Nursing in prison--a primary health care role to be proud of: a good prison nurse needs to have a high level of self-knowledge, confidence in her or his practice and the ability to maintain safe boundaries. It's the ideal job for a nurse committed to primary health care.

Improving the training of nurses in prison, supporting them in their roles, and raising health service standards within the countries 18 public prisons are the aims of four, recently appointed regional clinical quality assurance advisers. A fifth adviser--one for the Wellington region--and a national health services clinical leader are expected to be appointed soon. Covering the northern region (three prisons in total, though four when the Northland Regional Corrections Facility opens in March next year) is former Mt Eden prison nurse and team leader Dianna McGregor, who took up her new role at the beginning of September. Now based at Auckland Prison, Paremoremo, McGregor is excited about the new opportunities to improve prison health services and keen to ensure that nurses continue to drive these services.

One of the first tasks of the regional advisers is to rewrite the health section in the public prison manual. "Our policies and procedures and service specifications are very much in need of updating," said McGregor. "The manual is now out of date and a number of regional variations in health delivery have emerged over the years, with little regard for the need for national consistency. For example, we need clear guidelines in such areas as the delivery of methadone treatment, how to manage inmates' withdrawal symptoms and managing medical waste like sharps. We have set key strategies about how to do this work, beginning with an analysis of gaps in service, using guidelines from the New Zealand primary health care strategy and the prison health and disability support specifications.

"The job is huge, and crucial to ensuring we achieve excellent clinical practice and consistent service delivery in all public prisons. Most importantly, we must ensure any changes are developed around a nursing model of primary health care delivery. Nurses drive the prisons' health system and we need to be valued."

Included in the updated health section will be health and safety guidelines, nationally consistent job descriptions for nurses, a nationally consistent recruitment and selection package, a performance management system (Linked to the Nursing Council's competence requirements for annual practising certificates) and the newly developed national induction package. McGrego's other focus is helping to recruit more prison nurses for the northern region. There are nurse vacancies in almost all the country's prisons, with the situation worsening over the past 18 months, particularly in the Auckland region, where nursing numbers are sometimes down by as much as 50 percent. Caring for a total prison population of around 6800 inmates are 120 full-time equivalent nurses. Twenty-three of these positions are vacant at present, with a funding bid to increase the numbers of nurses as inmate numbers rise. "We have had to realign our services to meet this shortfall. Basically the nurses that we have can't fill all the requirements of the role. We've just had to focus on delivering urgent and emergency services."

Experience in prisons as a nursing student

McGregor, who began her nursing career as an enrolled nurse, has been a prison nurse since 1997, following completion of her nursing degree. A stint at Auckland Prison as a third-year nursing student had her hooked. She believes nursing in prisons offers an ideal primary health care role. Once considered an area of nursing where a nurse could "hide away", it is now a role that nurses take real pride in. She is disappointed that more nurses don't consider prison nursing as a specialty option, especially those who have had primary health nursing experience. The situation is made worse by the national shortage of nurses, the ageing nursing workforce and some angst among primary health care nurses about working in an unfamiliar environment.

"Once a nurse joins the public prison service, they tend to stay as they become very committed to the work. We do use a number of casual nurses to fill our vacancies, but it takes time to equip them with the skills and knowledge they need. Our permanent nurses are working very hard at present to cope with the staffing shortfall. The growth in our prison population is also placing a great deal of strain on the nursing resource."

When McGregor took up her new role over two months ago, she wondered whether she would become too desk-bound. But she has found she continues to have plenty of contact with inmates in both Mt Eden and Auckland Prisons, dealing with inmates' health-related complaints and nursing issues. "I love prison nursing, the autonomy you have and the opportunities to work in a dose knit team. Mt Eden has a very changeable prison population due to the high numbers of remand prisoners and the fact it is the receiving prison for all the Auckland district courts. Nurses provide 24-hour care over three shifts, the only prison in the land to do so, though we are expecting to move to an on-call night system before the end of the year. Currently there are 14 registered nurses, although not all are full-time. We have a doctor service every weekday morning, with a range of other health services providing clinics, eg physiotherapists, midwives, podiatrists and dentists.

"Within 24 hours of their arrival, all new inmates are given a furl hearth assessment. Some days, nurses can see 40 inmates or more. We also do three medication rounds per day, each taking between one and one a half hours. These rounds give the nurses the opportunity to observe inmates in their own environment--in their cells and units. This helps them assess the health issues an inmate may be facing or may be reluctant to speak up about." Controlled medications such as methadone are administered within the health centres.

McGregor sees the ability of nurses to work side by side with custodial staff as vital. "A prison is a unique community. Good communication between all staff is absolutely essential to ensure everyone's safety--staff, inmates and visitors--and to meet inmates' health needs. We are dealing with some very unpredictable people. Being able to manage them and to watch out for changes in mental health status and behaviour is vital."

Around ten percent of Mt Eden's prison population of 421 sentenced and remand inmates is classed as very unwell. The rest, says McGregor, are managed Like any other group of patients in the community. Around 90 female inmates--mostly remand prisoners or those serving light sentences--are herd in the nearby Mt Eden Women's Prison. Nurses encourage inmates to take responsibility for their own health, although McGregor admits that the culture of prison Life and some inmates' attitudes make that rather difficult to achieve. Some inmates, who have been sent to an Auckland hospital for treatment, may need to spend some recovery time at Mt Eden before being transferred back to their original prison.

Nurses see a full range of health issues, from a sore finger or acne, to workplace accidents, the management of chronic conditions tike coronary and respiratory disease, epilepsy, diabetes and arthritis, care of inmates with mental health issues or addiction, and dealing with fractures or an imminent birth. Some inmates may die in prison, and it will be the nurse's role to assist people to a dignified death. "Dying in prison may be a better option for someone who has no support structures or family outside the prison and for whom the prison is the closest thing to home they have ever known," McGregor said.

McGregor believes mental hearth issues have always been part of prison life--they are just more identifiable these days. "Prisons have also picked up more inmates who haven't been able to function in society or who have not been accessing the appropriate services in the community. We need more residential mental health units for these people, but the facilities are just not available. Here at least they get a bed of sorts and three meats a day."

Nurse David Barnett, who holds the psychiatric portfolio, manages the health needs of inmates in the special needs unit. Here offenders with psychiatric problems and "the non-copers" are cared for. A number may be eligible for transfer to the Mason Forensic Clinic, but are waiting a bed. Around 12 Mt Eden inmates are currently on the waiting list for admission to the Mason Clinic. A counsellor is employed six hours a week, covering the whore of Mt Eden Prison, including the women's prison.

Prison nurses work hard to normalise the environment for inmates. As McGregor said: "The nurses' role is to keep inmates well and safe, providing them with an opportunity to manage their health needs, until their release. It is not our role to pass judgement on why they are in prison. Whatever they have done outside prison, they are still people, to delivering health care to them, I don't want to know or need to know what their crimes are. I make an active choice not to find out what offenders have done.

"To be a good nurse in the prison environment, you need to be knowledgeable about yourself, confident about your practice and able to maintain safe boundaries. You also need to be non-judgemental in attitude and able to empathise with a group of people who come from a very different world from what is considered the norm; a world where poverty is rear and violence is commonplace. Being a Maori nurse is often an advantage, as I can connect with inmates who are from my Nga Puhi tribal area. The work is challenging. If inmates don't get what they want, they can be very stroppy. As nurses, we can talk to inmates about ways of changing their way of life and encourage them to attend programmes to address their offending. We see many coming back through that revolving door after their release, but there are also those who don't return and that's heartening."