How do nurses care for prisoner patients? Negative attitudes towards prisoner patients, and a range of moral and ethical conflicts, can make the caring role difficult for some nurses.

To be a good nurse, you need both technical skills and the ability to care on an emotional level for the well-being of patients. Much has been written by nursing theorists about this caring attitude, and that it is imperative to our role. As someone working in a particularly challenging nursing environment, I am interested in how nurses respond when this caring role becomes difficult to achieve. Earlier this year, nurses at Wellington Hospital were challenged in their imperative to care when convicted murderer Graeme Burton was hospitalised after being shot in the leg by police. The New Zealand Herald reported "Wellington Hospital staff are understood to be unhappy about having to treat Burton, who they regard as undeserving." (1)

Very little has been written about these potentially complex situations where nurses' understanding of, and belief in caring is challenged. How do nurses deal with this type of moral and ethical conflict?

"Nursing still carries with it the remnants of several historical stereotypes. From the time Florence Nightingale began her pioneering work in the 19th century, nurses have been viewed as "good women" exemplifying the feminine ideal. Do these or should these good women care for "bad" men such as prisoner patients? This question immediately confronts us with the gendered nature of both the nursing profession, which is around 90 percent female, and the prisoner population, which is approximately 90 percent male.

Another stereotype is nurses as angels of mercy filled with compassion and love. In part, this is an association with the Christian tradition and religious nursing orders, who have embraced society's disenfranchised and cared for all, no matter how "worthy" or "unworthy" they might seem. It is interesting to take a step back and consider how these perspectives have influenced, not only the public view of nurses, but also nurses' view of themselves.

A recurrent theme in current nursing literature is that caring is a moral ideal, not a moral imperative. Yet the underlying sense seems to be that if we don't care, we are "bad" nurses. Is it enough to go through the motions of caring for a patient or is the caring attitude at the heart of the matter and essential to being a good nurse?

I work in the operating theatre of a Melbourne hospital which has a secure ward and provides surgical services to around 350 prisoners a year. Nursing prisoners in a general hospital environment has been extremely interesting and is the topic of my PhD studies. I believe this unique patient group requires specific nursing interventions that are "caring" but that also maintain the nurses' integrity and ability to do their job. As American prison nurse Steve Dighton says "every practising nurse has had the experience of meeting that person who qualifies unequivocally as the 'difficult patient', but in jail, we have the equivalent of an entire hospital of them." (2)

When first asked, most of us would respond that of course we would treat a prisoner patient the same as any other. I have found that, in reality, this is often not possible, for a number of reasons. In this article I will touch on a couple of areas in my practice that have been of interest.

Prisoners' health issues

The major health issues facing this population group have been identified as infectious disease, substance abuse and mental illness. (3) Substance abuse among prisoners affects not only their general health but can also determine behaviour, influence prison culture and contribute to negative staff attitudes. The physical dependence can also result in manipulative, drug-seeking behaviour. This can make analgesia delivery in a post-operative environment stressful for both the nurse and the patient. In my experience, it is often not that the patient is seeking unwarranted analgesia but more that I am concerned about the potential they might be, and do not want to appear foolish or "played" In addition, patients with substance abuse issues will have a high tolerance to drugs and may genuinely require much higher analgesia doses than we would normally expect. Not understanding this reality might lead us to doubt their pain score and restrict, however inadvertently, the delivery of analgesia. Such extreme caution with analgesia by both medical and nursing staff is a factor in patient care. Fear of the patient becoming violent is a very real concern for some nurses. Reports of Burton hiding a knife under his hospital mattress (4) or, as I have seen, sharps being grabbed by a prisoner patient and used to threaten staff, show how verbal abuse and aggression from prisoners are not uncommon in the hospital setting. The fear of violence also taints all nurse/prisoner/patient interactions, as we tend to err on the side of caution, perhaps wisely.

The media plays a part in this perception of prisoners, as television perpetuates and reinforces the idea that people are in prison because they are dangerous. (5) The prison system itself is also a contributing factor when considering the relationship between prisoners and violence. The level of violence is reported as being substantially higher in prison than in general society, (6) with the culture of prison reinforcing violent behaviour.

The behaviour of prison guards influences nurses' perceptions of prisoner patients. In my unit, prisoners are always accompanied by at least two guards and handcuffed for most of their time in theatre. It is very easy to get a sense from the guards as to how risky they expect the patient to be; they act as an indicator of the prisoner's dangerousness or status. If the guards are keen to handcuff the person, are present in larger than normal numbers, or are armed, we assume there is reason. It has been suggested that contact between the nurse and their peers, whether they be other nurses, prison guards or medical staff, can affect perceptions of the prisoner patient, sometimes "amplifying preconceived ideas". (7) The presence of guards and handcuffs are visual reminders to all involved that the patient is indeed a prisoner and potentially dangerous.

Protecting patient confidentiality 

Ethical dilemmas also need consideration. Firstly, the presence of guards limits the prisoners' access to confidentiality; they are close enough to listen to all discussions with and about the patient. There are also the discussions that take place when the prisoner is unconscious, when medical staff are discussing information (eg prognosis) to which the prisoner patient is not privy.

Secondly, there is the concern about loss of dignity. (8) The patient may understandably be apprehensive or frightened, or exhibit any number of other emotions prior to surgery. Post surgery, patients are particularly vulnerable, expressing a range of emotions. The prisoner is exposed emotionally when guards and others from the prison environment/culture witness their vulnerability.

In my research, I have read little about the positive aspects of prison culture and the benefit of having prisoners as patients. It is worth remembering that prisoners are primarily from vulnerable, marginalised groups--those who are "impoverished, subject to discrimination, and stigmatization". (3) There are bigger social forces at work here than simply an individual making bad choices. It is a complex picture yet to be fully understood by most members of society.

It is tempting to view prisoners as victimisers but they are often victims themselves of domestic violence and abuse. They are often caught in a cycle from which it is hard to break free. "Once incarcerated, they become vulnerable, to themselves, to each other, to poor health and to the system." (9) One prison doctor has suggested, when exploring the broader issues of prison culture, "there can be some nasty people, as you might expect, but you also meet intelligent and amusing folks as well". (6)

I consider myself a compassionate person and a good nurse, as are my colleagues, but there is a difference in the way we engage with prisoner patients. It is hard to imagine all the issues a nurse caring for a prisoner patient needs to address unless you experience it first hand. In the general hospital environment where I work, we have spent less time debating some of these issues than nurses working in a forensic facility might do. These issues would have to have been considered very seriously in these environments. And, of course, we have all encountered "difficult" patients who are not prisoners--those who are violent, substance abusers, sexually explicit ... the list goes on.

I try hard to avoid knowing why the patient is incarcerated and have the most trouble caring for them compassionately when I know their crime. It is unfortunate when the prison guard asks me: "Why are you being so nice to that 'kiddy fiddler'?" And it gets difficult when we recognise a patient's face from the television news as someone who has just been charged with some terrible atrocity. Such was the case with Graeme Burton. It was inevitable the nurses would know who he was and that made their caring endeavours all the more complex.

If we assert that nursing is more than the act of caring, involving engagement on an emotional level as well, further investigation needs to be made into those aspects of caring that are particularly challenging.

Nursing theorist Patricia Benner writes that "nursing practice invites nurses to embody caring practices that meet, comfort and empower vulnerable others". (10) But what if we don't feel like meeting, comforting or empowering some of our patients? Does that make us "bad" nurses? The experience of caring for prisoner patients needs further discussion, as does any situation in which the delivery of nursing care becomes difficult. From such discussion, nursing may well evolve into a profession that places as much consideration on the emotional well-being of the nurse as it does on that of the patient.

References

(1) Cheng, D. (2007) Security watch tightens on Burton. New Zealand Herald, January 12. Auckland: APN Holdings.

(2) Dighton, S. (1986) Tough-minded nursing. American Journal of Nursing; 86: 1, 48-51.

(3) Peternelji-Taylor, C. (2003) Incarceration of vulnerable populations. Journal of Psychosocial Nursing and Mental Health; 41: 9, 4-5.

(4) Houlahan, M. (2007) Graeme Burton grabbed a knife in hospital. New Zealand Herald, February 5. Auckland: APN Holdings.

(5) Cooke, C. (2002) Understanding incarcerated populations. Association of Operating Room Nurses AORN Journal; 75: 3, 568-580.

(6) Cohen, L. (2000) Beyond bars (Prison doctors). Medical Post; 36: 26, 32.

(7) Holmes, D. & Federman, C. (2003) Constructing monsters: Correctional discourse and nursing practice. The International Journal of Psychiatric Nursing Research; 8: 3, 942-962.

(8) Fyfe, A. (2004) Managing prisoners in theatres. British Journal of Perioperative Nursing; 14: 12, 559, 561-562.

(9) Maeve, K. & Vaughn, M. (2001) Nursing with prisoners: The practice of caring, forensic nursing or penal harm nursing? Advanced Nursing Science; 24: 2, 47-64.

(10) Benner, P. (2000) The roles of embodiment, emotion and lifeworld for rationality and agency in nursing practice. Nursing Philosophy, 1, 5-19.

Ruth Crampton, RN, PGDip, MN, is a clinical educator in anaesthetic and post anaesthetic care at St Vincent's Hospital, Melbourne. St Vincent's offers sugical services for all prisoners in Victoria.