In the correctional setting, the patient is at the core of professional nursing practice. The fact that the patient is incarcerated is only a circumstance of his or her situation and does not, and should not, change how the nurse practices or how the nurse views the patient. Correctional nursing allows the nurse to practice the essence of nursing while recognizing that all patients have intrinsic value. Achieving and staying true to professional nursing values while practicing in the correctional setting can create a unique set of ethical, legal and professional issues for the nurse. This article will examine some of the ethical and legal issues correctional nurses must address in their practice.

Ethical Concerns
For the nurse in a traditional medical setting, ethical decisions occur occasionally and at times the nurse may face ethical dilemmas. In contrast, the correctional nurse may face ethical situations daily. The correctional nurse makes ethical decisions about care delivery, caring and patient advocacy in planning and providing safe patient care.

There are six ethical principles that arise frequently for the nurse who works in the correctional setting.

1. Respect for persons (autonomy and self-determination)
2. Beneficence (doing good)
3. Nonmaleficence (avoiding harm)
4. Justice (fairness, equitability, truthfulness)
5. Veracity (telling the truth)
6. Fidelity (remaining faithful to one’s commitment)

These principles serve as a guide to the nurse in making ethical decisions. The correctional nurse can find support for ethical decisions by referring to the American Nurses Association’s code of ethics. The code delineates the ethical standards for nurses across all settings, levels and roles, setting expectations as well as providing guidance.

One of the common ethical concerns that arises for the correctional nurse relates to demonstrating caring in a custody environment. Correctional nurses must find balance in displaying an attitude of care and compassion while recognizing and maintaining safe boundaries.

Another area of ethical concern is the nurse’s responsibility for ensuring that patients have access to care. The values associated with nursing practice include nurse advocacy, respect for humans and eliminating barriers to care. The correctional nurse is in a unique position to evaluate the quality and effectiveness of patient care. He or she works with custody to ensure that the health needs of inmates are respected and responded to in a timely manner.

End-of life care is another ethical concern for the correctional nurse. Patients die while incarcerated and the nurse has a role in helping the patient to die with dignity and comfort. In some prisons, nurse participation in execution may arise as an ethical issue. The correctional nurse should not participate in executions. This position is supported by the ANA’s code of ethics and NCCHC‘s Standards for Health Services in Prisons (standard P-I-07). Participation in execution is inconsistent with nursing values.

Finally, professional practice is an area that can create ethical concerns for correctional nurses. Nurses are encouraged to refer to the ANA’s scope and standards of practice for correction nursing and to their state’s nurse practice act in addressing practice issues.

[Editor’s note: Both ANA books are available in NCCHC's catalog.]

Legal Issues
The legal implications of nursing practice are tied to licensure, state and federal laws, scope of practice and a public expectation that nurses practice at a high professional standard. The nurse’s education, license and nursing standard provide the framework by which nurses are expected to practice. When a nurse’s practice falls below acceptable standards of care and competence, this exposes the nurse to litigation.

The basis for litigation can relate to negligence, failing to exercise the level of care that a reasonable, prudent nurse would under similar circumstances; malpractice; and professional negligence, which means an act of neglect committed in the nurse’s professional role. Acts of omission and commission will also subject the nurse to litigation and professional license review. Both litigation and professional license review can result in reprimand of a nurse’s license or loss of a license.

Correctional nurses can be especially vulnerable to litigation because the correctional patient population has a constitutional right to health care. Compounding this, inmate-patients encounter nurses more than any other type of health care provider. Failure to provide inmates with access to health care to meet their serious medical needs can be litigated under the Eighth Amendment as deliberate indifference or under the 14th Amendment as a civil rights violation.

Inmates have several ways to access health care, such as by submitting a request slip or form. Another way is through oral communication, for example, by telling a correctional officer of a need to be seen by medical, or mentioning a health concern to the nurse during medication administration.

Regardless of the method, the nurse has a legal and ethical obligation to respond to the request for care. In general, the nurse should see the patient to evaluate health needs and determine the level of care required. If the communication is from the officer to the nurse, the nurse has a responsibility to speak to the inmate. A face-to-face discussion would be best, but the nurse could also first speak with the inmate by phone, making sure to ask the right questions, and then determining if the inmate should be moved to the medical unit or if the nurse should go to the inmate’s housing area.

Based on the information provided, the nurse must determine the type and level of nursing intervention required, and then implement an action. The nurse may determine that the patients’ health needs can be managed within his or her scope of practice, or determine that a higher level of care is needed and refer the patient to a midlevel provider or physician, or refer for transfer to a health facility that can provide the care that is needed. It is always appropriate for the nurse to follow up to evaluate the inmate’s response to the intervention.

However the nurse is apprised of an inmate’s health needs, the nurse must document the health needs, how notification of the health need occurred, actions taken and the patient outcome.

Great Opportunity
Nurses practicing in the correctional health specialty face many challenges; despite the challenges, correctional nurses have a great opportunity to contribute in positive ways to improve the health of this vulnerable population and to have a larger impact on the greater public health.

— Mary V. Muse, MS, RN, CCHP-RN, CCHP-A, is the chief nursing officer for the Wisconsin Department of Corrections, Madison. This column is coordinated by Lorry Schoenly, PhD, RN, CCHP-RN, an independent consultant specializing in correctional health care and social media; she is based in Pennsylvania. Both are members of the CCHP-RN task force. For correspondence about this column, write to editor@ncchc.org.