Correctional nursing in Liguria, Italy: examining the ethical challenges

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  J PREV MED HYG 2018; 59: E315-E322 E315 Introduction . Correctional nursing can involve significant ethical difficulties. This study examined ethical challenges encountered by correctional nurses in the Italian region of Liguria. Empirical data were analyzed in relation to relevant ethical standards. The  former involved a study of 75 nurses and managers in the Ligu-rian correctional system, while the latter involved an analysis of the Italian Code of Ethics for Nurses and related standards for correctional practice. Methods . Quantitative and qualitative methods were used for the empirical study. Questionnaires were administered to collect data on participants’ characteristics and care settings. The Measure of  Job Satisfaction (MJS) was also administered. Five focus groups were conducted. Results . Quantitative Data:    Respondents identified factors that mostly impacted on recruitment and retention. Unfavourable fac-tors included: structural, organizational, and relational factors. Favourable factors included: nursing consultation, continuing education activities, and peer support. MJS results were equal to ‘unsatisfied’. Qualitative Data: five themes were identified through thematic analysis of focus group data: Health needs of incarcerated persons; Negotiation of the boundaries between care and custody; Job satisfaction related to nursing in a correctional setting; Barriers to providing good care; and Security needs. Ten categories of norms were identified in the Code as areas of ethical standards relevant for the empirical data. Conclusions . Our empirical findings demonstrate that these nurs-ing standards can be systematically compromised in correctional settings. Nurses feel compelled to provide ethically-problematic nursing services, with situations of moral distress. This research informs the development of needed policy, educational, and prac-tice changes for nurses in correctional settings. O RIGINAL   ARTICLE Correctional nursing in Liguria, Italy: examining the ethical challenges F. CARNEVALE 1 , B. DELOGU 2 , A. BAGNASCO 3 , L. SASSO 31  McGill University, Montreal, Canada; 2 SSD Medicina Penitenziaria ASL 2 Savonese, Savona, Italy; 3  Department of Health Sciences, University of Genoa, Italy Keywords Correctional nursing ã Moral distress ã Nursing ethics ã Italy Summary Introduction The aim of this study was to examine the ethical chal-lenges encountered by nurses practicing in correction-al settings in the Italian region of Liguria. Despite the regional focus of this research, we believe that this in-vestigation will also help advance our understanding of correctional nursing in other settings internationally. The term ‘correctional nursing’ is sometimes used in this article because it is widely used in the international literature, although we recognize the problematic tone of the term. For this reason, we frequently use the ex-pression ‘nursing practice in correctional settings’ as an alternative.International literature has demonstrated that nursing practice in correctional settings can involve significant ethical challenges [1-4]. These ethical challenges have been under-examined; frequently relating to dilemmas for which existing ethical standards are unclear or even contradictory. In particular, as nurses in correctional set-tings strive to attend to the health needs of patients and clients who are incarcerated, they are often called upon to use their clinical expertise for purposes of control or punishment.Nurses practicing in correctional settings confront com-plex problems [1, 5-10]. They have a high degree of re-sponsibility as they are required to manage emergencies and mental health problems, among other chronic condi-tions. Patient health information must be kept confiden-tial and not generally shared with correctional officers unless there is a justifiable reason. Nurses practice in settings where safety is a constant workplace concern. Nurses often report to a warden, rather than a health administrator, facing difficult negotiations of care prac-tices [1].The number of incarcerated persons in the United States has been increasing significantly. Incarcerated men and women have increased rates of serious and chronic physical and mental illnesses [2].   Maeve and Vaughn [2] highlighted numerous ethical problems faced by nurses in correctional settings: maintaining patient confiden-tiality; using chemical restraint for security rather than medical purposes; working with underqualified person-nel; providing care outside their scope of practice; car-ing for addicted prisoners; caring for the mentally ill; caring for incarcerated mothers and their newborns; managing the visitation rights of children whose parents are incarcerated; dealing with violence; coping with pro-longed isolation and segregation of inmates; providing adequate planning for released detainees; and involve-ment of nurses and physicians in carrying out the death penalty [2].  F. CARNEVALE ET AL. E316 In a critical examination of forensic psychiatric nursing in corrections, Holmes has reported that nurses are ‘ob- jects of governmental technologies’ [11].   They become the body onto which processes of conforming to the cor-rectional setting is dictated and inscribed. Nurse–patient relationships involve under-recognized power structures. Nurses frequently participate in behaviour modification programmes that involve unethical nursing approaches to mentally ill offenders [12].An ethnographic study of twelve prisons in England highlighted the significant responsibilities borne by nurses [8]. The National Health System has recognized the importance of synergy in the role of nurses with other health professionals in prisons (e.g., psychiatrists, social workers, etc.). In new models of care, nursing roles are authorized to provide prescriptions for minor illnesses (e.g., constipation, toothache, colds), perform intake assessments (e.g., nurse-led triage), and evaluate and manage complex chronic illnesses (e.g., nurse-led clinics). Physician assessments follow from assessments performed by nurses. Nurses are central agents in reha-bilitation programs for substance, psychotropic drug, or nutritional abuse; prescribing non-pharmacological treatments such as physical activity or behavioral pro-grams that promote sleep. The health service has devel-oped a culture that recognizes the importance of health and quality of care, limiting the abuse of control meas-ures.National evidence in Italy has highlighted that illness lev-els and health care needs are significantly more elevated among detainees than in the general population [13-15]. The most common illnesses include: tuberculosis, HIV, hepatitis, syphilis, and other sexually transmitted infec-tions. Mental illness is significantly elevated, as well as substance abuse [14]. Nursing ethical concerns relating to correctional settings have been scarcely examined in Italy. One study was conducted with detainees and nurses to in-vestigate the roles of nurses in these settings [16]. Most participants regarded nurses as mere treatment providers.A number of international statements and research re-ports have highlighted standards that should be upheld for nursing in correctional settings. For example, the Eu-ropean Code for Health in Prisons recognizes the rights of detainees to have access to health care without dis-crimination and highlights the ‘pathogenic’ impact of confinement on mental health [17].In Britain, recent increases in nursing staffing, training, and development of holistic practices and promotion of a code of ethics have demonstrated improvements in the health and social integration outcomes of detainees [14].The National Commission on Correctional Health Care identified six ethical principles for nurses in correctional settings: a) respect for persons (autonomy and self-de-termination); b) beneficence (doing good); c) nonmalefi-cence (avoiding harm); d) justice (fairness, equitability, truthfulness); e) veracity (telling the truth); and f) fidel-ity (remaining faithful to one’s commitment) [18].The journal  Nursing Standard   published a theme issue in 2010 that focused on correctional nursing. Within this volume, Perry published a competency mapping and a grid for evaluating the performance of nurses in correc-tional settings [6]. These competencies included: pre-vention of communicable diseases; the management of mental disorders and chronic illnesses in an inadequate context; integration with other professionals for evalua-tion activities; and regional networking to ensure conti-nuity of care.The International Association of Forensic Nurses has highlighted guiding principles for ethical decision-mak-ing in forensic nursing, that is: a) fidelity to patients and clients; b) responsibility to the public; c) obligation to science; and d) dedication to colleagues [19].The American Nurses Association has highlighted that correctional nurses have to balance an attitude of care while maintaining safe boundaries. Nurses should advo-cate for access to care. For patients that die while in-carcerated, nurses should help patients die with dignity and comfort. The American Nurses Association has also argued that correctional nurses should not participate in executions [20].There is an absence of explicit ethical standards for nursing practice in correctional settings in Italy. There have been, however, some significant structural shifts in correctional health services that imply potential im-provements in nursing practice conditions [21]. Heath professionals practicing within correctional settings, in-cluding nurses, are now administratively accountable to the Public Health Branch of the National Health System; rather than the correctional services administration, as they were before. This initiative sought to bridge prac-tice standards as well as collaborations among health professionals practicing within prisons with the broader community of practitioners in the general population. Moreover, this restructuring establishes a clearer bound-ary between security measures and responses to the health needs of detainees. The principal objective of this study was to examine the ethical challenges encountered by nurses practicing in correctional settings in the Italian region of Liguria. Drawing on a framework for ethical analysis referred to as the ‘is-ought problem’ [22], an empirical examina-tion of clinical practice was analyzed in relation to rel-evant ethical standards to highlight tensions that may exist between the a) ‘is’ of current practices (i.e., what nurses are   doing ); and b) ‘ought’ applicable to these practices (i.e., what nurses should be doing ). The former were documented through a quantitative and qualitative investigation and the latter were examined through an analysis of the Italian Code of Ethics for Nurses [23] and related standards for correctional practice in Italy and Europe. This research was conducted to help inform the development of policy, practice change, and educational initiatives to address the ethical challenges encountered by nurses in correctional settings. Methods The empirical component of this study is based on a re-analysis of data collected from an earlier study conduct-  CORRECTIONAL NURSING IN LIGURIA, ITALY: EXAMINING THE ETHICAL CHALLENGES E317 ed by three of the authors (i.e., Bagnasco A, Delogu B, Sasso L.) [24]. The study was conducted as part of one author’s (Delogu B.) graduate studies. The aim of the initial study was to document occupational challenges and job satisfaction among nurses working in correc-tional settings in Liguria, Italy. Upon completion of the research, the authors noted significant ethical concerns that were underlying the data. They therefore recruited the remaining author (FAC), a nursing ethicist, to assist with an ethical analysis of the empirical data along with an analysis of relevant norms. D󰁥󰁳󰁣󰁲󰁩󰁰󰁴󰁩󰁯󰁮 󰁯󰁦 󰁰󰁡󰁲󰁴󰁩󰁣󰁩󰁰󰁡󰁮󰁴󰁳 Participants in the study included nurses and their man-agers in the Ligurian correctional health system (i.e., Medicina Penitenziaria delle cinque AASSLL della Lig-uria) as well as nurses that worked within this system in the past. A total of 74 nurses participated in the study.A mixed methods design was used for the study, drawing on quantitative and qualitative methods. Measurement instru-ments from the international literature (described below) were translated, adapted, and validated for an Italian con-text by the University of Genoa doctoral nursing program. Q󰁵󰁡󰁮󰁴󰁩󰁴󰁡󰁴󰁩󰁶󰁥 󰁭󰁥󰁴󰁨󰁯󰁤󰁳 Participants were administered a questionnaire, adapted from the work of Almost et al. [25], to document the: a) demographic characteristics of the sample; b) care provision settings represented in the study context; and c) factors associated with job retention and nurses’ inten-tion to leave their jobs. To measure the latter, a validated measure of job satisfaction was attached to the question-naire (i.e. M easure of J ob Satisfaction, MJS) [26]. Work satisfaction is an important predictor of retention and in-tent to leave [27]. The MJS consists of 38 items grouped into five factors: a) personal; b) workload; c) profession-al support; d) training; and e) economic remuneration and opportunities for career development. For each MJS item, participants responded to the following question: ‘How satisfied are you with this aspect of your job?’: 1) very dissatisfied; 2) dissatisfied; 3) neither satisfied nor dissatisfied; 4) satisfied; 5) very satisfied. Q󰁵󰁡󰁬󰁩󰁴󰁡󰁴󰁩󰁶󰁥 󰁭󰁥󰁴󰁨󰁯󰁤󰁳 Focus groups were used to collect qualitative data. Five focus group meetings were conducted with nurses and nursing managers in: La Spezia, Savona, Genova Mar-assi, Pontedecimo, and Sanremo. Chiavari and Imperia were excluded as study settings because the number of nurses in these settings was too limited for the study. Five principal questions were used to orient the focus groups: a) How do you identify the health needs of de-tainees and which prisoners do you think have the great-est health needs?; b) How would you describe the differ-ences between working in a hospital and working in your context?; c) What are your needs today to perform this work?; d) What are the sources of satisfaction in your work activities?; e) What are the obstacles to providing good health services in your work setting? Qualitative data were analyzed with NVIVO 10 software. Results E󰁭󰁰󰁩󰁲󰁩󰁣󰁡󰁬 A󰁮󰁡󰁬󰁹󰁳󰁩󰁳 Quantitative Data Respondents identified favorable and unfavorable fac-tors that had the most significant impact on the recruit-ment and retention of nurses in their setting. Unfavora-ble factors included: structural, organizational, and rela-tional factors (Tab. I). Favorable factors included: nurs-ing consultation: 35.1%; continuing education activities: 31.1%; and peer support: 16.2%.  Measure of job satisfaction Fifty-nine participants completed the MJS to measure their level of satisfaction regarding five specific factors. None of the measures for the five factors reached a mean as high as 4.0, the level corresponding with ‘satisfied’. Personal Sat-isfaction and Satisfaction with Professional Support were the most highly rated (i.e., 3.878 and 3.814, respectively) and Economic Remuneration and Opportunities for Career Development had the lowest rating (i.e., 3.034). It is noteworthy that none of the means for the five fac-tors were less than 3.0; that is, none were oriented to-ward a clear measure of dissatisfaction. All means were below 4.0 (satisfaction) and above 3.0 (neither satisfied or dissatisfied), which implies that despite the signifi-cant difficulties encountered by these nurses they also derived some favorable returns from their work to coun-ter these difficulties. Qualitative data Five major themes were identified through a thematic analysis of data recorded during the focus groups: (1) Health needs of incarcerated persons (detainees); (2) Negotiation of the boundaries between care and custody; (3) Job satisfaction related to nursing in a correctional setting; (4) Barriers to providing good care; and (5) Se-curity needs. Tab. I.  Summary of quantitative results. Themes identified within each factor are listed. Theme I: Structural Distance & isolationLogisticalAbsence of a care setting32.4%27.0%21.6% Theme II: Organizational Insufficient staffHeavy workloadLimited professional autonomyExcessive professional autonomyResource restrictions24.3%21.7%17.6%16.2%13.5% Theme III: Relational Absence of continuing educationConflict with care recipientsConflict with correctional officersConflict with the medical team29.7%35.2%20.3%10.9% NB: The proportion of respondents who reported each theme is indi-cated in parentheses.  F. CARNEVALE ET AL. E318 1. Health needs of incarcerated persons (detainees) When compared to practicing in conventional hospital settings, correctional settings entail: (a) a much great-er number of patients for each nurse; (b) greater pro-fessional autonomy and therefore increased individual responsibility; (c) a particularly high proportion of health concerns related to mental health and substance abuse problems; and (d) a number of barriers for the nurse-client relationship, which require an alteration in how nurses approach patients. 2. Negotiation of the boundaries between care and custody Correctional settings have a culture of order and disci-plinary control, which overshadow concerns about the health of detainees. Participants reported that a greater proportion of their time is devoted to maintaining sec-urity rather than promoting health or managing illness. 3. Job satisfaction related to nursing in a correction-al setting Nursing practice in these settings can provide some opportunities for personal and professional enrichment, which was related to inter-professional work, detainee multiculturalism, and trust relationships that can be es-tablished with patients. On the other hand, job satisfac-tion can be compromised when: a) correctional officers expect nurses to collaborate with them to exert control measures on detainees; b) detainees try to manipulate nurses to obtain favors; c) there is insufficient time for nurses to develop a non-judgemental attitude with de-tainees; d) nursing practice requires advanced exper-tise in assessing health needs of detainees who are not presenting their symptoms honestly; e) working with substance abuse and mental health problems; f) person-al freedom is restricted in the workplace; g) there are insufficient nursing staff, which increases workload and reduces opportunities for rest breaks; and h) there is little recognition of the specialized competence required to practice in correctional settings. 4. Barriers to providing good care Security requirements seem to limit the professional au-tonomy of nurses. That is, nurses are not recognized as professionals but as mere providers of treatments with-out any autonomous thought. Prison administrators refer exclusively to physicians as the health care profession-als. Care is also sometimes compromised by conflictual relationships with correctional officers who tend not to recognize the health needs of detainees. Some pris-ons draw on ‘cooperatives’ for nursing staffing, which results in very high nursing turnover rates. This limits nurses’ ability to consolidate their competencies and compromises trust relationships between nurses and de-tainees as well as nurses and correctional officers. 5. Security needs The principal priority in correctional settings is secur-ity. Consequently, nursing actions are predominantly fo-cused on managing medications and sharps – rather than providing care. N󰁯󰁲󰁭󰁡󰁴󰁩󰁶󰁥 A󰁮󰁡󰁬󰁹󰁳󰁩󰁳 Empirical findings helped orient an analysis of relevant ethical norms that define ethical practice for nurses in correctional settings in Italy. The principal normative source that was examined was the Code of Ethics for Nurses in Italy (referred to below as ‘Code’) [23].Ten categories of norms were identified in the Code as areas of ethical concern highlighted by the empirical data. These included: General Responsibilities; General Ethical Considerations; Nursing Competence; Respect for the General Rights of Patients; Respect the Autono-my of Patients; Respect Patients’ Privacy and Confiden-tiality; Respect for the Wellbeing of Patients; Promote Inter-Professionalism; Promote Patient Safety; Prevent Conflict of Interest. Table II lists the specific sections of the Code related to each normative category. These normative standards highlight explicit nursing standards that can be systematically compromised in a correctional setting – given the empirical findings reported above – placing nurses in situations where they feel compelled to practice against the standards of the profession.Additional sources were examined for articulations of practice standards specifically relevant for health pro-fessionals in correctional settings; in Italy and Europe. Although these were not specifically focused on nursing practice, they provided specificity that complemented the more general norms drawn from the Code.The Italian National Bioethics Committee prepared a Report on ethical considerations that should be applied to the health of detainees, citing relevant Italian & Euro-pean norms [15]. The Report outlines health risks iden-tified among incarcerated populations and the health-related rights of detainees that should be respected. The Report commends the shift of administrative responsi-bility for health services from correctional authorities to state health services administration. This will help pre-serve the professional autonomy of health professionals and prevent the confusion of health services with secu-rity services (i.e. dual roles) within these settings, among other merits of such a restructuring. For example, health professionals responsible for providing health care to detainees should not also be responsible for providing expert assessments of the detainees’ health for the jus-tice or security procedures of the courts or correctional systems such as prisons (e.g. assessment of detainee’s capacity to endure disciplinary measures such as solitary confinement). A limitation of this Report, for the pur-poses of this study, is that it is predominantly focused on the practice of physicians, with occasional references to health professionals more broadly. Although the Report appears directly applicable to other health professionals, such as nurses, this is not explicitly articulated.The Report corroborates related international standards regarding detainees. Specifically, the European Code for Health in Prisons recognized that a) detainees should have a right to health services without discrimination; and b) the restriction of personal freedom can have a harmful impact on the mental health of detainees [17]. Disciplinary measures should therefore be restricted to minimize these harms. The World Health Organization
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