view the prisoner as a person in need of healthcare; an inappropriate approach may cause rioting, and therefore security problems, upsetting the desired balance.

In some prisons, nurses come from private nursing cooperatives and staff turnover rates were perceived as somewhat high. Our participants identified this as an obstacle to the continuity of care. Moreover, high staff turnover often hinders the consolidation of the skills required to provide good-quality care in this setting, to deal with complicated issues like manipulation or the risk of suicide, and reduces the possibility to develop a relationship of trust both between nurses and prisoners and between nurses and prison officers (box 13).

The obstacles to providing a good quality of care are exacerbated by communication difficulties with prison officers, whose chief objective is instead security.

Theme 5: safety

In the prison setting, the need for safety is the priority and it regards the personal safety of both nurses and prisoners. Mindful of the particular nature of this environment, prison nurses, in collaboration with prison staff, are required to exercise great caution in the management of drugs and sharp objects (box 14).

However, the fact that nurses had to cope with an excessively heavy workload jeopardized the safety of both nurses themselves and prisoners (box 15). ²⁰

In addition, nurses are forced to set priorities in their interventions whenever several critical events arise simultaneously in prison facilities that are far from one another. Moreover, the concept of safety involves not only the legal controversies that can spring from the improper management of the nurse–prisoner relationship but also the perceived lack of system safeguards, which do not always function adequately (box 16).

The concept of safety, linked to the roles of nurses and prison officers, was strongly underlined by some of our participants: on one hand, healthcare safety and, on the other, physical safety or custody, which is to be guaranteed by the prison officers (box 17).

Here emerges a paradox around the purpose of ensuring safety because the nurses’ purpose in prisons is to foster patient safety and health, but in the end their role is limited by the prison’s security priorities. In fact, one of our participants compared the safety–health dichotomy ⁵² to ‘… two giants that try to pass together through a door large enough only for one. Who should pass first, patient health or security?’ In our view, this metaphor effectively synthesizes the issue of safety in prisons, where it becomes a paradox, raising many ethical issues, because nurses are there to ensure patient safety but at the same time they cannot always ensure patient safety because their autonomy is limited by the custodians’ different way of ensuring safety founded on the priorities of prison security, such as discipline, order and control.

Patient safety is also compromised by the nurses’ difficulty to perform all those activities that enable them to provide the best possible care, and by obstacles generated by the prison setting, and the behaviours of prison officers and prisoners themselves.

Limitations

We think that the main limitation of this study was to conduct the focus group only with the nurses and exclude the other health professionals who also worked in the same prisons. The involvement of the other health professionals in the focus groups, in addition to providing a wider perspective, would have offered to occasion to develop a spirit of collaboration among the various health professionals working in the same prisons.