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CE Home Study Course 24 S E P T E M B E R 2 0 0 5 C A L I F O R N I A N U R S E vary in written nursing policy, procedures, and protocols for RNs in the correctional settings. Due to the culture of the envi- ronment, nursing policy lacks real en- forcement when an RN incurs problems in devising effective nursing care. In many facilities, nursing policies and procedures are poorly written. They are widely mis- interpreted by medical and custody per- sonnel and troublesome in defining the function of RNs in serving their patients. Poor policies lacking enforcement within nursing are often used against the RNs by various disciplines and agencies. Despite the establishment of standardized proce- dures for RNs since the 1980s, the state prison system still has not implemented them for correctional RNs. This lack of implementation places RNs in the archa- ic structure of calling a doctor to make an order for almost every nursing decision for a patient in an independent setting. Standardized procedures are a mainstay of enforcing safe, therapeutic, and effec- tive nursing practice, and necessary for the autonomy required of RNs practicing in correctional facilities. The role of correctional RNs needs fur- ther definition, particularly the RN's role in interfacing within a complex criminal jus- tice system and maintaining a professional nursing relationship with inmates as patients. For RNs to be able to do assess- ments that maintain the health of inmates within the limitations of jail and prison sentences requires recognition that this practice is uniquely different from all other nursing specialties. PATIENT ADVOCACY AND CORRECTIONAL NURSING In corrections it takes a strong stance by the RN to provide ethical and competent care, as the environment is inherently opposed to RNs caring and advocating for inmates. Most RNs would prefer the approval of law enforcement than the dif- ficulties of patient advocacy. RNs have no concept of their legal obligations to a patient in an environment that sanctions diversion from standards of care because the patients are criminals. Correctional nursing, lacking autonomy and its own voice to determine its own function, has largely adapted to the custody definition of nursing in order to survive in corrections. RN practice in corrections has been severely weakened, particularly in the RN role as patient advocate, due to the abu- sive and powerful attitudes it faces with- in the correctional setting. Nursing is actively harmed by rumors, gossip, inves- tigations, custody purposes in criminal proceedings, threats and harm to physi- cal safety, and other forms of intimidation. Noncompliance with working for the pur- poses of custody inevitably brings serious negative consequences for the RN. Retal- iation from the correctional system is an unspoken norm in the prison culture. Cor- rectional RNs often find themselves in need of union and legal representation to save themselves from what occurs in the course of their normal duties. These RNs have a unique vulnerability in their prac- tice setting. Traditionally prisoners have treated their RNs with gratitude and respect for quality care provided. Correc- tional nursing has very special moments as in other nursing specialties. In this environment, RNs are thwart- ed in their ability to act as effective patient advocates. Mostly in the state prison sys- tems and in environments void of effective union representation, RNs themselves lack strong advocates. RNs need protection from the control of custody, medical, and nurs- ing management and also predatory, vio- lent, or mentally ill prisoners. These entities are quick to sacrifice the RN role as patient advocate, including the RN role in providing effective inmate/patient care that is competent and equal to current stan- dards of nursing care in the community. The underlying culture that persists is to dispense with RNs as "sacrificial lambs" to serve the purposes of the institutions. LACK OF ACCESS TO APPROPRIATE HEALTHCARE Longstanding Barriers to Access to Care by California Inmates Accessing safe, therapeutic, effective, and compassionate healthcare in the Califor- nia Department of Corrections (CDC) rep- resents one of the most pressing issues facing California inmates. Examples of barriers to care include the $5 copayment; delays in diagnostic testing and follow-up treatment, access- ing specialty care and emergency medical attention; timely medication refills; and regular monitoring and treatment for chronic illnesses. Case Study No. 1 Barrier to Healthcare for California Women Inmates Medical Technical Assistants: Medical Technical Assistants (MTAs), mostly LVNs, have minimal medical training, yet act as gatekeepers to the prison health sys- tem. MTA/LVNs are considered custodial staff and are members of the guard union—California Correctional Peace Officers Association (CCPOA). Conse- quently, they demonstrate a custodial approach to medical care rather than a health professional approach. Many women prisoners report that MTA/LVNs often do not believe they are really sick and stand in the way of accessing quali- fied medical staff. Additionally, MTA/LVNs often make decisions they are unautho- rized to make under the LVN scope of practice. Post-surgical Follow Up: Women pris- oners often receive minimal—if not abu- sive—post-operative care. Women say that post-surgical orders are not followed and pain medications are often canceled. Many women articulate that the only post- operative pain medication they receive is Motrin or aspirin. Some patients are forced to change their own bandages and sometimes have to beg for clean dressings. Similarly, the removal of stitches, clamps, medical pins, and casts does not always occur in a timely manner, requiring some women to do it themselves. Chronic Care Programs: Women pris- oners diagnosed with certain chronic health problems (such as HIV, diabetes, hypertension, etc.) are supposed to see a doctor roughly every 90 days. These pro- grams often prove inadequate because the patient's Chronic Care Program (CCP) appointments do not happen on a regular basis. Some prison doctors refuse to eval- uate patients for other health issues, even if related to a primary CCP medical con- dition. For example, one prisoner attempt- ed for four months to get treatment for a serious foot infection that progressed to the point of puss-filled abscesses and chronic swelling, but her CCP doctor would only talk to her about her epilepsy disorder. Some women even receive dis- ciplinary write-ups just for asking about other ailments. Medications: Women report receiving the wrong medication or never receiving their medications at all. Prisoners often experience delays and difficulty in getting refills, especially with pain medications. For women with serious health problems, such as heart disease, seizure disorders, or high blood pressure, missing their med- ications may result in terrible conse- quences.