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CORRECTIONAL Nursing PRACTICE: What Makes This Practice Different?

Correctional nursing practice is not for the fainthearted but can be quite manageable with a common sense approach. The obvious difference between correctional and noncorrectional nursing is the patient we care for. Or is it?

Perhaps it is the environment in which we practice nursing. The correctional setting certainly is not the traditional model of nursing practice. The greatest difference, in reality, is how inmates' constitutional rights and court principles interact with nursing practice in the correctional setting. This difference exists because inmates have lost their rights to basic freedoms and live under supervision and government control.

The Eighth and 14th Amendment Challenge

Inmates must rely on correctional authorities to meet their medical needs. Because of this, the courts have interpreted the Eighth Amendment to the U.S. Constitution to mean that failure to provide convicted inmates with necessary medical care and treatment is cruel and unusual punishment. Regarding pretrial inmates, the courts have interpreted the 14th Amendment to require correctional facilities to provide the necessary medical care. Understanding the principles established by the courts will help pave the way for nursing in the correctional setting.

It is a clearly established principle of constitutional law that correctional facilities provide inmates with necessary medical treatment. This applies to the inmates' dental, medical, psychiatric and psychological needs. The nursing practice issue is: What is medically necessary? And in practice, the nurse cannot be deliberately indifferent to an inmate's serious medical need.

Clarifying Deliberate Indifference

Nurses must consider what is meant by deliberate indifference to a serious medical need. This certainly is not a term covered in basic nursing curriculum. But nurses can gain a working knowledge of the phrase "deliberate indifference to a serious medical need" by looking at the components defining the phrase.

Deliberate indifference may have different meanings depending on the particular facts of each case. There are certain generally recognized components of deliberate indifference to inmates' serious medical needs:

* Deliberate indifference is more than an honest mistake. A nurse must act intentionally in response to a serious medical need or must intentionally fail to respond to a serious medical need of an inmate.

* The nurse must exhibit a culpable state of mind. In order to have culpability, the nurse must have had the opportunity for deliberative process or had the knowledge of a problem that without appropriate intervention, there would be a substantial risk of serious harm to the inmate.

* The indifference to a serious medical need must have involved a choice by the nurse among alternatives and the nurse made a knowing choice among the alternatives regarding an inmate's care.

* The nurse had knowledge or appreciation of the consequences that may result from his or her action or lack of action.

* The nurse acted or failed to act with knowledge or appreciation of his or her conduct.

What is a serious medical need?

* The inmate is experiencing significant pain or suffering that may be relieved by medical care.

* The inmate suffers from a condition that has been diagnosed by a physician as requiring treatment.

* The inmate is experiencing a lack of medical or nursing care or a delay of care that may cause deterioration or worsening of his or her condition.

* The inmate has a high probability that his or her problem may result in a permanent medical condition.

* A layperson would be able to recognize that the inmate requires nursing or medical intervention.

What is not deliberate indifference in nursing practice?

* A nurse may engage in good faith disagreements over treatment modalities with an inmate.

* A nurse is not required to provide elective treatments or cosmetic treatments.

* A nurse is not required to allow an inmate a choice of medical providers or provide second opinions upon inmates' requests. The standard only requires the provision of necessary medical care.

* A nurse may substitute a formulary medication of the same family of medication with physician approval.

A personal challenge for me as a practicing nurse in corrections regarding such deliberate indifference concerned an aging long-term inmate in our prison system. By the length of his sentence, this particular inmate predictably would live his life within the walls of our prison. The inmate was an insulin-dependent, brittle diabetic and, for lack of a better term, the inmate was incredibly stubborn and lacked reasonable insight into his situation. He refused insulin and medical and nursing interventions. It became apparent that he would use this refusal action as a mechanism to attempt to manipulate prison administration into meeting his demands or possibly to gain attention.

A nursing assessment of the situation revealed the following:

* An elderly, incarcerated, brittle, insulin-dependent diabetic with a long sentence.

* Laboratory values with glucose blood levels in the 300-500 range.

* The inmate's behavior clearly demonstrates manipulative behavior.

* Without medical intervention, the long-term refusal of insulin will cause the inmate to develop heart, kidney, vascular and other serious medical conditions and complications.

* The possibility of diabetic coma and death.

* This behavior of insulin refusal is a pattern over a lengthy period of time.

The question contemplated was: By not intervening, is there deliberate indifference to the serious medical need of an inmate?

Among the ethical considerations were the following:

* In the community, individuals have the right to refuse medical treatment, such as insulin therapy.

* At what point do the cognitive impairment and/or judgment of the inmate become a factor under the standard of not being deliberately indifferent to the serious medical need of an inmate?

* It is established medical/nursing knowledge that significant serious physical changes will occur as a result of uncontrolled diabetes mellitus.

* Because of this inmate's incarceration, how far does the Department of Corrections' (DOC) responsibility for his serious health care needs extend? What are the liability issues for the DOC when an inmate refuses recommended treatment?

The question for a practicing nurse in corrections is whether the intervention of forced glucose blood tests, insulin injections and close observation of the inmate are necessary under the deliberate indifference standard. Or, as a nurse, may I allow the inmate by his refusal to deteriorate to the point of extreme illness or death?

Administratively and legally, this was a challenge in our correctional system. The inmate's behavior of consistently refusing his insulin and diabetic care was not going away. Our correctional system's legal and administrative teams supported going to district court to clarify the prison medical department's role in this situation. The outcome of the court proceedings was that the state trial court ordered the medical department to force-medicate and provide treatment for this inmate's diabetes mellitus. The North Dakota Supreme Court affirmed the state trial court's decision on appeal. The long-term outcome has been that the inmate has been voluntarily compliant with his diabetic care ever since.

The courts also have influenced the mental health arena of nursing in corrections. Nurses are being asked to care for increasingly more seriously mentally ill inmates. The consequence of the deinstitutionalization of the seriously mentally ill in our communities is that these individuals are finding themselves in the criminal justice system. Nursing in the psychiatric arena supports the use of medications for the seriously mentally ill because it improves the symptoms of psychosis. The most significant decision in this area is the case, Washington v. Harper.

Components of Washington v. Harper include:

* When an inmate is deemed mentally ill, is a danger to himself or herself or others, or is gravely disabled and is refusing treatment, it may be appropriate to intervene with anti-psychotic medication.

* Involuntary treatment of the inmate does not violate substantive due process when the inmate is found to be dangerous to himself or herself or others, or is gravely disabled and treatment is in the inmate's best medical interest.

* The inmate has rights to: an administrative hearing conducted by an independent administrative panel, notice of the hearing, be present, and present and cross-examine witnesses. The panel includes a psychiatrist and another mental health professional who have not been involved in the inmate's current diagnosis. This administrative hearing fulfills the requirement of procedural due process.

Washington v. Harper has helped correctional nurses by providing a framework to intervene appropriately in the care of the seriously mentally ill or gravely disabled inmate. The use of typical and atypical anti-psychotic medications as an intervention in mental health care of inmates dramatically decreases symptoms of psychotic disorders. Intervention through medication and the structure of the prison environment actually may enhance the quality of life of many seriously mentally ill inmates. When medicated and closely monitored, seriously mentally ill inmates actually may assimilate into the general prison population, away from segregation units.

The nurses' responsibilities during the forced medication process include:

* Correct inmate, correct dose, correct medication, correct dosing time and correct route of administration.

* Accurate and complete assessments and documentation of the signs and symptoms of mental illness.

* Administration of anti-psychotic medication.

* Alertness and assessment of side effects, inmate behaviors and inmate communications.

* Providing an empathic supportive approach using reassurance or redirection as indicated.

* Following physician orders.

The nursing practice in the correctional setting is provision of a standard of care to inmates that is humane and consistent with basic community standards of nursing practice. The U.S. Constitution and the courts have established the framework for correctional nursing practice, while individual nurses provide the judgment and common sense within that framework.

Kathleen Bachmeier, R.N.-C, M.S., is director of medical services at the North Dakota State Penitentiary in Bismarck, N.D.


Estelle v. Gamble, 429 u.s. 97, 97 S.Ct.285, 50 L.Ed.2d 285 (1976).

Bell v. Wolfish, 441 U.S. 520, 99 S.Ct. 1861, 60 L.Ed.2d 447 (1979).

Washington v. Harper. 494 U.S. 210, 110 S.Ct. 1028, 108 L.Ed.2d 178 (1990).

Wilson v. Seiter, 501 U.S. 294, 111 S.Ct.1970, 128 L.Ed. 2d 811 (1994).

Farmer v. Brennan, 511 U.S. 825, 114 S.Ct. 1970, 128 L.Ed.2d 811 (1994).

State ex rel. Schuetzte v. Vogel, 537 N.W.2d 358 (N.D., 1995).
COPYRIGHT 2001 American Correctional Association, Inc.
No portion of this article can be reproduced without the express written permission from the copyright holder.
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Article Details
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Author:Bachmeier, Kathleen
Publication:Corrections Today
Geographic Code:1USA
Date:Aug 1, 2001
Previous Article:Using Algorithms and Protocols In Diagnosing and Treating Offenders With Mental Health Disorders.
Next Article:Suicide Prevention In a Large State Department of Corrections.

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