AANP Member Spotlight: Delivering Quality Health Care in Correctional Settings

Hear from Jennifer Clifton, DNP, FNP-BC, CNE, CCHP, Associate Professor at the University of Utah College of Nursing and the American Association of Nurse Practitioners® (AANP) liaison to the National Commission on Correctional Health Care (NCCHC) Board of Directors, on how nurse practitioners (NPs) can influence health care delivered in jails, prisons and juvenile facilities.

Q: How would you describe the NP role in the correctional system?

A: According to NCCHC’s Nurses’ Scope of Practice and Delegation Authority whitepaper:

“Nurses deliver the majority of health care in correctional settings and serve as the gatekeeper for inmate access to all other health services. They are the professionals most often employed to provide health care services for inmates, and they have more contact with patients than any other health care professional.”

This includes registered nurses (RNs), licensed practical or vocational nurses (LPNs or LVNs), advanced practice registered nurses (APRNs) and other assistive nursing personnel.

NPs of a variety of specialties see patient-inmates across the lifespan. Within corrections, NPs provide health care to individuals from adolescence through geriatric years. We conduct physical exams, health screenings, medication management, sick calls and pregnancy and post-partum care. We also are involved in administrative work such as emergency planning, quality improvement (QI) and infection control. We lead corrections-specific research and precept students.

Precepting students is of unique importance in corrections. Yes, we are helping to build a more robust correctional nursing workforce for the future, but equally important — since most incarcerated individuals return to their communities of origin after incarceration — we help all NP students understand the connection between corrections and communities. Students see living examples of the results of social determinants of health, which they study in the classroom. Students and preceptors establish a connection that benefits both as the learner becomes a community provider. However, what students tell me is most impactful is learning of the humanity of the incarcerated population. Only the most hardened people leave a correctional rotation unchanged.

Correctional NPs advocate for our patients and provide education to correctional administrators, judges, caseworkers and correctional staff. These multiple aspects of my job are what I find most professionally fulfilling, Additionally, as an NP who works primarily with juveniles with developing adolescent brains, I know we can make a difference in the lives of a high-risk population who may otherwise have little opportunity to interact with health care professionals. In Utah, the Juvenile Justice Services (JJS) is a division of the Utah Department of Human Services, so there is a rehabilitative and therapeutic focus during the youth’s time in incarceration. This promotes the type of environment that allows nurses and NPs in our system to shine.

For example, in a study I co-authored, we found that health literacy in a sample of incarcerated juveniles in a long-term correctional setting was actually higher than that of the standard population. While no causal relationship can be drawn, I believe that the close relationship between the correctional nurse or NP and youth-inmate contributed to this result. Incarcerated youth in our system see the nurse on site daily and thus have frequent access to health care and knowledge by individuals educated specifically on adolescent development.

Q: What are some of the unique challenges facing health care providers working within the correctional system?

A: One aspect unique to correctional care is that we are health care providers working closely with non-health care personnel. In contrast to a community health clinic, where most people are there to give and receive health care, the priority of a correctional facility is safety and security.

An example of this clash of values is often apparent when an inmate requires medical attention outside of the correctional facility. NPs need to explain to correctional administrators why care cannot be delayed, and why that care needs to be delivered outside the building, while understanding that inmate time out of the building adds stress to correctional personnel.

Having an inmate out of the building requires staff supervision, which may lead to understaffing within the building and can be dangerous to staff and other inmates. Alternatively, it can be expensive if additional staff is called in to work. It is important to compromise where you can but stand your ground when the health of your patient demands it.

Q: How can NPs working within the correctional system best advocate for the patients in their care?

A: In our nurse-led practice, nurses are the front line and the RNs triage patients. NPs see the patients referred to us. We’re making the majority of the health care decisions, and so we’re the ones who can best speak to facility administrators to advocate for our patients. Additionally, we can speak to lawmakers providing real-life examples to influence correctional legislation and funding.

In my practice, we have done all of this. In 2015, the correctional system did not want to fund screening of asymptomatic sexually transmitted infections (STIs), so they disallowed funds to be spent on screening. This caused me to approach the state legislature for funding. As a result of my lobbying efforts, the JJS received one-year funding from the state legislature to screen and treat youth admitted into our facilities for STIs. We chose to focus on chlamydia and gonorrhea, as these were the most prevalent among adolescents in our area and the least traumatic for which to screen using a urine sample.

Initially, there was pushback to instituting this screening in many rural facilities because correctional administrators and staff found it intrusive and unnecessary. After a year of screening, however, our data showed that Utah’s rural youth experienced a rate of STIs similar to the urban youth, and the screening program became more widely accepted. We were able to provide our results to state legislators and have received ongoing funding to screen and treat these infections.

Our next step is to take STI screening outside the facility clinic and to the youth of the juvenile system who reside in community at large — this is the majority of youth in the justice system and those who are most likely to be currently sexually active. It is hoped that the combination of community screening and expedited partner therapy will be very impactful on this population. Additionally, our screening includes questions about high-risk sexual behaviors, sexual abuse and sex trafficking — information that has never before been systemically gathered. Having this information allows us to intervene and better serve the youth by providing much needed services.

Q: What is something readers may be surprised to learn about correctional health care?

A: First, in our system, the nursing and NP turnover rate is low. I’ve been doing this work for 15 years; if this field is something that appeals to you, there is so much room to grow and make a difference in people’s lives. You can be on the front lines of system-wide changes. You can be impactful as the health care expert who understands the correctional system to change the correctional setting and standards of care.

There is a lot of autonomy in the job and many opportunities to educate. When an inmate has diabetes, for example, we talk to staff to explain the condition, answer their questions and hopefully minimize their anxiety related to housing a diabetic patient. NPs also take 24-hour calls and are available to address staff questions and concerns as they arise.

Second, to be a correctional NP, you have to be a very good observer. You must have excellent clinical skills to identify manipulation or attention-seeking behaviors. Unlike traditional health care settings, in corrections, 10% of diagnosis comes from a patient’s history while 90% is based upon objective findings. For example, patient-inmates may manipulate staff by complaining of back pain to get pain relievers and an extra mattress. They may claim allergies for special soaps or a special diet.

A youth with diabetes may refuse meals after receiving insulin or manipulate insulin dosages hoping for a trip to the emergency department. Additionally, these youth are under stress and are often experiencing a change in diet, so they may be experiencing erratic blood glucose levels. These kinds of situations are difficult to manage and require a trauma-informed approach to care along with a high level of suspicion and observation to keep the youth safe during their time in a correctional facility

Third, the use of trauma-centered vocabulary is extremely important. More than 90% of the young women in corrections and many of our young men have experienced some sort of sexual trauma, physical abuse and/or neglect. It is imperative that all health care providers, not just the mental health team, use trauma-informed language and therapeutic support.

Psychiatric mental health NPs (PMHNPs) play an important role in my work setting and work closely with the primary care NPs and nursing staff to educate and support us in our understanding of mental health care. PMHNPs provide therapy and medication management for serious mental health issues in a vulnerable population. PMHNPs spend much of their time making community referrals to continue mental health care upon an inmate’s release. PMHNPs can speak very eloquently about psychiatric conditions to facility administrators, judges and others within the correctional system while acting as an advocate for the incarcerated individuals.

Lastly, correctional health is a blooming specialty. In many instances, universities are providing students with the opportunity to gain experience in corrections. It is generally accepted that interventions that may work in “the outs” may not be available or effective in corrections. There is a growing body of inmate-centered research to promote the health care of individuals in the correctional system. National and local conferences, professional journals and professional organizations support this growing specialty.

Q. How is COVID-19 affecting the care you provide in corrections?

A: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has hit correctional facilities hard, and our team, along with all correctional health care providers, has had to move quickly to adapt. Consequently, primary care NP and PMHNP visits are now done mostly via telehealth while the nurses remain on site. The nurses and NPs work together to determine which cases require on-site NP visits.

While we would like to get the primary care NPs back on site eventually, PMHNP visits may permanently transfer to telehealth visits, allowing us to maximize our workforce. The biggest cultural shift I am seeing is the growth of teamwork between our health care team and correctional administrators. The “us” and “them” mentality has dissipated and a “we are in this together” mentality has taken over. The two groups communicate more frequently and productively to prioritize resident health care.

While this level of interaction may not be sustainable, we are building systems that will lead to a permanent increase in collaboration. COVID-19 has also provided NCCHC the opportunity to advance its collective expertise, as correctional administrators across the country are seeing the benefits of a robust health care team. While some facilities have had to drop out of the NCCHC accreditation process to the focus on the coronavirus, others have decided to seek accreditation because of the high level of comprehensive health care the NCCHC Standards place on a correctional facility.

Q: What has your experience been like serving on the NCCHC Board of Directors?

A: NCCHC sets the standards and guidelines for correctional health care. The organization also accredits correctional facilities and provides the opportunity for professionals to earn basic and advanced certifications.

Before my appointment, AANP had not been formally affiliated with NCCHC and an NP had never served on the NCCHC Board of Directors (BOD). As the health care providers in many correctional settings, NPs need a voice on the NCCHC BOD. This has been widely recognized on the BOD, and I have been warmly received by my BOD peers.

When NCCHC creates and modifies accreditation standards and its certification exam for providers, I want to make certain that NPs are not overlooked. I’m very honored that the current chair of the BOD and many of my peers have been open to advancing the roles of NPs within NCCHC and correctional health. Several NCCHC standards still do not allow for NPs to practice to the top of their licensure and this remains motivation for me.

Being on the BOD gives me the platform to say, “Here is what NPs can do. NPs should be able practice at the top of their license in their state and this should be in compliance with the standards for NCCHC accreditation.” I frequently remind my peers that in 22 states in the U.S., NPs are independent providers.

Q: Why is it important to share the NP point of view with national organizations like NCCHC?

A: NCCHC was initially established as an off-shoot of the American Medical Association (AMA), so their standards are naturally physician-centric. The standards do not always reflect the reality of NPs playing a growing role in correctional health care.

Institutions where NPs have leadership roles may not be eligible for accreditation because, often, standards require a physician to fulfill many roles that an NP is educated and licensed to provide. For example, NCCHC standards state that a physician must have the leadership role in the QI team. However, NPs are educated to lead QI teams. Further, using AANP research data and sharing the standards for NP education allows me to demonstrate the need to update that language from “physician” to “health care provider.”

Establishing credibility by earning certifications, interacting with correctional peers and providing education on the NP role is hugely important. NCCHC offers NPs an opportunity to speak at national correctional conferences and publish in a peer-reviewed journal. NPs need to take advantage of these platforms to showcase our work. I am on both the NCCHC Juvenile Health Committee and the Accreditation and Standards committee, but many other committees have no NP representation. There is a core group working to advocate for more NPs to have an increased presence on committees and to be more involved and more visible within the organization.

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