Treating Inmates in Hospitals: Guidelines and Security

The most famous cherry blossoms outside of Japan are in the grounds of Baltimore’s Union Memorial Hospital.

Public Enemy No.1, Al Capone, donated 2 cherry trees to the hospital as a thank-you present for treating his late-stage syphilis. The sexually transmitted infection, contracted as a young nightclub bouncer, ravaged his brain over the years and gradually made him insane.

Upon release from the notorious prison island, Alcatraz, Al Capone was refused treatment by Johns Hopkins Hospital before being accepted into Union Memorial. The caponettes, as the cherry trees are nicknamed, will forever pay homage to the medical staff who treated him there.

You might never have to care for an infamous gangster, but you may one day find yourself treating an inmate in a hospital. This article will break down this complex area of healthcare, including the ethical dilemmas, security issues, and considerations for the treatment of incarcerated people.

Incarceration in the United States

The United States has the highest incarceration rate in the world. According to the Prison Policy Initiative, approximately 2 million people are in prison at any one time, equal to 1% of the US population.

The incarceration rate increased dramatically by 400% between 1970 and 2000 as a result of political policies, according to the Vera Institute of Justice. This high rate disproportionately impacts certain racial and ethnic groups; for instance, Black people account for 13% of the general population but 37% of the incarcerated population.

Furthermore, over 80% of arrests are for non-violent or minor offenses. Inability to pay bail can then result in a driver’s license suspension or prison time, discriminating against economically disadvantaged communities.

The current immigration policy is also significantly driving up incarceration numbers: 59,000 people are being held across the country. Vera reports that some detained immigrants have reported medical neglect.

Ethical dilemmas for treating inmates

Prisoners’ right to healthcare is protected by the Eighth Amendment, which protects them from “cruel and unusual punishment,” in this case denying them adequate medical treatment.

In the study, “Caring for Hospitalized Incarcerated Patients: Physician and Nurse Experience,” some nurses stated that there should be no difference in caring for an inmate, because a person is a person. However, other nurses expressed concerns about safety, confidentiality, and the lack of clear hospital guidelines.

Undoubtedly, treating incarcerated people can be a grey area both in terms of policy and practice. It can also ignite significant ethical controversy, as this next case demonstrates.

The first heart transplant for a prisoner

The case of the first prisoner to receive a heart transplant in the United States caused great controversy as the healthcare bill to taxpayers surpassed $1 million.

People also disagreed with the treatment because a prisoner was allowed to go on a waitlist, a luxury many uninsured citizens can’t afford. To be eligible, people must show they can pay the full medical costs of the transplant, at least $150,000, according to the article “US Prisoner at the Center of Heart Transplant Row.”

Of course, the other side of the argument is that everyone deserves good healthcare regardless of financial or societal circumstances.

Famous prisoners who have been hospitalized

The nurses in the Medical Center for Federal Prisoners in Springfield, Missouri, have treated mafia bosses, a porn publisher, a terrorist, and a spy.

Robert Stroud, known as the Birdman of Alcatraz, was also treated at the Springfield Medical Center for the last 4 years of his life. He was sentenced for murder and proceeded to kill 2 more people in prison. He became a self-taught ornithologist in prison and even smuggled out a book on birds for publication.

The Hollywood terror, Charles Manson, was hospitalized in Bakersfield for an internal lesion at the age of 83. Thomas Silverstein, famous for spending more than 35 years in solitary confinement after killing a prison guard, died in a Colorado hospital.

These famous cases draw intense media interest, but in most ordinary cases, medical staff may not know the crime the inmate committed.

Healthcare for incarcerated people

Healthcare for inmates is a complex topic. As incarceration rates rise, the population ages, and prison in-house clinics are increasingly hit by the nursing shortage, the situation will surely become increasingly more complicated.

Increased pressure on healthcare for inmates

The prison population is aging, according to a study by the Pew Charitable Trust. States that participated in the study reported a 41% increase in the number of prisoners aged 55 or older between 2010 and 2015.

Older populations generally require more hospitalizations. In the prison population, this may be even more extreme as health problems can be caused and exacerbated by substance misuse, stress due to isolation, and violence.

According to the Prison Policy Initiative, the estimated annual healthcare cost for inmates is $14.6 billion. In efforts to contain that cost, many prisons have contracted out healthcare to private medical groups, built on-site hospitals, and expanded Medicaid coverage.

Inmate patient care in hospitals

Many prisons have on-site clinics or units to treat inmates; however, hospitalization may be required for acute conditions, specialized care, or diagnostic tests.

There are different levels of healthcare response for inmates. To illustrate, here are the gradients and response times in Florida:

Emergency situations, like a heart attack, bypass the formal process of requesting treatment, and a 911 responder may take the inmate directly to a hospital.
Urgent conditions are those that require treatment within 21 days or will become critical.
Routine procedures, such as a hip replacement, may be delayed by up to 45 days. In some states, these procedures might be postponed until after the prisoner is released.

Security and transportation

In the event of hospitalization, inmates must be transferred securely on buses, also known as sweat boxes. They must also be accompanied by additional security officers who stay with them during their treatment.

Correctional facilities typically contract with specific hospitals that implement additional security measures. An ambulance transporting an inmate would only divert to a non-contracted hospital in an emergency.

Prisons can be located in more rural or isolated areas, delaying arrival time at hospitals. Often, states will try to place older inmates or those with chronic health conditions in prisons with good on-site healthcare or near a big hospital.

Considerations when treating an inmate

It is important for nurses to be aware of the following issues in case they need to treat an incarcerated person.

Security protocol for inmate patients

Inmates are generally shackled in hospitals, although the policies and implementation of shackling are not consistent across facilities. Often, correctional officers determine whether shackles are used.

Shackles are designed to prevent flight risk, self-harm, or physical risk to medical personnel. Shackles are distinct from restraints, which may be used with non-incarcerated patients to ensure safety.

Many healthcare organizations have policies that call for indiscriminate shackling of incarcerated patients, including during pregnancy, labor, surgery, and in end-of-life situations.

The inmate is also accompanied by security guards. These guards are often present with the patient when their medical history is being taken and during physical exams. This can undermine the accuracy of the medical information provided and compromise patient confidentiality.

Personal safety and best practice

According to the study “Caring for Hospitalized Incarcerated Patients: Physician and Nurse Experience,” 81% of nurses reported feeling safe when caring for an inmate. The same number reported feeling safe when interacting with a custody officer.

The study demonstrated that neither nurses nor physicians commonly asked for patients’ shackles to be removed. Nurses were more likely than physicians to ask officers if the inmate posed a safety risk. They were also less likely to ask officers to leave the room during a physical examination.

None of the nurses asked inmates why they were incarcerated; however, 25% did ask the officers the reason.

It should also be noted that some normal clinical practices may differ; for instance, nurses may not be allowed to inform inmates of their discharge or to contact the next of kin. The best practice is to always speak to a supervisor or manager for clarification.

Socio-economic considerations

Nurses who treat incarcerated people may benefit from an awareness of the prevalence of substance abuse and mental health issues among this population.

Mental health issues

According to a study by the Bureau of Justice Statistics in 2011, 37% of inmates had been told by a mental health professional that they had a mental health disorder, including depressive disorder, schizophrenia, bipolar disorder, or post-traumatic stress disorder (PTSD). The study determined that 1 in 4 prisoners in jail met the criteria for serious psychological distress.

The Healthy People 2030 report, titled “Incarceration,” stated that incarcerated women are more likely to suffer from mental health issues than their male counterparts. They are also more likely to have been victims of child trauma, including sexual and physical abuse.

Education and health literacy

The incarcerated population typically has lower levels of education. Healthy People 2030 states that people without a high school diploma have a higher probability of being incarcerated than their educated peers.

In many cases, it might also be assumed that they have lower levels of health literacy due to their socio-economic background and lack of healthcare access before incarceration. Therefore, educating patients about symptoms and ongoing healthcare is vital.

Common health complications for inmates

Inmates can present with health complications from substandard living conditions, including dental problems, tuberculosis, or gastrointestinal problems.

According to Healthy People 2030, inmates are more likely to have:

High blood pressure
Arthritis
Cancer
Asthma
HIV
Tuberculosis
Hepatitis C

Female inmates with a history of substance abuse are more likely to present with tuberculosis or hepatitis C. Incarcerated females are also at a greater risk of having a sexually transmitted disease.

Personal qualities and values

Undoubtedly, treating inmates is challenging on many levels. It can be very stressful, complicated, and even confusing for nurses.

In the study, “Caring for Hospitalized Incarcerated Patients: Physician and Nurse Experience,” several nurses reported a lack of clarity and training around the hospital’s policies for incarcerated patients. This also led them to feel unsure about whether they could challenge prison officers when they interfered with care.

In light of these challenging circumstances, the American Nurses Association states that intelligence, confidence, and assertiveness are 3 vital qualities for nurses treating inmates.

Paula Stelsel, nursing supervisor at Dodge Correctional Institution in Waupun, also has some advice to offer. The mission of her facility is to ensure that inmates get what they need on the inside to successfully reintegrate into society.

Stelsel says that healthcare, especially health education, is a big part of reintegration. That can include educating inmates about the importance of nutrition, sleep, and continuing their healthcare journey when released.

“One of my passions is making it so that people know what’s available outside of jail,” says Tania Wenzel, a public health nurse who provides nursing care at a county jail. “Because the vast majority are from, and will come back to, our community.”

Registered nurse, Robert Frank, who also worked at Dodge, had the following to say:

“A lot of inmates haven’t had care, so you can enact meaningful change just by providing your compassionate care as a nurse. Their health literacy is pretty low, and a lot of them are very appreciative of the help that you give them, the compassion that you show them, the empathy. They’ve just never experienced those things.”

Conclusion

Treating inmates is challenging. The security and safety issues cannot be taken lightly.

You also need to be prepared for the fact that neither your training nor hospital policies will provide clear guidelines. If in doubt, always speak to a supervisor or manager for clarification.

If you do treat an incarcerated person, take into account the complex surrounding issues of mental health, poverty, health literacy, and substance abuse.

Read more about managing ethical issues in nursing.

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