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Caring for prisoner-patients: Student nurses on clinical placement observe that how nurses care for prisoners in hospital is affected by whether or not they know why the patient has been imprisoned.

Person-centred care is a main focus for registered nurses (RNs) and for the students they mentor. Applying the principles of person-centred care, as outlined in the Nursing Council's code of conduct, (1) ensures care is delivered equitably, regardless of a patient's circumstances, culture or religion. This also applies to patients who are prisoners. (2)

According to the Health and Disability Commissioner, patients must be treated with respect. (3) The World Health Organization also states that imprisoned patients must have access to all available health services, like any other patients. (4)

Student nurses working in hospital wards on their clinical placements are paired with RNs for support and guidance. This system allows the student to participate in patient care and to observe exemplary behaviour from their preceptor RNs. However, an RN's practice may not always be exemplary.

RNs are expected to practise in a way that aligns with the council's code of conduct, which contains eight fundamental principles of care. (1) However, nurses are also human beings, with emotions that may affect their practice. (5) Having to care for an imprisoned patient may come as a surprise to the nurse and affect his/ her perception of the patient.

The two scenarios below describe observations made by some of us on clinical placement.

Scenario 1

A patient was admitted to the ward from prison. All staff were advised the patient would have two guards present at all times, one directly handcuffed to the patient. The reason the patient was imprisoned was not disclosed. This non-disclosure was ultimately seen as an important factor in how care was provided.

The prisoner was struggling with tobacco withdrawal, and the preceptor RN provided the patient with smoking cessation support, including nicotine replacement therapy (NRT) lozenges. The patient accepted and used NRT frequently throughout their admission.

On one particular shift, an RN (not from the ward) was called in due to a staffing shortage. She asked the RN caring for this patient why she was "running back and forth" providing NRT, as she believed they did not deserve it. The preceptor explained that the fact they were a prisoner did not mean they did not deserve a standard of care equitable to that given to other patients on the ward. If she did not provide adequate care, she would not be doing her job properly.

The student nurse found it inspiring to observe how the preceptor RN advocated for the patient, demonstrating both professionalism and compassion. This incident was the only ethical dilemma that presented itself, as all other healthcare professionals working on the ward treated the patient impartially. The preceptor RN and all other professionals saw this person as a patient, not a prisoner, who was as deserving of appropriate and high-quality care as any other.

Scenario 2

Another student had a quite different experience when caring for an imprisoned patient. In this case, the patient's criminal record was included in the patient's folder, so the information was known to the health-care team. Unfortunately, the facts were quite shocking and the crime severe. Information was soon shared with other ward staff not primarily responsible for this patient's care. Nurses shared their opinions; a minority expressed disgust.

One of the responsibilities a student nurse has is to answer call bells when the RN is unavailable. On one occasion, the RN was on a lunch break, and the student nurse answered a call bell from the imprisoned patient. The patient said they were in pain. Using the numeric pain rating scale, the student nurse assessed the pain to be a 6/10. This can be interpreted as a moderate, bordering on severe level of pain, thus requiring action to help the patient cope. (6,7) When communicating the interaction to the RN, the response was "They can wait [until the lunch break is over]". (8) Although the reasoning behind the response was not explicit, it could be inferred that, due to previous conversations and the RN's explicit views about the patient's crime, the patient was being forced to wait for pain relief.

Research

There is minimal literature about student nurses' experiences with prisoners as patients in a hospital. However, there are studies about RNs' experiences with having prisoners as patients. A study from Australia observed and interviewed 12 RNs about caring for prisoners in hospital. (9) The nurses reported that knowing the prisoner-patient's crime(s) created ethical dilemmas and proved to be emotionally exhausting. As a consequence, some of the RNs provided the prisoner-patients with half-hearted care. (9)

This study reflected scenario 2, where the RN responded poorly towards the imprisoned patient. Deciding the patient could wait for pain relief, rather than acting immediately, violates right four of the Code of Health and Disability Services Consumers' Rights. This states that "every consumer has the right to have services provided in a way that is consistent with their needs". (3) Nurses should advocate for all their patients--we have a responsibility to uphold excellent standards and to be ethically competent.

Those nurses who say they need to know the imprisoned patient's crime(s) base their arguments on concerns for personal safety. One nurse in an American study is quoted as saying: "I'd like to know whether I should keep at an arm's length 'cause sometimes the guards don't pay enough attention". (10) Philosophy professor Paul Neiman concludes many factors contribute to a prisoner's crime(s), and health-care professionals should, therefore, not know their patients' criminal history. (10) Knowing the patient's crime can affect the relationship between the patient and nurse, and undermine the nurse's duty to care.

Upholding patients' rights

To care does not mean simply carrying out tasks and following guidelines. As nurses, we must display goodness and compassion to patients who trust us with their health. Nurses should not deprive patients of their rights, despite our own personal beliefs. This is reinforced by international human rights law, which stresses the importance of prisoners having "access to preventative and remedial health services, and prohibits any discrimination in access to healthcare and underlying determinants of health". (4)

Although prisoners are serving a sentence, the conditions in which they are kept must never jeopardise their health. (4) Scenario 1 demonstrates this. Here the RN did not make the patient wait for any treatments or expose the patient to prejudice.

However, in scenario 2, the RN's actions violated the patient's right to timely health care. As nurses, we must not place ourselves in a situation where our practice could be labelled ethically incompetent. We must always ensure we are working with our patients, keeping their best interests at heart.

Recommendations

Accessing health-care services is a basic human right. Prisoners have lost the right to freedom, but they still have the right to good care. The Human Rights Act 1993 protects prisoners from unlawful discrimination. (11) If a prisoner requires urgent health care, it must be provided without discrimination.

Paul Neiman's study describes nurses researching a patient's criminal history to gain the knowledge they believe they need to maintain their own safety. However, he argues this knowledge will affect how nurses provide care to the prisoner-patient, violating their duty to care.

In our experience, we have seen prisoners being treated perfunctorily, as in the phrase: "They can wait." To ensure a student or RN avoids biased practice, they should not seek to know why the patient has been imprisoned. RNs should also refrain from listening to stories about their patients' actions. They should avoid reading information about the patient's criminal history if it is included in the patient notes. They should also refrain from gossiping with other healthcare professionals.

The RN needs to treat patients humanely and avoid discrimination, despite any personal opinions. This can be challenging and often creates an ethical dilemma for nurses trying to provide the best care possible. If they know about the prisoner's crime, their personal opinions and emotions may affect the way they provide care. (9)

Nurses need to treat prisoners as they would any other patient. (1) They must work in partnership with patients, showing respect, trust and integrity. The nurse must consider the person as a patient before they consider them a prisoner. The patient has the right to respectful care and to have their health concerns acknowledged. (12)

If the nurse caring for the imprisoned patient feels they are unable to provide equitable care, they must inform the nurse in charge. In this way, the patient may not be exposed to unfair care and the nurse protects her practice by identifying a potentially unsafe situation. Neiman states that "nursing education does not typically include training in criminal justice or philosophy of law and punishment". (10) To prevent negative scenarios, nurses need to be educated to help them cope better with such situations.

Education may be provided at university or by the student's RN preceptor, who can inform them of the best way to handle these challenging situations. Education will help improve the quality of nursing care for prisoners and reinforce the nurse's ethical obligation to provide equitable care.

Conclusion

From our observations and research, we concluded that when nurses knew why a patient had been imprisoned, the care they gave was affected negatively. In contrast, when patient criminal records remained confidential, there was no impact on the quality of care provided. It is human nature for our emotions to affect how we behave in the workplace. (5)

Ethically, all patients must be treated equally, regardless of their history. However, situations may arise that affect nurses' clinical decision-making. If RNs are to maintain a trustworthy client-nurse relationship, they should abstain from obtaining unnecessary patient information; recognise all patients as patients, regardless of their criminal activity; practise with respect, trust and integrity; and get the education they need to manage difficult situations.

A final note: Our reflection is based on observations and some assumptions made at the time. Our advice to other students would be to discuss any such ethical issues with their preceptors to clarify the thought processes and rationale behind their preceptors' decision-making.

This article was developed under the guidance of professional teaching fellow at the school of nursing, University of Auckland, Cathleen Aspinall.

* References for this article are on p44

The authors are second-year nursing students at the University of Auckland.
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Title Annotation:Practice
Author:Cabrillas, Alyssa; Clay, Matthew; Glass, Tayla; Haraldsen, Helene; Perich, Ilaria; Taylor, Victoria
Publication:Kai Tiaki: Nursing New Zealand
Date:Nov 1, 2019
Words:1708
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