Mental health/illness and prisons as place: Frontline clinicians'perspectives of mental health work in a penal setting

Nicola Wright a,n, Melanie Jordan b,1, Eddie Kane c

a School of Health Sciences, University of Nottingham, Institute of Mental Health, Triumph Road, Nottingham NG7 2TU, United Kingdomb Institute of Mental Health, University of Nottingham, Triumph Road, Nottingham NG7 2TU, United Kingdomc Centre for Health and Justice, Institute of Mental Health, Triumph Road, Nottingham NG7 2TU, United Kingdom

a r t i c l e i n f o

Article history:Received 28 October 2013Received in revised form4 July 2014Accepted 4 July 2014

Keywords:Mental healthPrison as placeSocial settingProfessional boundariesHealth work

a b s t r a c t

This article takes mental health and prisons as its two foci. It explores the links between social andstructural aspects of the penal setting, the provision of mental healthcare in prisons, and mental healthwork in this environment. This analysis utilises qualitative interview data from prison-based fieldworkundertaken in Her Majesty's Prison Service, England. Two themes are discussed: (1) the desire andpracticalities of doing mental health work and (2) prison staff as mental health work allies. Conceptscovered include equivalence, training, ownership, informal communication, mental health knowledge,service gatekeepers, case identification, and unmet need. Implications for practice are (1) the mentalhealth knowledge and understanding of prison wing staff could be appraised and developed to improvemental healthcare and address unmet need. Their role as observers and gatekeepers could beconsidered. (2) The realities of frontline mental health work for clinicians in the penal environmentshould be embraced and used to produce and implement improved policy and practice guidance, whichis in better accord with the actuality of the context – both socially and structurally.

& 2014 Elsevier Ltd. All rights reserved.

1. Introduction

Mental health care provision within the UK occurs within acomplex system of different providers (statutory, private and thirdsector) and tiers of service (primary care or specialist services)(Nicaise et al., 2012). This complicated web of services and struc-tures has been highlighted by authors such as Gask and Lester(2008) and Nicaise et al. (2012) as leading to fragmentation and insome cases duplication in care delivery. For individuals in prisonestablishments, this system is even more challenging to navigate asthere is an additional interface between NHS healthcare health careappraises and the public prison service that covers Englandand Wales.

Within Her Majesty's Prison Service (HMPS), prisoners are entitledto healthcare (including mental health services) which may be pro-vided by NHS, private or third (voluntary) sector services. However,‘prison settings are a challenging environment in which to manageand deliver healthcare’ (Powell et al., 2010: 1263). Thus, research thatexplores the issues of health and place in this setting and appraisescontemporary problems in this field of healthcare provision is timely

and relevant. As deViggiani (2006) argues prison healthcare servicesare in need of development.

Nurse et al. (2003: 484) identifies that ‘there is a high prevalenceof mental health problems in prisons and insufficient provision forthese problems’. Psychotic disorders reportedly affect 7% of sen-tenced male prisoners in comparison to 0.5% of men societal wide(Jewkes and Johnston 2006: 229). Ten per cent of men and 30% ofwomen have had a previous psychiatric admission prior to prison(Edgar and Pickford, 2009). In the United States of America theDepartment of Justice (James and Glaze, 2006) state that more than56% of State prisoners, 45% of Federal prisoners and 64% of jailinmates have a mental health problem. Co-morbidity is also anissue within prisons. Many prisoners have a complex mix of mentaland physical health problems and the use of alcohol or illicitsubstances may complicate their situation further.

The mental illness profile of HMPS's prisoners as a groupremains ‘under-recognised, not high enough on the public healthagenda and a constant daily nightmare for prison systems’ (Fraseret al., 2009:410). It has been demonstrated before that context iscrucial in relation to the conduct of mental healthcare in a prisonsetting (Jordan, 2010). Gojkovic's (2010) national study of mentalhealth provision and organisation in English prisons reports atension for mental healthcare staff in relation to ‘delivering care ina punitive environment’ (p. 284). Indeed, ‘the provision of mentalhealthcare and the pursuit of good mental health in the prison

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Health & Place

http://dx.doi.org/10.1016/j.healthplace.2014.07.0041353-8292/& 2014 Elsevier Ltd. All rights reserved.

n Corresponding author. Tel.: þ44 115 8230576.E-mail addresses: nicola.wright@nottingham.ac.uk (N. Wright),

melanie.jordan@nottingham.ac.uk (M. Jordan).1 Tel.: þ44 115 7484300.

Health & Place 29 (2014) 179–185

milieu are challenging’ (Jordan, 2011, p. 1061). It is therefore appro-priate to devote further attention to social and institutional structuresthat permeate the prison setting and affect mental health services(Jordan, 2010).

For mental health patients in a prison setting ‘mental health-care receipt experiences and environments are important’ (Jordan,2012a: 722). As debated in this article, the same is true for mentalhealthcare provision and those frontline providers/staff whoundertake mental health work in penal settings. For the prisonhealthcare clinicians involved in this study, the nature of healthand place is salient for both political and personal reasons. ‘Thedelivery of mental healthcare within the prison system is acomplex process’ (Brooker and Birmingham, 2009, p. 1); reasonsfor this place-orientated complexity are explored in this article.

1.1. The present study

The analysis presented in this paper is drawn from a largerpiece of work which evaluated the mental health commissioningand providing arrangements within three male HMPS establish-ments. This project also explored the met and unmet mentalhealth needs of prisoners. To maintain confidentiality it is notpossible to name the establishments in this publication. Withinthe UK and NHS more generally, the provision of healthcare is splitinto organisations which “commission” services and those whichprovide them. In brief, commissioning refers to the planning andpurchasing of services (from the NHS, private and third sectororganisations) to meet the health needs of a local population (TheKings Fund, 2011). DH and HMPS (2001) Changing the Outlook:A Strategy for Modernising Mental Health Services in Prisons offi-cially introduced the principle of equivalence to prison mentalhealthcare. The equivalence strategy calls for prison mentalhealthcare to be in-line with the range of community basedmental health services available beyond the prison setting.

Part of the wider project involved using qualitative researchmethods to explore the experiences of providing mental healthcarein the prison setting by frontline healthcare staff (further details ofthe participants are included later). Semi-structured interviews wereconducted across three HMPS sites. This paper uses some of thefieldwork data to develop the literature surrounding mental health-care in the prison setting (Jordan, 2010b). Jordan (2012b) identifiesthat there are numerous methodological issues with using interviewsto collect data. These include “the structure of interview questions,participant unfamiliarity with the process, body language and non-verbal communication, plus discussions concerning conversationalturn taking and interviewee agency” (Jordan, 2012b). Therefore,interviews were conducted sensitively in the prison settings andmethodological aspects were reflected upon by the researchers(Jordan, 2012b). The study team was based at the Centre for Healthand Justice at the Institute of Mental Health and included a mentalhealth nurse, sociologist and a specialist in secure services provision.

In summary, the contributions of this article are fourfold. First,we address a neglected area in the literature relating to theexperiences of providing mental healthcare within penal settings.We build on the existing evidence base by discussing the role ofprimary and secondary/specialist healthcare staff groups in provid-ing mental healthcare to the prison population. We use concepts ofpersonal desire and political practicalities to explore mental healthwork in the prison setting. This is a novel approach not addressed inprevious studies. Second, we highlight the barriers and facilitatorsto mental health work in this specific context. Third, we identify theimportant role played by social relationships and informal networks(rather than, for example, formal healthcare procedures) within thesetting which are used to manage prisoners' mental health needs.Finally, we discuss the roles and responsibilities of prison wing staffin relation to mental health work.

2. Method

2.1. Fieldwork and participants

Participants were recruited from primary and secondaryhealthcare services. They included both mental health specialiststaff, for example Registered Mental Health Nurses (RMNs),Clinical Psychologists and Psychiatrists, as well as non-specialiststaff such as Registered General Nurses (RGNs) and GeneralPractitioners (GPs). Within the prison setting (as in the widercommunity) a distinction is made between primary care, compris-ing mainly physical healthcare and some short term, mental healthinput (from specialist staff such as RMNs) and mental healthspecific, secondary care (termed in-reach in prison settings)services. Mental health support provided by primary care serviceswithin the prison environment include a triage service for prison-ers who have not previously had mental health problems, prisonreception screening (on first entering the prison establishment, anurse completes a health screen to ascertain if there are anyongoing physical or mental health issues which require treat-ment), or the provision of time-limited brief interventions forprisoners with problems such as anxiety and depression. In contrast,in-reach services provide specialist mental health support to prison-ers with severe and enduring mental health problems such asschizophrenia and bipolar disorder. Twenty-three of the participantsrecruited to the larger study are relevant for the analysis presentedhere. Unfortunately, the study did not include the required approvalsto conduct interviews with prisoners. It is acknowledged that this is alimitation of the project and a recommendation would be to includethe recipients of prison healthcare in any future work. Indeed, thishas been analysed elsewhere, for example: Jordan (2012a).

Table 1 summarises the professional backgrounds of theparticipants. In all three prison establishments primary careservices were provided by a private sector organisation. Whilesecondary, in-reach services were run by the NHS.

The overall study was commissioned by a NHS Primary CareTrust and recruitment occurred via healthcare service leads andmanagers. These individuals informed their staff about the aims ofthe study and what their involvement would entail. ParticipantInformation Sheets and Consent Forms were given to all thoseinvolved and individuals were reminded that they could withdrawtheir consent at any time. They were also informed that theinterviews were being audio recorded but they could request forthis to stop should they wish to do so. A semi-structured interviewschedule was developed – with themes identified from theliterature and relevant policy documents. Table 2 summarisesthe key topics included. Prompts were also used to encouragemore detailed responses, where necessary. Interviews were com-pleted in April 2013 and lasted between 30 and 90 min.

Table 1Professional backgrounds of the study participants.

Professional background Number of participants

Primary care In-reach Total

Administration 1 0 1Clinical psychologist 0 1 1Dual trained nurse (RGN and RMN) 1 0 1General Practitioner (GP) 1 0 1Psychiatrist 0 2 2Registered General Nurse (RGN) 8 0 8Registered Mental Health Nurse (RMN) 2 5 7Service manager 1 1 2Total 14 9 23

N. Wright et al. / Health & Place 29 (2014) 179–185180

2.2. Data analysis

The audio files were transcribed verbatim and thematic analy-sis was conducted on the data. This involved a detailed readingand preliminary coding of the transcripts. These initial codes werethen extrapolated and combined to produce overarching themes.The themes explaining the data were based on the aims of thestudy. This analysis process is similar to the work of Grbich (2007),who considers thematic analysis to consist of two complementarydata reduction techniques: block and file and conceptual mapping(pp. 32–35). The first two authors independently analysed the databefore discussing their coding with each other. Good agreementwas found between the identified concepts and themes.

3. Results and discussion

As stated previously the analysis presented here draws on workfrom a larger study and has four aims: (1) to explore theexperiences of staff in prison settings of providing mental health-care, (2) to discuss the barriers and facilitators to mental healthwork in the prison context, (3) to look at the role of socialrelationships and informal networks, and (4) to consider the roleof wider prison staff. Two overarching themes were identifiedfrom the data which explored mental health work in prisonsettings: “the desire and practicalities of doing mental healthwork” and “prison staff as mental health work allies”. In thissection of the paper both of these themes are discussed andcontextualised by relating them to the existing evidence base andusing direct quotation from the interviewees where relevant.

3.1. The desire and practicalities of doing mental health work

Mental healthcare provision within the prison setting is acomplex system comprising multiple actors. This in itself is notunique, as mental healthcare within the wider community can alsoinvolve many agencies and professional groups. However, theprison setting as a context has its own specific security require-ments and custody personnel. For example, the roles and require-ments of prison officers and prison security measures in mentalhealthcare are unique to the penal setting. Despite the specificrequirements prisons present, there is a need to ensure that thecare provided is equivalent to what is available in the widercommunity. The DH (2005) Offender Mental Healthcare Pathway

reiterates this principle of equivalence. However, Niveau (2007)states ‘from a clinical point of view, the principle of equivalence isoften insufficient to take account of the adaptations necessary forthe organisation of care in a correctional setting’ (p. 610). It is alsoworth noting that it is widely considered that equivalence has notbeen fully achieved and continues to pose an ‘enormous challenge’(SCMH, 2007: 2) for prisons. Therefore, providing for mentalhealth needs in the penal milieu is a convoluted endeavour.

Data from this study suggest that although equivalence inquality of service should be aspired to, the form and structure ofmental health provision must reflect the unique context prisonoffers:

“In terms of absolute equivalence, it can’t be, it’s a prison, it’sdifferent, and therefore it’s about: What are the important thingsabout what we’re delivering? … What is it about the services thatwe’re providing, and the quality of the services, that we need tohave a similar, or as far as possible the same level of quality andthe same level of availability, as you would get in the community”(P006).

As well as the custodial nature of the prison environment,participants identified other challenges to undertaking mentalhealth work. First, mental healthcare in prisons can be conductedby those who are not primary experts in the field (e.g. at thereception screening stage by RGNs). Second, fragmentation incommissioning and provision can lead to a lack of clarity and/orcompetition regarding roles and responsibilities for staff (e.g. thegap between primary and secondary mental healthcare). Thirdly,communication in relation to mental health work is often depen-dent on informal social networks – rather than, or in addition to,the official written records. These three topics are now exploredin-depth.

The interview narratives from healthcare staff highlight thatmuch ‘low level’ mental health work is conducted by individualswho are not trained nor have expertise in this area. For example,RGNs expressed concerns about assessing mental health andpsychiatric history during the prison reception interview (forexample asking questions relating to self-harm and suicidal idea-tion) as well as the dispensing of psychiatric medications on prisonwings. One participant described how she felt that she let prison-ers down due to her lack of detailed mental health knowledge,particularly outside of the in-reach service office hours when therewas little alternative support available:

Table 2Subject areas used to guide the data collection interviews.

Broad interview subject areas Sub-topic prompts

Services and pathways � Roles and responsibilities in relation to mental health.� Inter-agency collaboration.

Availability and appropriateness � Prescribing practices in relation to mental health medication.� Recruitment and retention of mental health staff.

Communication and data sharing � Governance and sharing of mental health information.� Workplace relations between different personnel.� The mental health knowledge of custody staff.

Guidance and recommendations � Identification and screening.� The in-reach focus on severe and enduring mental health problems.� Implementation of the Care Programme Approach (CPA).� Service user groups whose needs are not met.

Resources and provision � Adequacy of resourcing for mental health care.� Resourcing and the ability to plan care in the short, medium and long term.

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“I know that I can make people safe, and I know I’m a goodcommunicator, and I will get them help, but I do feel like I let themdown a bit, particularly at weekends” (P002).

Prisoners are held within the prison setting twenty-four hoursa day seven days a week. However, the specialist in-reach mentalhealth services were only available between the hours of approxi-mately 9 am and 5 pm Monday–Friday. Given that mental illnessdoes not confine itself to office hours, this led to anxiety regardingout of hours psychiatric crises. Thus, there was the perception thatother professionals and services were ‘picking up after mentalhealth’; this narrative was particularly specific to primary carestaff:

“I feel like I’ve moaned massively but that’s because there is a bitof an issue in here regarding how much we do for everybody else Iguess” (P001).

In-reach staff also highlighted problems with their prescribedworking hours and the timings and regime of the prison (e.g. theadministration of psychiatric night-time sedation as it had to begiven early, often at six o’clock in the evening, which was not idealfor the individual prisoners/patients).

To summarise, primary care staff stated that it was not a lack ofdesire to do mental health work which was difficult for them, buta concern about operating outside their sphere of practice withlittle supervision. Many primary care staff stated that they wouldbe willing to complete training to become dual registered nursesin both adult general and mental healthcare:

“Yeah we are not mentally health trained, I would like to be dualtrained, I think it would be really beneficial, but they are not goingto train me to do that. So we just kind of have to keep askingquestions – Is this the right thing to do? Am I approaching this theright way?” (P001).

Furthermore, interviewees identified structural and politicaldivisions and gaps between the various health and prison servicesin relation to mental healthcare:

“The inter-play between provider organisations is not alwaysseamless” (P010).

Disagreements between services about who should see aparticular prisoner for their mental health needs and at whatpoint in the care process were felt to hinder early intervention forthe individuals benefit. An often cited example was the referralroute to secondary services. In-reach staff described beingapproached directly by prison officers and prisoners for helprather than contacting primary care first:

“Sometimes there maybe needs to be some clearer, erm, what’s theword I’m looking for, direction for the [prison] staff about whothey’re referring to … I get an awful lot of requests … to in-reachdirectly from prisoners, … The minute I walk down a wing I get,‘I need to be seen by you’, I say, ‘Well it actually needs to gothrough, you know, primary first’, with which the prisoner is finebut the [wing] staff seem to be a bit unclear generally … I supposenobody's really sat them down and explained what the differenceis [between primary and secondary]…When they think of mentalhealth they directly, especially if something's going wrong, theydirectly seem to think of the in-reach team rather than primary,and I think they struggle to differentiate between the two” (P008).

It was also felt that the expectations of prison staff wereunrealistic in relation to what mental health services couldprovide. In-reach staff described an assumption that they wouldbe involved with all prisoners who self-harmed whether or notthey had a mental health problem. Although policy drivers such as

the Care Programme Approach (CPA) were seen to provide apossible structure for interagency collaboration and joint working,its implementation in practice did not fully support or generatethis ideal multi-stakeholder model. The Care ProgrammeApproach provides a mechanism for delivering and coordinatingcommunity services to individuals diagnosed with mental healthproblems (DH, 2008). Individuals who require complex, multi-stakeholder care packages from specialist, secondary care servicesare described as being “on CPA”. Whereas those who require onlyshort term, single agency or primary mental healthcare are notsubject to CPA (DH, 2008). Prisons are considered to be commu-nity settings for mental health services and therefore the princi-ples of CPA apply within this context.

However, data from this study found that there were contra-dictory understandings of who should or should not be ‘on CPA’.In addition, the completion of documentation was occasionallyprioritised over and above the actual practical use of CPA as ameans of bringing people together in the spirit of collaborativeworking.

Ironically, fragmentation and a lack of ownership over mentalhealth work in the prison setting also led to a duplication ofprovision. One in-reach CPN stated that she had been unawarethat as well as seeing her, a prisoner on her caseload was alsoseeing a counsellor from the prison service:

“To find out that he’d been referred to counselling, and he’d beenseeing the counselling woman for three or four weeks … and itwas only by accident that I found out, because I went over to seehim and she was in with him” (P007).

Similarly, in those establishments where there was an expecta-tion to engage in therapeutic group work with forensic/prisonpsychologists, the boundaries with NHS psychiatry services andmental health work at the healthcare centre were not always clear.

Despite the difficulties with determining ownership of mentalhealth work in the prison settings there were examples of goodcollaborative practice and joint working. This was often describedas being in spite of the structures in place rather than beingfacilitated by them. Collaborative working was instead dependenton informal, verbal, and social contact between individual collea-gues who opted to communicate well together.

Difficult working relationships were identified throughout theprison setting; for example at a service management levelbetween primary care and in-reach services, and between front-line clinicians who work in the same service. In relation to theseproblematic workplace relationships and the notion of informalcommunication networks in the setting, the aforementioned poorrelations were perceived to hinder knowledge sharing and amic-able collaborative working.

Although the informal routes of communication worked wellfor individuals, this could result in a lack of structured and writtendocumentation in relation to intended pathways and processes.The issue of risk management was frequently cited as an areawhere this was particularly complex. Healthcare staff wantedinformation relating to the risk an individual may present to them,for example hostage taking behaviour. Interestingly, gaining accessto the formal databases which held this information was notperceived to be the solution. Instead verbal communication waspreferred amongst colleagues who worked well together.

In relation to the recording of information on databases,interviewees described a process where only the minimumrequired was documented. Two main reasons were proposed forthis. The first centred around concerns that the computer systemwould fail (and had done so in the past) and so hard copies wererequired as a ‘back up’ and second that it was not in the prisoners'

N. Wright et al. / Health & Place 29 (2014) 179–185182

best interests to have all information related to mental healthwidely recorded:

“So there are issues about data, I think; there are big problemswith, with the fact that I’m not always convinced that confidenti-ality is properly maintained. I think that we sort of lost sight ofpatient confidentiality” (P009).

There was also some evidence of a hierarchal inter- and intra-professional desire to not share data and retain ownership of it;whilst at the same time expecting other professional disciplines inthe prison to communicate with them. In essence, some healthcarestaff expected to be given access to others' data but not at theexpense of sharing their own information.

3.2. Prison staff as mental health work allies

This section explores prison/wing staff and how this profes-sional group might assist with prison-based mental health work.The role of prison staff as mental health work allies is considered.

Healthcare clinicians' interview narratives were analysed in rela-tion to (1) problems with the identification of those prisoners withmental illness and unmet mental health need and (2) clinicians'working relationships with prison staff. As a result, suggestions aremade for how these two facets of mental health work in the prisonsetting could be developed in tandem. The Fig. 1 below acts as anintroduction to these debates. (N.B. MH – mental health).

The interview narratives from prison healthcare staff suggestedthat case identification for mental illness required development.The argument was made that unmet mental health need exists inthe prison context because insufficient opportunities for identifi-cation are built into healthcare work. The over-reliance on recep-tion screening (a one off event, which unless a problem isidentified is not repeated during imprisonment) was raised as anarea of concern. The tool used at reception screening was designedto identify immediate issues related to risk rather than a mechan-ism for profiling mental health need. This was considered insuffi-cient and other points within the prison system needed to beidentified for mental health needs assessment. The role of prisonwing staff as intentional observers and gatekeepers to the referralprocess was highlighted as a potential solution.

This issue was linked to concerns regarding a relative absenceof proactive mental health work in the prison milieu; the serviceswere considered to be mainly reactive in nature and lacking apreventative care pathway. To summarise, there is a desire toincreasingly search for, then pick-up and address, unmet mentalhealth need in the prison.

“Interviewer: What about any potential missing diagnoses orunmet need? Do you feel that all mental health issues are beingdetected? For example, what about personality disorder, learningdisability, or intellectual disability?

Participant: There's quite a lot, to be honest” (P011).

Thus, prison staff on the wing could usefully be recruited toplay a more active role in case identification and referral. Thismakes common-sense due to the amount of time this professionalgroup spends with the prisoner population in comparison to theprimary and secondary healthcare staff – who were often locatedon a separate healthcare centre wing/area.

As detailed in the Bradley Review, ‘staff working in the criminaljustice system … require at least a ‘basic’ level of mental healthawareness in order to both identify and effectively work with thehigh proportion of offenders with mental health disorders’(Sirdifield et al., 2010: 39). However, concern was raised byinterviewees about the adequacy of the mental health knowledgeheld by prison staff in order to accurately identify and referprisoners to services. This was particularly the case for thoseindividuals who were quiet on the prison wings and did notpresent a management problem or have overt signs of mentalillness.

“Education for officers regarding mental health issues is incon-sistently provided” (P010).

Gojkovic (2010) explores the delivery of mental healthcare inprisons and debates the care–custody balance experienced bywing staff. ‘Tension of care and security is perhaps best evidentin the case of prison officers who are in daily direct contact withoffenders’ (Gojkovic, 2010: 285) and who ‘may not always recog-nise the symptoms of a mental health problem’ (Gojkovic, 2010:285). Thus, the possibility of prisoners suffering mental ill healthin (albeit well-behaved) silence on the wings is raised as apotential concern by healthcare staff. Thus, an additional strandof prison-based proactive mental health work could be imple-mented to address this problem. Arguably, prison staff could play apivotal role in this new mental health work.

According to the clinicians interviewed, relations betweenfrontline prison staff and healthcare staff were often good. Thisworkplace rapport was based on the understanding that prisonstaff spend far more time with prisoners than healthcare staff, andare therefore well placed to assist with mental health work – eventhough this usually occurs via informal communication channels.

A development in the understanding of mental illness in thisprofessional group was also seen to be a mechanism for beginningto address the stigma associated with mental illness and accessingmental health services in prisons:

“Interviewer: In terms of prison staff then, so not clinical staff, justother staff, how would you describe their mental health knowl-edge, plus any ramifications of this?”

Participant: Nine out, well no, say seven out of ten [it] is quitepoor.

Interviewer: Does that matter?

“Participant: Yeah I think it does. You know, at the end of the dayeach person should be treated individually, whether they’ve gotFig. 1. Summary of key debates identified in interview narratives.

N. Wright et al. / Health & Place 29 (2014) 179–185 183

mental illness or not. They should be treated on their individualmerits, unfortunately you’ve got some officers who’ll treat every-one the same … Their whole attitude changes when you’re there:‘Oh, this is a mental health nurse, she's come to see you, she'scome to cart you off’. They have a laugh and a joke, and sometimesthe prisoners will laugh with it, but you’ve got those odd prisonersthat are thinking: ‘Well I can’t see her because I’m going to beclassed as a nutter” (P012).

If prison staff are to be provided improved mental healthawareness training, what should this staff development comprise?Similar to psychiatric nursing training? How are prison staff to beprompted to engage in training?

Forrest and Masters, (2005) identify two approaches to mentalhealth nurse education: user/carer informed and traditional. Theuser/carer informed approach emphasises teaching mental healthqualities and attitudes – not traditional mental health theories ordiagnostic labels. Moreover, this user/carer approach to knowledgeand education intends to challenge and inspire change in mentalhealth practice and service provision via highlighting patients'/users' agendas. Therefore, prison-based mental health awarenesstraining for wing staff should, arguably, be delivered in referenceto prisoners' mental health agendas, needs, problems, and desires.Norman (2005) argues: ‘the debate is between those nurses whoare concerned primarily with understanding the process of nursingas a discrete activity based on the relationship between the nurseand individual person in distress, and those who are concernedprimarily with interventions or treatments for patients with diag-nosed mental illness’ (p. 174, italics in original). In relation toprison staff, it is the first of these two forms of knowledge that isrelevant for mental health awareness training. It is the nature ofthe relationship between wing staff and mentally distressedprisoners (both overtly and covertly) that is of importance – andnot the clinical treatment of illness per se. Clinical names, phrases,and aetiology are cited as not important or relevant knowledge forprison staff; instead, it is an understanding of the behaviouralaspects of mental illness that are warranted.

‘The culture of an organisation is also important in implement-ing change’ (Lester and Glasby, 2010: 49) in the field of mentalhealth policy and practice. Therefore, it is important to considerthe cultural nature of prison officers' work in the prison setting.The possibility of cultural resistance to any mental health aware-ness training is to be considered. Maltman and Hamilton (2011)evaluate personality disorder awareness workshops for prisonstaff and conclude professional attitudes are crucial. ‘Positiveprofessional attitudes towards personality disordered clients havebeen linked with extensive clinical and strategic benefits. Thelargest influences on such attitudes are associated with stafftraining, supervision and support’ (Maltman and Hamilton, 2011:244). Maltman and Hamilton (2011) discuss practical implications:‘The findings indicate that personality disorder awareness trainingshould initially engage with trainees’ perceptions of their personalsecurity and vulnerability when working with this client group,rather than aiming to increase liking, enjoyment and acceptance ofsuch offenders' (p. 244). Given this, mental health awarenesstraining for prison staff should commence by addressing concerns,understandings and beliefs in relation to mental illness and mentalhealthcare in prisons. Knowledge, outcomes and implicationscould then be a secondary focus. In this way the trainees are thefocus of the training by concentrating on any prison officiers'anxieties, questions and associated stigma first and foremost.

Finally, Ramluggun et al. (2010) report ‘the conflation ofknowledge and experience of staff working in prison places themin a favourable position to contribute to the current reform ofoffender health’ (p. 70). Certainly, the experiential knowledge ofprison staff is remarkably valuable. This articles supports the

involvement of wing staff in the development of future mentalhealth policy and practice in prisons; after all, this professionalgroup spends far more time with the prisoner group than thehealthcare staff.

4. Conclusion

The prison as a setting for mental healthcare presents anumber of distinct challenges for those involved in the provisionof services. This paper has focused on the experiences of bothspecialist mental health and primary care clinicians. It is acknowl-edged that a limitation of the study is the lack of interviews withprisoners themselves and any future research should endeavour toinclude those incarcerated within HMPS. We have also highlightedthe importance of context to the provision of mental health care inprisons. To this end, we have placed this study firmly within thecontext of HMPS and the associated healthcare systems. Despitetaking this focus and drawing heavily on UK based evidence thethemes which have been identified in relation to prison staff aspotential allies in mental health work (as both observers andgatekeepers), the fragmentation of services and the crucial role ofsocial networks between differing personnel are transferable toprisons in other settings. For example, the topics analysed hereand implications might be transferred to the female prisonestablishments in England and Wales and perhaps also theImmigration Removal Centres. The role and influence of socialnetworks is an interesting finding as it demonstrates that amicablejoint-working in these settings is not standard practice but isinstead both personnel and personality dependent.

Implications:

(1) The mental health knowledge and understanding of prisonwing staff might be appraised and developed in order toimprove mental health/illness in prisons and address unmetmental health needs. The roles of observers and gatekeepersmight be considered.

(2) The realities of frontline mental health work for clinicians inthe penal environment could be embraced and utilised toproduce and implement improved mental health policy andpractice guidance, which is in better accord with the actualityof the context – both socially and structurally.

Acknowledgements

The healthcare staff at the prison establishments are thankedfor their time and participation in this project.

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