Ethical Issues, Moral Courage and Moral Resiliency in Correctional Nursing

In the correctional setting, as in all healthcare settings, nursing practice is patient-centered, and our Nursing Code of Ethics is foundational to that practice. The fact that our patients are incarcerated does require some practice adjustments, as we care for our patients in an environment that is not primarily focused on health care, but the essence of our nursing practice remains the same as our nursing colleagues in other settings. Our key ethical principles include the following (from The Nursing Code of Ethics, ANA, 2015):

A respect for human dignity and an acknowledgement of the worth of every human being;
Understanding that our primary commitment is to our patients;
The promotion, advocation for and protection of the rights, health, and safety of our patients;
The authority, accountability, and responsibility for our nursing practice, which includes making decisions and actions consistent with our ultimate obligation to promote health and optimal care to our patients;
A responsibility to promote our personal health and safety, preserve our wholeness of character and integrity, maintain competence, and continue personal and professional growth so that we are better able to care for our patients;
Establishing, maintaining, and improving the ethical environment in which we work, through both personal and collective efforts;
Advancing the profession of nursing through research, scholarly inquiry, professional standards development, and policy generation;
Collaboration with colleagues and other health professionals and the public to protect human rights, promote health diplomacy and reduce health disparities; and
Articulation of nursing values, maintenance of the integrity of the profession, and the integration of the principles of social justice into nursing and health policy through our professional organizations.
Adhering to our professional nursing principles while practicing in the correctional setting may pose challenges at times, and it is best if the nurse anticipates how they will respond in such circumstances before they arise.
For the nurse in a traditional medical setting, ethical decisions occur occasionally and at times the nurse may face an ethical dilemma. In contrast, the correctional nurse may face ethical situations often. Defining the nurse-patient relationship, advocating for the patient in the planning and provision of safe patient care, and delivering nursing care are all times when correctional nurses may need to refer to their Code of Ethics to determine the best course of action.

One of the common ethical concerns that arises for the correctional nurse relates to demonstrating caring in a custody environment. While the nurse-patient relationship continues to be based on the health and well-being of the patient, in the correctional setting, stronger physical, emotional, and mental boundaries must be maintained. Correctional nurses must find a balance in demonstrating an attitude of caring and compassion while recognizing and maintaining safe boundaries. Caring behaviors cannot include physical touch, as may have been the case in prior nursing positions. Words and actions establish a caring relationship in our setting, not handholding, touch, or a shoulder squeeze.

Another area of ethical concern is the correctional nurse’s responsibility for ensuring that patients have access to care. As advocates for our patients, correctional nurses have a moral obligation to identify and eliminate barriers to care. We are in a unique position to evaluate the quality and effectiveness of the patient care provided, and work with our custody partners to ensure that our patients’ health care needs are met.

Adherence to our professional practice is also an area that can create ethical concerns for correctional nurses. According to the ANA Code of Ethics, correctional nurses are accountable for their own nursing practice and bear the primary responsibility for the nursing care their patients receive. We are responsible for the quality of the care provided, and it is vitally important that correctional nurses only perform duties for which they have been trained and are competent, and which are permitted by their scope of practice and organizational policies and procedures. We may be asked as correctional nurses to perform duties that we know we cannot do because of lack of training or scope of practice, and our Code of Ethics is clear that we should decline to perform them. The NCCHC has written a white paper about nursing authority, responsibility and delegation that speaks to some of these issues.

As correctional nurses, there are often additional pressures from our custody colleagues, our employers, and even other incarcerated individuals to forego placing the well-being of our patients as our top priority. In these instances, we can look to the development of moral courage to help us remain strong in our convictions and actions. Moral courage is needed to overcome the fear of being ridiculed, ostracized, or unfairly treated for taking a patient-focused stand in a situation where dual loyalties exist. To develop moral courage, it is important to reflect on the foundation of our professional practice, including our Code of Ethics.

Moral resilience is the capacity of a person to preserve or restore integrity in response to moral adversity. It is the ability and willingness to speak and take appropriate, patient-focused actions when faced with moral/ethical adversity, knowing that they are doing the right thing. Correctional nurses can develop moral resilience through such practices as self-awareness; skill development in communication, negotiation, conflict resolution and interprofessional collaboration; mindfulness; self-care; and developing and maintaining a strong support system.

In summary, the Code of Ethics is foundational to correctional nursing practice and should be referred to when correctional nurses are challenged with an ethical decision. Common areas of potential ethical conflict for correctional nurses include defining the nurse-patient relationship; advocating for the patient in the planning of safe patient care; and providing patient-focused nursing care. The development of moral courage and resilience will help correctional nurses properly address the ethical concerns that may arise and maintain their patient-focused practice.

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Author Lori Roscoe, DNP, PhD, APRN, CCHP-RN, is the Accredited Provider Program Director for NCCHC, co-chair of the NCCHC Nursing Education Subcommittee, and a member of NCCHC’s Multi-Disciplinary Education Committee. Through her companies, The Correctional Nurse LLC and Correctional HealthCare Consultants LLC, Dr. Roscoe provides accredited continuing education specialized for correctional nurses and maintains CorrectionalNurse.Net, a blog about correctional nursing practice, and offers professional consulting services in correctional healthcare operations, staff training and legal matters.