A Qualitative Study of Factors Influencing Psychiatric Nursing Practice in Australian Prisons

A Qualitative Study of Factors Influencing Psychiatric Nursing Practice in Australian Prisons

John Doyle, BA, RN, DipEd(Syd)

TOPIC. Factors influencing the practice of psychiatric

nursing in Australian prisons.

METHODS. A qualitative study of psychiatric nurses

(N = 30) working in a prison.

FINDINGS. The psychiatric nurses identified the

folzowinsfactms as influencing their work challenging

patients, threats to personal survival of patients, the

technology and artifice of confinement, conflicting

values of nurses and corrections staK stigma by

association, and prisoner identification of the nurses

with prison administration.

CONCLUSIONS. Psychiatric nurses who work in

forensic settings must adapt to less than optimal

practice conditions.

Key words: Applied research, forensic nursing,

forensic patients, psychiatric nursing, qualitative

studies

John Doyle, BA, RN, DipEd(Syd) is Lecturer, Faculty of Health, University of Western Sydney, Macarther, Cambelltown, NS W, Australia.

I n 1998, more than 100,000 Australian men and women will receive mental health care within Australia’s prisons and correctional custodial facilities. Representative of a pluralistic and multicultural Australia, this unique client group will include Aboriginals (Native Australians), women, migrant, HIV-positive, aged, young, homosex- ual, developmentally disabled, and mentally ill prisoners. It will include homeless, unemployed, and a great many first-time offenders who have never known emotional stability, safety, or personal security and whose dysfunctional or socially disadvantaged backgrounds have desensitized them to victimization, violence, and exploitation. Disproportionately, many Australians entering their nation’s correctional institutions will have had little educational opportunity for either a voice or a productive role in society.

The disproportionate representation of the mentally ill in prisons in the developed world is an issue of concern for mental health professionals both in Australia and internationally (Dunn, Selzer, & Tomcho, 1996; Lego, 1995; Morrison, 1996; Petemelj-Taylor & Johnson, 1996). Many offenders experience their first episode of mental illness in prison. While some offenders enter prison with a past history of psychiatric disorder, for others the stress and personal demands of adjustment to incarceration precipitate episodes of psychosis, attempted suicide, or self-mutilation.

The problems associated with the provision of quality mental health care to incarcerated offenders have been identified as diverse, complex, and pressing (Metzner, 1997). Despite offender populations being composed predominantly of young males and females under the age of 40, morbidity and mortality are significantly higher than for their counterparts in society at large. Incarcerated offenders experience a greater prevalence of psychosis, self-injury, self-harm, suicide, and chronic lifestyle diseases such as ischemia and diabetes than

Perspectives in Psychiatric Care Vol. 35, No. 1, January-March, 1999 29


comparable cohorts in the general community; personality disorder, substance abuse, and comorbidity are sig- nihcantly higher (Metzner). The prislon psychiatric population represents those individuals in developed societies who are the victims of social injustice, inequity, and economic causation (Tumin, 1996). In Australia, as in the United States and Britain, the incarcerated population is institutionalized, concentrated, and comes largely from lower and disadvantaged socioeconomic groups.

Like other Western democracies,. Australia is experi- encing a crisis of corrections and criminal justice. A hard- ening of community attitudes toward crime and punish- ment, the impact of truth-in-sentencing legislation, and a decade of economic stringency have resulted in overcrowding and an almost exponential growth in prison populations (Grant, 1992).

In Australia the incarcerated population is

institutionalized, concentrated, and comes

largely from lower and disadvantaged

socioeconomic groups.

As other forms of institutionalization decrease in Western society, the prison increasingly has become identified as the central and dominant form of confinement (Faugeron, 1996). This has occurred while other forms of restrictive custody, such as the detention of iUe- gal immigrants and boat people and the seclusion or restraint of the mentally ill in public hospitals, have been circumscribed in recent decades by legislative and policy changes or economic stringency in public-sector spend- ing. Penal incarceration, particularly remand, is being used more readily as a pragmatic, de fact0 solution to a range of social problems, including homelessness and the untreated mentally ill.

Mental health care is delivered in many U.S., Australian, and British jurisdictions by psychiatric nurses in prisons and jails. Forensic psychiatric nursing has experienced substantive role development in the last decade as a highly specialized area of mental health nursing practice (Doyle, 1995). The emergence of corrections psychiatric nursing internationally as a recognized specialty has been hailed as one of the ”most exciting and challenging developments confronting the nursing profession” (Peternelj-Taylor & Johnson, 1995, p. 12).

Little research exists, however, on the nature of mental health nursing practice in prisons and the professional and clinical issues encountered by nurses caring for offenders. Several articles have been published in the United States and Great Britain concerning the problem- atic aspects of providing care in prisons (Burrow, 1993; Gulotta, 1987; Maeve, 1997; Peternelj-Taylor & Johnson, 1995).

A prison is identified by forensic nurses as a place where violence and manipulation are inherent. In prisons, failure to muster the ability to ”endure and tri- umph is, for the nurse, “to fall by the wayside as a vic- tim, or to become an accomplice” (Peternelj-Taylor & Johnson, 1995, p. 13). This occurs in a milieu identified by Maeve (1997) as ”perverse,” where caring, the core value of nursing, is expressly denied.

Given the strength of these descriptors and the unique manner in which forensic mental health nurses view their practice and practice arrangements, this highly specialized area of psychiatric nursing would seem to warrant research attention, particularly praxis research, which focuses on issues of concern for the researched and where systematic and informed action may be required (Stanley, 1990).

To study issues of concern to nurses delivering mental health care to offenders, a praxis research approach was chosen (Lather, 1991). Praxis research, also called applied research, was selected for its potential to pro- duce data that would be meaningful and utilitarian for subjects themselves, as well as for forensic nurses. Research for praxis values the equitable, accessible, and democratic dissemination of findings to the researched

30 Perspectives in Psychiatric Care Vol. 35, No. 1, January-March, 1999

for their benefit. The application of this research will not be discussed here because of space constraints.

Methods

Subjects

The subjects (N = 30) were registered psychiatric mental health (PMH) nurses employed to deliver care to imprisoned and remanded male and female offenders in a large, metropolitan, central industrial prison-the Long Bay Prison Hospital. Nurses who participated in the study delivered 24-hour care in a walled, s m e , 120-bed unit for assessment and acute and rehabilitation services.

Data Analysis

The research design used a preliminary focus group of 10 psychiatric mental health nurses to identify and explore issues of concern to the subjects (Street & Walsh, 1996). Themes identified in the focus group were explored through in-depth interviews as typified by Massarik (1981), using open-ended questioning and nondirective language techniques. Twenty nurses were interviewed-those who had participated in the focus group and another 10 nurses who expressed an interest in the research. The interviews were tape-recorded and transcribed. Transcripts were subjected to qualitative thematic textual analysis, clusters of themes were com- pleted under overarching attachments of meaning and the emergent understandings were returned to the subjects for clarification and comment. The resultant narra- tive identified and explored a range of problems identified by the subjects.

Findings and Discussion

Challenging Patients

Prison is a unique social system where inmates live, unwillingly and resentfully, in a highly structured and regulated environment. Privacy is nonexistent, surveil-

lance is perpetual. A sigruficant proportion of offenders display behaviors associated with severe personality disorders, either psychopathic or borderline. Many incarcerated offenders suffer from schizophrenic illnesses and depression. Within the prison inpatient population drug and alcohol dependency are almost pandemic, with many clients requiring detoxification on entry to prison and continuing to abuse mood-altering substances while incarcerated. In the overcrowded physical conditions of the prison, client behaviors challenge professional nurses. For example, constant harassment of nursing staff by prisoners for sedatives or analgesia for complaints of headache, anxiety, depression, insomnia, substance withdrawal, or other somatic distresses often results in a climate of tension and exasperation. Failure to respond in a salutary fashion to clients’ vague, gener- alized, or poorly communicated complaints of somatic distress can lead patients to perceive nurses’ clinical judgment as partisan and aligned with the custodial staff.

A significant proportion of offenders

display behaviors associated with severe

personality disorders, either psychopathic

or borderline.

Threats to Personal Survival for Patients

PMH nurses identified the incarceration process itself as likely the most traumatic and confronting event facing clients within the whole correctional and criminal justice continuum. The loss of liberty, dramatic and immediate reduction of personal autonomy, and attendant curtail- ment of social networks and their emotional support represent a crisis for the individual. This is identified by



nurses as compounded by a policy of streaming both remanded and sentenced prisoners together on the basis of their length of stay or other classxfication criteria. This policy places young, often first-time offenders in coercive and unsafe environments, regardless of their prearrest circumstances.

~ ~ _ _ _ _ _ _

Corrections mental health nurses often

have little control over their practice

environs and share many of the same

overcrowded living and working spaces.

Subjects noted that while some pIisoners adapted rea- sonably well to the challenges and rigors of incarceration, others suffered tangibly or stniggled visibly. Most people, on entering prison or remand, are thrust into a volatile, unpredictable environment where the risk of personal danger is omnipresent. For most young offenders, this results in overwhelming feelings of anxiety, despair, hopelessness, personal disempowerment, and finality. During this initial process of intake or reception, however, PMH nurses do not have the opportunity to intervene to prevent prisoners’ anxiety from escalating to psychosis or major depression. Instead, prisoners who revert to psychosis or major depression are transferred to the prison hospital.

The Technology and Artifice of Confinement

Prisons are built for both geographical and symbolic isolation. The political, social, and philosophical motive for this is not entirely unfamiliar to PMH nurses, given that the large public asylums of the last century were con- structed on remote sites. While asylums of the era of moral treatment stressed the therapeutic benefits of peace

and tranquillity, albeit in isolated seclusion, the corrections mental healthcare setting is dominated by prison architec- ture and the technological artifice of surveillance and control. !+cure perimeters, armed towers, locked doors, cells, bars, electronic surveillance, and razor wire are omnipresent reminders of the monolithic and unremitting administration of correction and criminal justice.

Prisons are built purposely to seclude, segregate, confine, regulate, and observe the actions of every individual. PMH nurses practicing in prisons or correctional settings deliver care in an atmosphere where society’s intentions toward its criminal elements are all too evi- dent. Like their prisoner patients, corrections mental health nurses often have little control over their practice environs and share many of the overcrowded living and working spaces as their offender clients. PMH nurses often must interview or conduct therapy sessions in very confined physical spaces, under surveillance and in the presence of custodial staff who control the physical movement of any client at any time, justlfylng their initiative on the basis of security requirements.

General overcrowding in austere, stark, and personally diminishing physical surroundings was identified by PMH nurses as exacerbating a whole range of inpatient morbidity and associated behaviors. While penological research has linked overcrowding to incremented aggres- sion and recidivism (Duff, 1993, PMH nurses identified it as exacerbating psychiatric morbidity by producing vio- lent and self-harmful ads in young offenders and frequent somatic complaints in older prisoners. Nurses also identified the effects of overcrowding as compounding their own sense of perennial surveillance, particularly when they had no recourse but to deliver nursing interventions such as injections in the presence of custodial officers. These normally routine procedures, when carried out in crowded conditions with the accompanying commentary of others, became status degrading for the nurses.

Conflicting Values of Nurses and Prison Staff

Although mental health nurses have delivered care within correctional institutions throughout the devel-


oped world for much of this century, their practice has been subject to conflicting ideologies: healthcare provision and its science of health care versus criminal justice with its sociologically based disciplines of penology and correction.

For PMH nurses, this means responding to executive directives and operational measures designed for security with the omnipresence of custodial staff. It has resulted in a loss of ownership of their practice, or at best a perpetually negotiated compromise of practice values to mitigate or accommodate the philosophical priorities of compliance, segregation, security, discipline, acquies- cence, regulation, and order.

In an Australian context, the philosophy and values of correctional functions trace their historical and cultural antecedents to the very genesis of the national psyche: the beginnings of a colonial penal settlement. They have remained, as observed by Justice Nagle (Grant, 1992), often impervious to many of the reforms and fundamen- tal realignments of values in modern society. Despite official policies of cultural relativism and attempts at achieving gender, class, and racial equality in prisons, reforms seem to have been subsumed by the method of corrections and its de facto philosophy of “incapacita- tion.” When the intransigence of administrative goals is imposed upon nurses, their priorities are both problem- atic and seemingly antithetical to nurses’ contemporary, holistic, and progressive practice values.

In some instances custodial officers control prisoners’ contacts with PMH nurses. For example, PMH nurses must at times dispense medication to clients through a cell trapdoor without actually seeing the client and can make further contact only at the discretion of custodial officers. At other times nurses find themselves subject to requests from and persistent attempts at persuasion by custodial officers to administer psychotropic and other sedative medications for the comfort of the officers rather than the clients.

Incarceration itself represents only a single stage on a rehabilitation continuum for the mentally ill offender but one that, ideally, makes them accessible to treatment. Although official policy subscribes to the rehabilitation

ideal (Tumin, 19961, ”treatment” in reality seems to be a blend of punitive, rehabilitative, and deterrent philosophy; its routines, rituals, and staff attitudes are ever-present reminders to patients and nurses of the results of criminal behavior and the state’s power and determina- tion to control it.

Corrections staff identify and label

inpatients as deceitful and delinquent by

nature.

The expressed attitudes and actions of custodial staff often reflect an arbitrary view, which circumscribes any constructive engagement with prisoners by mental health nurses and questions the validity and intrinsic worth of any therapeutic intervention beyond that of the simply deterrent or punitive. In their daily interactions with clients in the prison treatment setting, subjects are exposed to the rhetoric of prison officers. This often reflects a despairing or frustrated sense of cynicism and some degree of confusion-an ad hoc amalgam of reformist, punitive, or antithetical views. In a milieu where nurses consider all behavior meaningful, corrections staff identify and label inpatients as deceitful and delinquent by nature, their incarceration itself a valida- tion of this view. The failure of clients to respond to mental health nursing interventions is identified by custodial officers as indicative of a form of ingratitude. Axiomatic to this view, an exacerbation of psychotic symptoms or relapse is viewed as akin to re-offending and, by association, indicative of the sufferer’s criminal nature. Mentally ill offenders are identified in a deroga- tory manner by the argot, or occupational cultural term, of ”spinners.” This attaches to the mentally ill offender considerable stigma as a deviant within the prisoner subculture and ensures a degree of ostracism from peers-



an additional source of pathogenesis that nurses attempt to ameliorate.

Stigma by Association

Constant exposure to the negative attitudes and attendant actions of custodial staff was identified by subjects as compounding their sense of loss of ownership of their practice and intrusion upon their core practice values. Many nurses identified a distinctive social stigma associated with their caring for society’s ”failures.” Socially, many PMH nurses did not disclose to fnends or nursing colleagues where they work, identifying themselves as belonging to what Brodsky (1982) deemed a ”twilight occupation” (p. 74). Forensic nursing seemed to carry a stigma by association, society not wanting to see nor nec- essarily hear from those whom it pays to care for its incarcerated members-out of sight, out of mind.

Prisoner Identification of Nurses With Administration

A confounding element of the practice environment was the omnipresence of a powerful! all-subsuming prisoner subculture, with its nihilistic values, argot roles, and codes of behavior. Much of the antipathy from clients experienced by PMH nurses resulted from measures to maintain status w i t h the prisoner subculture. Prisoners gained status among their peers by criticizing nurses. Regardless of the level of commitment, concern, and professionalism shown by nurses, a proportion of clients remained uncooperative, unconcerned, or subversive to their treatment goals. Aware of the limited capacity of the prison system to respond to their antipathy or pas- sivity, some patients continued to perceive nurses as vul- nerable, visible, and convenient representations of authority as embodied by the criminal justice system.

Despite the nurses’ good will and nonjudgmental professionalism, many offenders viewed cooperation, self-care, and initiative in meeting treatment goals as col- laboration with a system of enforced oppression. Failure to follow even simple nursing directives can be traced to the values of the prisoner subculture that staff could be

viewed as the enemy. Semiplausible objections or expressions of thinly veiled contempt accorded an offender prestige by subtly challenging the legitimacy of nursing and, therefore, corrective services’ authority.

Similarly, in psychotherapy, nurses’ efforts were identified by clients as attempts at ”brainwashing.” Such def- initions, when adhered to by patients, deemed any therapeutic intervention ineffective and the existence of any form of authority in the treatment milieu as threatening and conspiring against the dignity and autonomy of the prisoner. In this way any therapeutic measure taken by nurses was disputed as a hypocritical palliative or a measure of repressive control.

Conclusions

Corrections PMH nurses deliver care to a unique and challenging client population. Incarcerated offenders experience high prevalence rates of psychiatric morbidity as well as constant and unremitting exposure to the pathogenic influences of imprisonment itself, the effects of the process of ”prisonization,” and the all-subsuming values of prisoner subculture, with its relentless hierar- chy of gratification and coercion.

The historical practice arrangements for this

mental health nursing specialty have

resulted in the intrusion of the philosophy

and values of correction and criminal justice

on practice goals and their outcomes.

Prison mental health nurses work in an austere and isolated environment dominated by the technological art&e of surveillance and control, both symbolic of the


power of the modem state and its correctional system to deliver society's intentions towards its criminal elements. Historically, corrections mental health nursing arose from the prison-based provision of health care to incarcerated inpatient populations. The locus of practice for this specialty area of psychiatric nursing has remained essentially unchanged. A crisis of overcrowding and concomitant pressures within prison systems has ensured that nurses continue to share many of the less than optimal conditions of their offender clients.

The historical practice arrangements for this mental health nursing specialty have resulted in the intrusion of the philosophy and values of correction and criminal justice on practice goals and their outcomes. This has resulted in compromise and resistance by PMH nurses to accommodate the operational measures, routines, and priorities of the administration. The ideological intrusion of a disciplinary philosophy that is often at best incon- gruous, if not antithetical to the core values of nursing, has generated problems for corrections psychiatric nurses, warranting further ongoing research to inform changes in prison-based practice.

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A Qualitative Study of Factors Influencing Psychiatric Nursing Practice in Australian Prisons