Undertaking action research in prison: Developing the Older prisoner Health and Social Care Assessment and Plan

Abstract

Older prisoners are the fastest growing group in prisons. They have complex health and social care needs and the coordination of their care is suboptimal. An action learning group including health care staff, prison staff and older prisoners was established at one prison in England. The group developed the Older prisoner Health and Social Care Assessment and Plan (OHSCAP) which is a health and social care assessment and care planning process for the better identification and management of older prisoners’ needs. This paper describes and critically analyses the process of action learning in prison to develop and pilot the OHSCAP. Data were collected through reflective notes from the action learning group facilitator, reflective diary writing from group members, emails, research project steering group meeting notes and interviews with action learning group members. The constant comparison method of data analysis was used. We found that action learning is a valuable approach for developing practice in the challenging prison environment. There are important considerations when using action learning in the prison setting. These include maintaining the groups’ focus; clarifying roles and procedures; providing practical and theoretical space and considering the groups’ composition.

Keywords

Action learning prison prisoners older health social assessment care planning

Introduction

There has been a marked rise in the number of older prisoners in the majority of developed countries across the world (American Civil Liberties Union, 2012; Grant, 1999; Ministry of Justice, 2004, 2013; Uzoaba, 1998). For example, in England and Wales, the percentage of sentenced prisoners aged 60 and over rose by over 100% between 2002 and 2011 (Ministry of Justice, 2013). Consequently, adults aged 60 and over are the fastest growing age group in the English and Welsh prison estate (Ministry of Justice, 2013). This is as a result of an aging population; the use of indeterminate sentencing; the court sentencing an increasing number of older adults to prison for longer periods of time and improvements in forensic science techniques resulting in older adults being convicted for crimes they committed as younger individuals (Ginn, 2012). The rise in numbers of incarcerated older adults poses difficulties for prison and health care staff who are required to appropriately meet the complex health and social care needs of older adults within the challenging prison environment.

In a recent project to develop an assessment tool and care planning process to support the health and social care of older prisoners, an action learning group was used to support its development and piloting. In this paper, we focus our attention on the process and outcomes of action learning as a method to support the development of the tool and care planning process in the prison setting rather than reporting on the actual content development of the tool. Detailed information regarding the content development of the Older prisoner Health and Social Care Assessment and Plan (OHSCAP) tool can be found elsewhere (see Senior et al., 2013).

Background

Older adults in prison have multi-faceted health needs (Fazel, Hope, O’Donnell, & Jacoby, 2004; Fazel, Hope, O’Donnell, Piper, & Jacoby, 2001). They have higher rates of morbidity than both younger prisoners and those of a similar age living in the community (Fazel et al., 2001). Over 80% of older prisoners have at least one major illness (Fazel et al., 2001). These most commonly include cardiovascular diseases, arthritis, respiratory diseases and endocrine disorders (Loeb & AbuDagga, 2006). In addition, it is estimated that over half of older prisoners have a psychiatric diagnosis with depressive illness being the most commonly diagnosed (Fazel, Hope, O’Donnell, & Jacoby, 2001).

There is a lack of agreement concerning the definition of ‘social care’ amongst prison staff (Senior et al., 2013). Some prison staff adopt broad definitions (incorporating assistance with finances, housing and employment) whereas others use more restricted descriptions referring only to personal care. Without clear agreement on the definition, it is difficult to determine who is responsible for the provision of social care to older prisoners and consequently they are frequently not honoured their legal right to social care whilst incarcerated (Her Majesty’s Chief Inspector of Prisons (HMCIP), 2008; Prison Reform Trust, 2008; Williams, 2012). The authors adopt a broad definition of ‘social care’ as used within the recently proposed Health and Social Care Act (2012) for England and Wales. The Bill states that social care includes ‘all forms of personal care and other practical assistance for individuals who by reason of age, illness, disability, pregnancy, childbirth or dependence on alcohol or drugs, or for any other similar circumstances, are in need of such care or assistance’ (Department of Health, 2012, p.93). Where social care is provided in prison, it has largely been seen as the sole responsibility of prison health care services as opposed to a wider multi-disciplinary obligation (HMCIP, 2008). The White Paper, ‘Caring for our future: reforming care and support’, detailed the reform of adult social care in England and Wales and includes a pledge to develop a new framework clearly outlining where the responsibility for social care in prison sits (Department of Health, 2012).

There is a paucity of research regarding older prisoners’ social care needs. Older prisoners frequently suffer from mobility difficulties which are exacerbated by the narrow doorways; long walks and lack of hand rails in prison (Snyder, Van Wormer, Chadha, & Jaggers, 2009). They may also experience incontinence and a lack of appropriate services to support them with this issue (Williams, 2012). Hayes (2010) reported that, in his sample of 262 older prisoners, more than a third had some level of functional need in activities of daily living, and 14% had mobility difficulties. Nearly half were imprisoned in a geographical area far from their home, which made contact with their social support networks extremely difficult.

There have been repeated calls for a national strategy for older prisoners (HMCIP, 2008); however, to date this has not been realised. The Department of Health (2007) have produced a toolkit for good practice for older prisoner care. The guidance recommended the use of specific health and social care assessments especially designed for older prisoners’ needs and that these should be repeated at least every six months, with care plans developed and reviewed. In spite of this guidance, only 19% of prisons holding adult males have implemented such an assessment (Senior et al., 2013). Consequently, health and social care provision in prison predominately relies on information obtained via a generic, screening instrument used at reception (Grubin, Carson, & Parsons, 2002). There are specific adaptations of the instrument for men and women; however, there are no specific versions for older prisoners. Furthermore, social care needs are excluded from the generic assessments. Prior research has shown that, if health problems are not identified at reception into prison, they are unlikely to be detected later during a person’s time in custody (Birmingham, Mason, & Grubin, 1997). There is therefore a need for specialised assessments and care planning for the effective identification and management of older prisoners’ health and social care needs following reception into custody.

Action research and action learning

The OHSCAP was developed utilising action learning and action research techniques. According to Meyer (2010), action research is an approach to research rather than a specific method of data collection, underpinned by cycles of planning, acting, observing, reflecting and re-planning. Authors have referred to these cycles as a spiral because action research is a continuous and iterative process (Altricher, Kemmis, McTaggart, & Zuber-Skerritt, 2002) ‘that alternates continuously between enquiry and action as part of the research process’ (Munn-Giddings, McVicar, & Smith, 2008, p.466). Meyer (2010) suggests that ‘action research typically blurs the boundaries between education, practice and research’ (p.258) where practitioners and researchers work closely together to innovate, develop and manage changes in practice. According to Bucknall, Kent, and Manley (2008), emancipatory action research integrates reflection and critique, action spirals, strategic intent and collaboration with stakeholders where the research approach is characterised by participation, collaboration and inclusion.

Action learning has been used in a wide range of areas, such as in supporting the development of clinical leadership (Edmonstone, 2008); developing mental health services (Lamont, Brunero, & Russell, 2010) and in supporting student nurses (Heidari & Galvin, 2003). It has also been successfully used in the prison setting with both health care and discipline staff in developing practice and promoting collaborative working (Giblin, Kelly, Kelly, Kennedy, & Mohan, 2012; Walsh, 2009; Walsh & Bee, 2012; Walsh & Freshwater, 2006, 2009). Given its value in supporting reflection, learning and development, action learning can be used as a method of simultaneously developing practice and collecting data in action research projects. The authors are not aware of any previous research that has involved prison staff, NHS staff and prisoners working collaboratively in an action learning group.

Approach to research

An action learning group comprising prison health care staff (nurses and health care assistants), prison officers and older prisoners was established at one adult male prison in England. Project facilitators held an open meeting in the prison to introduce health care and discipline staff to the project and to ascertain interest in joining the action learning group. Information about the wider project was given to those who attended, in addition to information about the value and process of action learning. At the first action learning group, 14 people attended including two older prisoners, primary health care staff, a Governor, prison officers from residential areas, the gym and first night centre. There was consistent representation throughout the life of the group from prison officers and older prisoners; however, the involvement of health care staff reduced significantly as the project progressed. Upon reflection, the facilitator attributed this to the focus on social care rather than health care.

The action learning group met monthly between November 2010 and April 2011 with an experienced facilitator (EW) to develop the assessment tool which was then piloted in practice for 12 months with three interim meetings to refine and amend the tool in light of feedback from the pilot. The tool was piloted again until the group met in October 2011 when minor amendments were agreed. Another piloting phase was undertaken with the tool and the group met again in January 2012 to receive more feedback. The group met for a final time in March 2012 when the assessment tool was ‘signed off’ by all members present and the group disbanded.

Due to the inclusion of serving prisoners in the action learning group, the venue for meetings had to be inside the prison. The first two meetings were held in the prison chapel; however, it became clear that this was unsuitable for the work given its large size and lack of table top workspace, and the group moved into a smaller, more appropriate room.

Given its iterative nature and need for transparency, action research requires the collection of data from various sources throughout the development phases in order for each cycle to inform the next. Therefore, in this part of the study, data were collected through reflective notes from the action learning group facilitator, reflective diary writing from group members, emails, research project steering group meeting notes and interviews with action learning group members. These sources all contributed to the analysis of the actual process of action learning and the development of the assessment tool.

Following action learning group activity and piloting of the OHSCAP, semi-structured interviews were undertaken with action learning group members and to ascertain experience of action learning and to evaluate the OHSCAP. Six action learning group members were interviewed including prison officers, health care staff and prisoners. Two of these interviews were held face-to-face and the remainder were conducted over the telephone. Interviews were audio recorded and lasted between 20 minutes and 1 hour.

All qualitative data were analysed using the constant comparison method of analysis (Holloway & Todres, 2010), and the computer software NVivo was used to conduct the analysis. Data were analysed until theoretical saturation was reached. Analysis of the data uncovered themes in two distinct areas: the use and experience of action learning to develop the tool and the actual developing/piloting of the assessment tool. This paper focuses upon the former area.

Findings and discussion

Four sub-themes emerged from the data analysis pertaining to the experience of action learning to develop an assessment tool in the prison setting: maintaining focus, seeking clarity, space and group composition.

Maintaining focus

Facilitating the group to maintain the focus of their work was at times challenging. The group had a tendency to solve specific issues as they arose rather than focus on a system to assess and manage them. For example, in discussing the key components of the assessment tool, mobility was identified as an important area to address. The potential issues around mobility included lack of seating on the exercise yard. The group immediately began to consider solutions. One of the prisoner group members noted how solutions to problems came from the action learning group:

And, as I say, the things that have … we’ve just talked about now, the chairs in the wings, the benches out in the yard, I personally believe that they’ve come from them meetings, you know, which has been good. (Action learning group prisoner member)

In another example of the challenge of maintaining focus in the group, discussion turned to support for older ex-service prisoners whilst they are in prison:

… it’s one of them classic examples where things come to light at meetings like that, which possibly wouldn’t have done at any other time and you automatically act on them, as I say, the classic example is the British Legion thing [The British Legion being able to support ex-armed forces with accommodation needs], it actually came to light at the meeting and it was brought up at the meeting and somebody took note and said, yeah, that is a good idea and it has actually been used since and we’ve actually got the addresses of different areas of the British Legion, where you can actually get in contact with them and go from there. (Action learning group prisoner member)

Whilst generating practical solutions is considered to be one of the functions of an action learning group, the move away from considering mobility in more general terms for the purpose of developing an assessment tool to focussing on one particular prisoners’ issue, was commonplace in the group, and was managed through facilitation in bringing the group back to the wider discussion. Interestingly, even within the interviews with action learning group members, interviewees (particularly prisoners and prison officers) found the notion of reflecting on the OHCSAP challenging and tended to focus on the specific issues faced by older prisoners. Again, it was necessary for the interviewer to continually steer the focus of the interview back to the OHSCAP and action learning experience.

Facilitating action learning within prison can be challenging. The closed nature of prison, both physically through locked gates and bars, and psychologically due to the need for staff and prisoners to remain emotionally detached, leads to reluctance to engage with open methods that have reflection and transformation at their core (Freshwater, Cahill, Walsh, Muncey, & Esterhuizen, 2012). The nature of a closed system is such, that practice is outcome driven and task orientated which we suggest links directly with behaviours that Menzies-Lyth (1988) refers to as defences against anxiety. These include denial of feelings and a desire to engage in ritual task performance to eliminate the need for decision making. Denial of feelings protects prison staff from acknowledging the challenging and stressful nature of their work. Engaging in ritual task to eliminate the need to make decisions is supported in prison by an overarching prison regime that dictates the running of the establishment. Therefore, by focussing on tasks and outcomes, staff are able to remove themselves from reflecting on their own practice and focus on getting specific actions completed, to achieve a tangible outcome.

The culture within which prisoners live and work provided a further challenge relating to maintaining focus. Whilst there is a move within prison health care settings to involve prisoner patients in health care through patient participation and involvement strategies (Cowman & Walsh, 2013), requesting staff and prisoner involvement in policy and practice development is still in its infancy. Therefore, in a culture that is traditionally and predominantly autocratic rather than democratic, we found that staff and prisoners will paradoxically lose focus when asked to contribute to development and turn their attention to more tangible activity.

With group members finding difficulty in maintaining focus, the facilitator worked with them to identify and appreciate other benefits to action learning in terms of interprofessional working and understanding of each other’s roles and perspectives. This was particularly noted by one of the action learning group members who stated that:

I think it (the action learning group) did raise the profile of the older prisoner, certainly on A Wing (the vulnerable prisoner wing), in the fact that possibly their health needs were somewhat different to their more younger counterparts. (Action learning group staff member)

The value of action learning in raising awareness of other perspectives was clearly noted by group members. One member stated:

I think it’s always good to work in collaboration with all different aspects of the prison environment. It’s always nice to share practice with prison staff and with healthcare staff. (Action learning group staff member)

This concurs with Hoogwerf, Frost, and McCane (2010, p.52) who state that ‘by engaging in action learning, health professionals can learn, among other things, each other’s language and develop an insight into each other’s professional knowledge’.

Seeking clarity

During discussion of the development of the assessment tool, action learning group members were asked to consider who they felt would be the most appropriate person to undertake the assessment. This encouraged them to begin to think about roles and responsibilities when caring for older prisoners. Reflection on the roles and working practices of the wider prison officer population, led to a more in-depth, almost philosophical discussion about the role of the prison officer, where reflection on their own roles were minimal:

This led to conversation about the barriers to caring for older prisoners e.g. cultural issues and the risks of [prison officers] being seen to be caring e.g. pushing wheelchairs, collecting meals etc. (Facilitator notes, December 2010)

The group did not reflect on their own particular roles to any great depth, which could possibly be construed as a defence against anxiety (Menzies-Lyth, 1988) but instead concentrated on the difficulties of prison officers presenting a caring approach to their work with older prisoners. By doing this, group members reflected more generically about prison officers and therefore removed the personal aspect of reflection. The facilitator felt that the group readily engaged with this approach as a way to avoid sharing personal reflections on practice, another defence against anxiety.

Action learning group members also required clarity in understanding the collection and sharing of information regarding older prisoners. Challenges to the flow of information around the prison were discussed at length and identification of these particular issues informed the development of the screening tool in terms of its operationalisation. Following reflection on roles, responsibility and information collection within the prison, group members were quite surprised to learn that information pertaining to the assessment of older prisoners was routinely collected by reception staff and first night centre staff. The group concluded that it was the effective communication between staff was lacking:

In some ways much of the information we would expect to be collected regarding the older prisoner, is already collected. The group cannot see any huge gaps in the information. However, what they have decided is missing, is effective communication of the information. (Facilitator notes, January 2011)

However, of more interest to us in this paper is the way in which the need to gain clarity around roles, responsibilities and the movement of information led to facilitated reflection on practice for group members. Encouraging prison staff to reflect on their own practice can be challenging, however, when framed through an action learning process with a specific aim (developing an assessment tool and care planning process), broad superficial reflection took place readily. Reflection on own practice was less easy for group members.

Space

Given the reflective nature of action learning, it is important that action learning group meetings are held somewhere that members feel comfortable to reflect on practice, discuss issues and express emotion (McGill & Brockbank, 2004). Snoeren, Niessen, and Abma (2011) note the importance of a communicative space in action research, which promotes free and uninhibited communication. This is particularly important where there is potential for conflicting power issues between participants. As the focus for this action learning group was the development of the assessment tool and care planning process, it was important that the space for meetings also enabled and facilitated creative thinking. Initial meetings were held in an open plan area with no tables, just seating. This was felt to stifle creativity and reduced the possibility of smaller group work activity as it promoted a more formal atmosphere. Indeed, after the first meeting the facilitator noted:

We need to move the venue to somewhere that we can have tables and flip charts to get creative. (Facilitator notes, November 2010)

Once the meeting was moved to a smaller room which had tables, it was noted by one of the action learning group members that this was an improvement:

The location of the meeting was better as we had tables to work on. I still think there is a lot of ground to cover but I really enjoyed the last meeting. I am glad to be part of the development of this assessment. (Action learning group member reflective diary entry)

Although the physical space was different, it was felt by the facilitator that the psychological space provided by the action learning group time was important to members, particularly because the autocratic prison environment provides limited opportunity for such reflection. The action learning space enabled group members to take a step back from the daily workload and encouraged them to reflect on individual and organisational practices. In needing to consider how the assessment tool and care planning process would work in practice, group members were required to consider what assessments were currently in place for older prisoners and how practices were enacted. This space enabled group members to uncover ‘taken for granted’ practices and consider their practice in more depth, thus providing insight:

After some general discussion about the venue and dates of subsequent meetings, the group began to consider current practices that occur in the prison as regards older prisoners. Although they initially stated that there were no specific processes in place for managing/assessing older prisoners on reception, it became clear that there were. (Facilitator notes, November 2010)

Group composition

The group dynamics in an action learning group are important to understand if facilitation is to be successful (McGill & Brockbank, 2004). The action learning group comprised prison officers, prisoners and health care staff. Given the inclusion of both prisoners and prison officers, there was potential for power and authority to influence the discussion and hence the development of the assessment tool and care planning process. In order to reduce the impact that this power imbalance might have on the group and its work, a set of ground rules were agreed at the start of the group, thus promoting a space where group members felt safe to talk and reflect.

Part of the dynamics in this action learning group centred on the skill mix and professional backgrounds of staff. There was potential for significant clashes of healthcare and security philosophies in the group, as prison staff with their disciplinary focus worked with health care staff with their caring focus. It is widely accepted that whilst health and social care are foreground in any holistic approach to care, it is only the health care services in prison where it is clear who has responsibility for commissioning and provision. There remains confusion in prison as to who is responsible for providing social care services, particularly to older prisoners (Senior et al., 2013; Williams, 2012). This ambiguity was illustrated by one member of healthcare staff who, when talking about completing the OHSCAP stated:

I don’t know because I’m probably thinking now looking back, it seems it felt maybe that the prison seemed to look at it cause it was became more of a social angle rather than health. And then you’d got that split, well is it a health situation or is it a prison situation? So I don’t know. Because then at the end of it I understand that it went over to the prison and I believe that to my knowledge now health care don’t have any involvement into the follow up now. (Action learning group staff member)

Health care staff and senior management attendance at the monthly action learning group meetings was not consistent. Indeed, towards the latter end of the life of the group, no health care staff attended. There were some concerns that the lack of senior staff involvement may have an impact on the implementation of the intervention.

My concern was that it maybe wouldn’t carry as much kudos because there wasn’t sort of high seniority there. (Action learning group staff member)

Although disappointing, other group members felt that it was not an issue, and indeed a smaller group was deemed beneficial:

The meeting was small last month. I felt this helped and we were able to move forward more quickly with things. (Action learning group member diary entry)

From the facilitator perspective, the inconsistent attendance was deemed not to have had an impact on the rest of the group:

Again, attendance was not ideal; however, those who are attending regularly remain enthusiastic. (Facilitator notes, January 2011)

This perspective was supported by the findings from the interviews with the action learning group members who felt it was more important that the staff who attended were interested in developing support for older prisoners rather than ensuring equal representation from health care and prison staff.

And staff wise, I think it’s more important that staff are interested in what you’re doing rather than having specific qualifications … If somebody’s interested then you’re more likely to get better work out of them, rather than ‘Well I’m in this role but I’m not really interested in it. (Action learning group staff member)

For the majority of the life of the group, it consisted of prison officers and prisoners. Although for some of the tool development and piloting, the health care perspective was missing, it was felt that having the prisoner perspective in the group was important and valuable. One of the prisoner group members noted how the group was a positive experience where they were encouraged to contribute:

Yeah, they [prisoner action learning group members] didn’t feel as if they were intimidated in any way from the officers or from the members that were there at all, they were encouraged to voice their opinions. (Action learning group – prisoner member)

Whilst the lack of health care involvement in the majority of the development of this tool could have been perceived as problematic, in practice it was felt to have minimal impact. Health care information from all prisoners is collected and their health care needs assessed quite quickly on entry into prison. What became clear through the work of the action learning group was the acknowledged lack of social care assessment and provision for older prisoners. It can be surmised that once this was identified, health care staff felt that their attendance in the action learning group was unnecessary. Indeed, when one of the health care staff was asked about who should complete the OHSCAP, they remarked:

No, I think Officer (X) is competent and he is more than capable to identify if healthcare need to be involved at any juncture. (Action learning group staff member)

In addition to a possible feeling of not being required, health care staff reported difficulty in attending meetings due to a lack of staff. One of the health care staff when asked about reasons for the lack of healthcare involvement in the action learning group reported:

Availability of staff, constraints on being able to release staff into meetings, as ever in prison health care! (Action learning group member staff member)

The lack of health care input into the development of the tool enabled prison officers and prisoners to focus particularly on those aspects of need that were not being met or assessed appropriately, namely social care needs.

The composition of the group meant that whilst the tool was being developed, discussion regarding broader issues for older prisoner, such as the lack of seating on the exercise yard, took place. As there were staff in the group who could effect change quickly, solutions were found to these problems. The social care needs of older prisoners have been in appropriately seen in the past as the responsibility of health care staff as opposed to a wider disciplinary responsibility (HMCIP, 2008). The reduced health care involvement provided an opportunity for prison officers to take responsibility for some of older prisoners’ social care needs and created a system for prison officers to effectively work in conjunction with health care staff to care for older prisoners. Such developments are necessary because there is a high level of ambiguity surrounding the responsibility for older prisoners’ social care needs (Senior et al., 2013; Williams, 2012).

Conclusions

In this paper, the use of action learning as an approach to developing a new assessment tool and care planning process for the health and social care of older prisoners has been explored. From feedback and reflection on the experience of action learning, four key themes have emerged which are maintaining focus, seeking clarity, space and group composition. All are important to consider in taking forward knowledge generated regarding the use of action learning in the prison setting. Supporting a group to maintain a clear focus in action learning is a skill required of any action learning group facilitator; however, whilst it may appear that for an action learning group to lose focus, attention is taken away from the aim of the group, it can in fact be beneficial on many levels, especially in organisations where decision making and action can be slow and restricted through hierarchical government. Findings around seeking clarity and action learning group space have demonstrated the importance of psychologically safe spaces in prison for reflecting on practice. In order to ensure the effectiveness of the action learning group in prison, consideration needs to be given to its composition, especially where staff groups have significantly differently philosophical perspectives, i.e. care and security. Paying attention to potential challenges with power dynamics and interprofessional relationships is important. However, prisoners can be effectively and meaningfully involved in the development of health and social care initiatives in prison through action learning.

Action learning was successfully used to develop and implement the OHSCAP in a prison environment where changes to service delivery can be difficult due to the hierarchical structure and security driven focus. After a short time to settle into the work, this prison action learning group worked well in developing and piloting the assessment tool. The value of action learning as an approach to develop practice and relationships cannot be underestimated; however, there are issues which must be explored and addressed prior to its use in the challenging prison setting, if it is to work effectively.

Footnotes

Acknowledgements

The authors wish to thank the staff and prisoners who participated in this research project. The authors also thank Dusty Embury for leading the review process of this article. Should there be any comments/reactions you wish to share, please bring them to the interactive portion (Reader Responses column) of the website: .

Funding

This project was funded by the National Institute for Health Research, Health Services and Delivery Research Programme (project number 08/1809/230). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HS&DR Programme, NIHR, NHS or the Department of Health.

Author biographies

Elizabeth Walsh is an Associate Professor in the School of Health Care at the University of Leeds. She is a qualified nurse with clinical, academic and practice development experience in prison health care settings. She is the Chair of the Royal College of Nursing, Nursing in Criminal Justice Services Forum and an Adjunct Professor at the School of Nursing, University of Ottawa, Canada.

Katrina Forsyth is a Research Associate and PhD student at the Offender Health Research Network at the University of Manchester. Her research focuses on older prisoners. She holds a Masters degree in Research Methods.

Jane Senior is manager of the Offender Health Research Network, based at the University of Manchester. She is a qualified mental health nurse with clinical and academic experience in prisons, secure, acute and community mental health settings.

Kate O'Hara is an employment based postgraduate scholar at the Irish Penal Reform Trust completing her doctoral research in conjunction with Dublin Institute of Technology. She was previously a Research Assistant at the Offender Health Research Network at the University of Manchester.

Jenny Shaw is a Professor of Forensic Psychiatry and Academic Lead for the Offender Health Research Network at the University of Manchester. She is also Clinical Director for the Specialised Services Network and a Consultant Forensic Psychiatrist at Lancashire Care NHS Foundation Trust.

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