Apr 01, 2010

Caring in Corrections

Daniel St. Louis Photographic ArtsRNs Cathy Kearley and Susan Steeves at work at Springhill Institution, a medium-security facility in Springhill, N.S.

Nurses play a key role in providing care to offenders serving time in Canada’s prisons. More than 700 nurses are employed by Correctional Service of Canada (CSC), and many of them go to work in one of Canada’s 53 federal penitentiaries. They represent the largest group of health-care professionals working in the correctional system, attending to the health-care needs of inmates from the time they enter the system, through transfers to other institutions and to their eventual release into the community. They provide a wide range of services. 

Correctional nursing is unique. While nurses remain focused on providing the best possible care to offenders, they face numerous challenges in having to do it in a secure setting.

“The work isn’t for everyone,” says Susan Steeves, chief of health services at Springhill Institution, a medium security facility in Springhill, N.S. “When I interview nurses, I tell them they’re either going to love this and not want to leave, or they’re going to turn around in the next five minutes and leave quickly.”

Canada’s prison population comprises people of all ages, ranging from juveniles to older adults, and of all ethnic, racial and socio-economic backgrounds. Often, inmates are marginalized and have little or no formal education. Many have a history of drug abuse or mental health problems and may be living with chronic diseases such as diabetes, hypertension or tuberculosis made worse by years of neglect and a lack of medical care.

“When they come in here, inmates have a lot of health issues,” says RN Karla McGraw, one of six full-time nurses at Atlantic Institution, a maximum security facility in Renous, N.B. “Many are infected with hepatitis C from intravenous drug use or unsafe tattooing. Some are HIV positive.”

Daniel St. Louis Photographic ArtsSteeves and RN Lori Embree balance the competing demands of providing care with the need for safety and security.

McGraw sees upwards of 50 inmates a day. “We’re a hospital within the walls of the prison,” she says. “We have a physician twice a week, a dentist once a week, a physiotherapist once a month and an optometrist every six weeks.” An important part of McGraw’s job is to administer methadone to those who are in the addiction treatment program and to make sure painkillers or other prescription drugs get to those who need them. Inmates have to ingest high abuse potential medications directly in front of her and follow them with a glass of water so she can confirm in writing that they’ve been taken. “A lot of inmates seek out psychotropic drugs that they can use in ways other than what they were prescribed for,” she says. (Methadone is administered separately from other medications. A correctional officer monitors the inmates for 20 minutes afterwards to prevent any diversions or illicit use of the narcotic.)

McGraw also treats the wounds of inmates who intentionally injure themselves. (They break the blades out of disposable razors and use them to slash themselves.) “You have to realize you are not dealing with the average Joe,” she says. “Our inmates engage in risky behaviour. That’s why they’re here.”

Inmates are in prison 24 hours a day, 7 days a week. If they want to accomplish something — even if it endangers their health and safety — they have plenty of time to think about how to do it. “Look around the room you’re sitting in right now,” says McGraw. “If you really want to harm yourself, you have what you need. You don’t have to have someone hand you the knife.”

Drugs and other contraband that make their way into prisons complicate matters. CSC is making efforts to stop the flow, but that may not help everyone. Some inmates have addictive personalities and will abuse a drug inside prison walls that they wouldn’t abuse outside.

It’s also common for inmates to take a seemingly innocent item and turn it into something that isn’t. “If they want a tattoo, they’ll use a motor from a small appliance if they have to,” says Steeves. Medical items such as syringes must also be closely monitored by nursing staff. “We cut up IV bags and tubing because they can be used to help make homebrew.”

The challenge of working in a secure setting comes from juggling the competing demands of providing care with the need for safety and security. Despite the presence of correctional officers, nurses have to be mindful of an unexpected situation that could arise. That rarely happens, but the potential is there, and nurses have to be vigilant. Most wear a personal alarm on their waist, but they also have to be alert to changes in behaviour. “If an offender starts to get angry or act strangely during an interview, I stop the interview. If someone acts inappropriately at the medication window, I ask them to leave and come back when they are ready to talk. You can’t let yourself get too comfortable. You have to remember where you are,” Steeves says. Inmates do lose their temper and become upset but usually come back a day or two later and apologize. “If you’re fair but firm and treat them with respect, nine times out of ten they will show you the same respect in return.”

It’s important to strike a balance between the need for personal safety and the need to maintain confidentiality. McGraw says she’ll lift the blind but close the door so the guard can see in and not hear what’s being said. That’s what the infectious disease nurse would do if she had to tell an inmate he was HIV positive, for example.

Nurses do more than just treat health problems. In the time spent talking, listening and interacting with inmates, nurses are always on the lookout for ways to help them be healthier. If an inmate has a sore back, Steeves looks at his overall well-being. “I might say to him, ‘if we could get 20 pounds off, that might help your back and your health.’”

At Springhill, nurses plan peer counselling programs that are geared to large groups and encourage offenders to take part in health fairs, where outside specialists provide screenings and information on hypertension, diabetes and other diseases.

Inmates may be required to enrol in substance abuse or other programs to apply for and be granted parole. They have to prove to the system that they’re doing their part to move their lives forward. “When you see a change in their attitude or behaviour, that’s the moment you realize they’ve got it. They understand and are trying to change,” says McGraw.

At Nova Institution for Women, in Truro, N.S., many inmates have mental health issues and a history of harming themselves or abusing drugs. Often, they have been sexually, physically or emotionally abused. “It’s a real eye-opener to learn what society has done to these women,” says RN Elaine Tattrie. Those convicted of a non-violent crime or a first offence may be released in as little as six months. “We don’t have them for long. We work on a short timeline to try to impact their lives in a positive way.”

Tattrie provides care to inmates in the maximum security and segregation units, where women are separated from the other inmates for various reasons. Their movement is restricted, and they spend a large part of the time in their cell.

Tattrie says segregation is a last resort and that regardless of where the women are housed, their health-care needs are always met: “If they have to see a doctor, they do. If they have to see a mental health professional or one of the nurses, they do. We would never deny anyone in segregation the right to medical care.”

Nurses at Nova provide prenatal care and address a variety of health concerns that arise — everything from cramps or a hurt toe to withdrawal symptoms or vomiting from hepatitis C treatment. Despite the high level of security, correctional officers don’t have to accompany inmates when they are being seen by a nurse or having a medical exam. “That’s nice because we can have an open, therapeutic relationship that’s based on respect for one another,” says Tattrie.

She likes to set some time aside to do health promotion, one-on-one (to explain the results of an abnormal Pap, for example) or in groups on an issue she thinks the women on the unit should be aware of. When inmates with a mental illness were being bullied, Tattrie showed a video about the stigma of the disease and its impact.

Inmates are concerned about their weight and body image. “They all want to be thin,” says Tattrie. She initiated a program, lasting several months, that addressed eating and exercise, BMIs and how to make healthy choices. The maximum security and segregation units are the only ones in the institution where the women don’t prepare their own food. The rest of the inmates live in shared dwellings where they cook and eat meals together as a household. (They have a list of what they can buy and have money allotted to an account to purchase groceries at a location within the prison area.)

Teaching the women how to make healthier choices is a way of helping them get their lives back on track, especially the ones who have families. Tattrie explains that mothers may be allowed to see their children on scheduled visits. “We have women who are very proud of their grandchildren and show us pictures.”

When correctional nurses show up for work, they don’t check their compassion at the front gate. It doesn’t matter why an inmate is behind bars, only that he or she is a human being who deserves and may be in need of care. “I don’t want to know why they’re there,” says Steeves. “My role is to provide patient care the same way I would to anybody else. Nurses aren’t here to judge inmates for what they may have done. That is the court’s function.”

Tattrie agrees. “We don’t get paid to make assumptions and decide who gets what. We are here as health-care providers, and everyone gets equal treatment.”

Steeves acknowledges that some inmates have done horrific things, but she also knows of others who may have simply been in the wrong place at the wrong time. One man, who had been in a bar fight in which someone died, often sat and talked with Steeves about the circumstances of his incarceration. He later sent the nursing unit a note thanking them for “treating me like a real person.” “He was somebody who was on his own from a very young age without any parental support. No one had ever shown him any kindness before,” she says.

Courtesy of Correctional Service of CanadaStony Mountain Penitentiary. The federal, medium-security institution in Winnipeg, Man., was built in 1876. It currently has a capacity of 546 inmates.

Working in corrections is anything but routine. Twenty years ago, Steeves answered an ad for a position as a correctional nurse. She had already worked in emergency, orthopaedics and surgery but was looking for something different. She found it: “You work with different specialists and do a little bit of everything. I may be assisting the physician with applying a cast one day and doing CPR the next. If you like to learn, it’s ideal.”

“People ask me what I do in prison,” says Tattrie. “‘Do you just give the inmates pills?’ They don’t understand the holistic nature of this type of nursing and how it draws on all your nursing expertise. I knew surgical nursing inside out for 18 years but that was one specific type of care. Since I’ve been here I have gotten to do triaging, wound care, mental health nursing, meds and infectious disease — things that I might never have experienced otherwise.”

Correctional nursing used to have a bad rap. Some people thought that nurses who couldn’t find work anywhere else went to work in prisons. In fact, it attracts highly skilled nurses from all backgrounds and all types of expertise. “These days our inmate population is so diverse and we are recruiting nurses with ICU, emergency and surgical backgrounds,” says McGraw.

Steeves says there is plenty of room for growth. “I have found that if you have an idea you think would benefit offenders, you can usually sell it and go with it.” She wanted to start an infectious disease program after noticing that hepatitis C and HIV rates were increasing. She approached her manager and asked if she could work on it, and got the go-ahead. “Within no time, the need grew and I was asked to be the infectious disease nurse. In the hospital or community, that wouldn’t have been as easy. Working on the inside, if you come up with a good idea they’ll say, let’s give it a try.”

Tattrie helped plan the release of an offender who had been incarcerated for much of her life. She says it was hard getting the community to be non-judgmental and give the woman, who is in her 40s, a chance. She has now been out for two years. “She had never been successful in the community before. I still think about her all the time and how much she learned and has grown.”

That was gratifying. And the others have similar stories. For Steeves, it was the inmates who came to trust her when she worked in infectious disease. They would tell her when someone was having a problem or abusing drugs. The fact that she was able to establish a rapport with them and have that level of trust was “a huge accomplishment. It made me realize I was doing my job. I have been offered jobs in the community and been asked to return to the hospital, but I’m not interested. It’s not the pay, and it’s not the benefits. It’s doing this kind of work.”

McGraw expresses the same sentiment. She enjoyed working in a hospital emergency department and was sad to leave that job. But when a position in corrections opened up, she couldn’t say no. “I’ve never been sorry,” she says.

She remembers treating an inmate who had been stabbed and needed to be airlifted to the regional hospital. He ended up having open heart surgery. He eventually recovered, and when he returned to prison to complete his sentence he made a point of coming down to the nurses to say “you guys rock.”

A role for public health nurses
In 2003, Manitoba Health and Manitoba Corrections joined forces to tackle the high rates of communicable and sexually transmitted diseases among the province’s prison population. “It’s working,” says Jean Orton, a public health nurse who has been with the program since 2005. “I’ve seen huge changes since I started. I have repeat offenders who get tested every time they return.” Orton’s job is to provide one-on-one counselling for STIs and communicable diseases. She also does followups and referrals for those who test positive for HIV and hepatitis C.

The program is strictly voluntary. Orton says inmates tend to learn about the service from others and then put in a request for an appointment. “Currently, we have a two-week waiting list,” she says. Besides testing and providing information, the nurses also give presentations on topics like positive parenting and nutrition.

If inmates want to talk about other issues, if they’re anxious or worried, Orton tries to help by suggesting they put in a referral to see a mental health worker or spiritual care provider.

RN Marilyn Sloane, director of health services for Manitoba Corrections, helped to initiate the program and credits it with expanding the reach of public health to high-risk groups both inside prisons and out in the community.
Offenders begin to encourage their partners and family members to get tested. And when they are released, they have established a connection with public health that they didn’t have before.

Nurses Employed by Correctional Service Of Canada


Percentage of CSC nurses working inside prisons, providing ambulatory care, physical health and mental health services


Percentage of CSC nurses working in the 52 regional treatment centres or four hospitals managed by CSC, providing inpatient physical and mental health care.



Prison Population


Approximate total number of offenders that CSC oversees


Number of offenders in prison


Number who are supervised in the community


Factor increase in the cost to provide offenders with health care because of a greater number of issues such as mental health, substance abuse problems, HIV, hepatitis C, and chronic diseases including diabetes, cardiovascular diseases/risk factors, and respiratory disorders.



Mental Health


Between 1997 and 2005, the percentage increase in the number of offenders identified as having a mental disorder on admission


Between 1997 and 2005, the percentage increase in the number of women offenders in federal custody identified at admission as presenting mental health problems


Percentage of offenders with mental disorders having more than one disorder



Infectious Diseases & Substance Abuse


Estimated prevalence of HIV among inmates in CSC institutions


Estimated prevalence of HIV in the general population


Estimated prevalence of HIV among women offenders


Estimated prevalence of hepatitis C virus (HCV) among offenders in CSC institutions


Estimated prevalence of HCV among the general population


Estimated prevalence of HCV among women offenders


Percentage of offenders in Canadian federal institutions who have some sort of substance abuse problem



Quick facts source: Correctional Service of Canada website

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