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C A L I F O R N I A N U R S E S E P T E M B E R 2 0 0 5 27 accessing qualified health staff during medical emergencies. Medical Technical Assistants (MTAs) often serve as first responders to these situations and make medical judgments outside their scope of licensure. Prisoners suffering from debil- itating chronic illnesses (e.g. HIV, hyper- tension, diabetes) are enrolled in a Chronic Care Program (CCP) and often report they do not receive regular moni- toring and treatment for their diseases. Lastly, prisoners often experience harm- ful and expensive delays and difficulty in getting medication refills, especially with pain medications. Many prisoners report receiving the wrong medications or never receiving their medications at all. For pris- oners with serious health problems, such as heart disease, seizure disorders, or high blood pressure, lapses in doses represent a significant health risk. COPAYMENT SYSTEM California's copay system requires most prisoners to pay $5 in order to access medical services. Submitting a health services request form and paying a $5 copay is the first step in accessing med- ical attention within the California state prison system. Five dollars represents a significant expense as most prisoners lack a steady income from outside supporters. Prisoners fortunate enough to receive a paid job assignment often earn less than $0.50 an hour. The $5 copay policy often forces many prisoners to choose between accessing medical care and purchasing needed items from the canteen, such as hygiene goods to supplement the meager supply provided by the prison, stamps to stay in touch with loved ones, and food items to supplement the highly unhealthy meals provided in the chow hall. Lawmakers and prison officials ini- tially claimed the $5 copay would offset the hefty costs of providing prisoners with healthcare but studies suggest otherwise. In 2000, California state auditors recom- mended the elimination of the copay pol- icy because it "has not generated the expected revenue, nor has the department analyzed the program to assess whether it actually has reduced visits sufficient to offset the operating costs." This CE will continue in the November 2005 issue of California Nurse. Hedy Dumpel, RN, JD is Chief Director of Nursing Practice and Patient Advocacy for the California Nurses Association. The history of nursing in corrections has not been formally traced, or docu- mented, other than perhaps a rare RN in history in the 1800s. Registered nurses have been practicing in correc- tions since the late 1960s and early 1970s as they began to filter into pris- ons and jails in sparse numbers. Our identification of the beginning of RNs in corrections comes from the memo- ries of RNs still working in the field. LVNs were first employed as peace offi- cers in the California state prison sys- tem in 1942 on Alcatraz Island due to the quasi-military predominant power structure of correctional authorities. RNs have participated actively in the evolution of correctional health standards since the 1970s, which largely defined health standards in medicine and clinical practice and administrative relationships between health providers and correctional authorities. Amidst a 30-year national impetus on county jails and state pris- ons to obtain accreditation for health services to defend against lawsuits, correctional nursing remains unde- fined in scope and practice to this day. Other than being referred to in national standards by nursing and other health disciplines, the practice of nursing in corrections has been defined by individual RNs in isolation from the rest of the practicing nursing specialties in America. There is essen- tially nothing written about correction- al RNs, who have yet to define their own uniqueness or science as a nursing specialty. Correctional nursing has been left to survive and function within the predominant influences of correc- tional facilities. The perceptions of RNs by security personnel in their role and function have been largely abusive and dictatorial. RNs have been caught in conflicts stemming from the violent and extremely judgmental environ- ment within prisons and jails. Corrections is a world operating in general isolation from public view. It draws immediate judgment and unedu- cated attitudes from within and with- out the field. Correctional RNs are generally not considered distinct or dif- ferent from the environment they work in. A correctional RN is not considered "good" and competent in the security viewpoint when addressing the needs of prisoners. Prisoners are perceived as manipulative and disruptive to security and not deserving of the healthcare that is given in society. Society judges that prisoners are not deserving of financial resources to provide health- care as images of crime come immedi- ately to mind. The law defines that prisoners have a right to healthcare equal to that of the community and lack of understanding of this legal con- cept is very problematic for RNs. This perception fails to consider the RN pro- fessional obligation toward inmate patients. The voice of RNs in the daily struggle to provide nursing care is sub- sequently overtaken and drowned out. RNs that are viewed as "good RNs" by correctional and law enforcement personnel are RNs who adopt a puni- tive security stance with inmates who are in need of care. This is in stark contrast to nursing care that is provid- ed without question or suspicion if a prisoner were in a community hospi- tal. In the community setting, ethical nursing is supported and enforced. Ironically, in contrast to how they are perceived inside these facilities, the courts regard correctional RNs with the respect and credibility given other RNs in the community. RNs have been called more and more frequently to appear in court as an interface with the criminal justice system. Perhaps if RNs were called "criminal justice RNs" instead of "correctional RNs," it would improve their image and understanding of who they truly are as a profession. Other agencies within the criminal justice system have further torn apart the patient advocacy role of correctional RNs. RNs have been forced to serve the purposes of prosecutors, defense attor- neys, and multi-jurisdictional investiga- tors—to name a few. RNs often unknowingly violate the rights of patients without any resource of legal guidance. It requires an educated legal correctional RN to defend this role in these other legal arenas that are becom- ing more common for RNs. Jail and prison politics threaten the safety, repu- tations, and jobs of RNs acting as patient advocates true to their profession. The History of Correctional RNs