Nursing in Prison 3031306627, 9783031306624

Citation preview

Nursing in Prison Joanne Brooke Editor

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Nursing in Prison

Joanne Brooke Editor

Nursing in Prison

Editor Joanne Brooke Centre of Social Care Health and Related Research Birmingham City University Birmingham, UK

ISBN 978-3-031-30662-4    ISBN 978-3-031-30663-1 (eBook) https://doi.org/10.1007/978-3-031-30663-1 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Contents

 rison Populations, Culture, Violence, and Drug Misuse������������������������������   1 P Melindy Duffus and Joanne Brooke  ealthcare in Prison������������������������������������������������������������������������������������������  31 H Joanne Brooke  he Role of the Nurse in Prison������������������������������������������������������������������������  55 T Joanne Brooke  rimary Care in Prison ������������������������������������������������������������������������������������  83 P Joanne Brooke and Nina Shamaris  ental Health Care in Prison �������������������������������������������������������������������������� 109 M Monika Rybacka and Joanne Brooke  risoners with Intellectual Disabilities������������������������������������������������������������ 135 P Vicky Sandy-Davis  ubstance Misuse in Prison������������������������������������������������������������������������������ 159 S Joanne Brooke  alliative and End-of-Life Care in Prison ������������������������������������������������������ 187 P Lydia Aston  ecommendations and Conclusions���������������������������������������������������������������� 211 R Joanne Brooke

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List of Tables

Prison Populations, Culture, Violence, and Drug Misuse Table 1

Slang words and terms��������������������������������������������������������������������  22

Healthcare in Prison Table 1

Overview of the Declaration of Human Rights (1948) ������������������  32

Primary Care in Prison Table 1

The four domains and core competencies of an ACP (primary care nurse)������������������������������������������������������������������������  97

Substance Misuse in Prison Table 1

Overview of the main substances reported by prisoners ��������������  162

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List of Case Study

The Role of the Nurse in Prison Case Study A Nurse’s Experiences of Working in a Prison and Collaborating with Prison Officers����������������������������������������  73 Primary Care in Prison Case Study Holistic Care������������������������������������������������������������������������������  101 Case Study Autonomous Decision-Making��������������������������������������������������  102 Case Study Patients’ Best Interest����������������������������������������������������������������  104 Mental Health Care in Prison Case Study Case Study

Realistic Expectations of a Clinical Placement in Prison������������������������������������������������������������������������������������  127 Learning Opportunities for Mental Health Student Nurses ������������������������������������������������������������������������  128

Prisoners with Intellectual Disabilities Case Study Learning Disability Student Nurse’s Experience of a Clinical Placement in Prison����������������������������������������������  152 Substance Misuse in Prison Case Study A Positive Experience of a Substance Misuse Nurse����������������  178 Case Study Supporting a Prisoner Who Was Unwilling to Detox����������������  180 Palliative and End-of-Life Care in Prison Case Study Time-Consuming to Approve a Compassionate Release Application��������������������������������������������������������������������������������  198 Case Study Risk Assessment Within a Compassionate Release Application��������������������������������������������������������������������������������  198

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List of Boxes

Primary Care in Prison Box 1 Box 2 Box 3 Box 4 Box 5

Reception Screening������������������������������������������������������������������������  88 Follow-up Screening������������������������������������������������������������������������  88 Health Promotion All Prisoners Are Likely to Need ����������������������  93 Health Promotion Many Prisoners Are Likely to Need������������������  94 Health Promotion Some Prisoners Are Likely to Need������������������  94

Mental Health Care in Prison Box 1 Box 2 Box 3

Essential Components of Assertive Community Treatment (ACT)��������������������������������������������������������������������������  118 Identifying the Most Appropriate Treatment Option��������������������  122 Stepped-Care Model: Common Mental Health Conditions and Recommendations������������������������������������������������������������������  123

Substance Misuse in Prison Box 1 Box 2

Nurse-led Public Health Interventions������������������������������������������  173 Nurse-led Physical Health Interventions ��������������������������������������  174

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Prison Populations, Culture, Violence, and Drug Misuse Melindy Duffus and Joanne Brooke

1 Prison Populations The first section of this chapter will provide information on current prison populations, with a focus on both the United Kingdom and the Prison Service of England and Wales, as well as the United States and Australia. The prevalence of prisoners as classified by biological sex will be discussed per country, although overall 96% of the prison population are male and the remaining 4% are female. The fastest growing group of prisoners within these prison populations are those in the age group of 50 and over. An ageing prison population is not unique to the Western World, but a global phenomenon. The ageing prison population will be described and possible reasons for this growth will be discussed, including ageing of the general population, tough on crime sentencing and convictions of historical crimes.

1.1 Prison Populations In the United Kingdom in the week ending June 2021, the total adult prison population was approximately 87,500, which accounts for 1% of the general population. Prison services in the United Kingdom include the Prison Service of England and Wales, the Northern Ireland Prison Service and the Scottish Prison Service. The adult prison population in the United Kingdom is divided as follows: M. Duffus School of Social Sciences, Birmingham City University, Birmingham, UK e-mail: [email protected] J. Brooke (*) Centre of Social Care, Health and Related Research, Birmingham City University, Birmingham, UK e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 J. Brooke (ed.), Nursing in Prison, https://doi.org/10.1007/978-3-031-30663-1_1

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78,756 prisoners within the Prison Service of England and Wales (Ministry of Justice 2021), 7417 prisoners within the Scottish Prison Service (Scottish Prison Service 2021) and 1377 prisoners within the Northern Ireland Prison Service (Department of Justice 2021). In England and Wales, only 4% of the adult prison population were women (Sturge 2021). The majority of information provided within this book refers to male prisoners within the Prison Service of England and Wales, unless otherwise stated. In the United States, the total adult prison population in 2022 was approximately 1,797,000, excluding detention due to immigration status, or those detained in Indian Country or Military jails (Sawyer and Wagner 2022). Of this prison population, approximately 10% (i.e. 200,000 prisoners) were women (Kajstura 2019). Prisoners in the United States are held within state prisons, local jails, federal prisons and jails. In the United States, jails are commonly used as short-term facilities, and prisons for those who have been sentenced and are facilitated by either the Federal Bureau of Prisons or by the State. The approach of mass incarceration in the United States directly impacts on millions of people, and it has been estimated that 79 million people in the United States have a criminal record (Sawyer and Wagner 2022). In Australia, the adult prison population has increased over the last decade, from 29,700 in 2010 to 41,060 in 2020, which accounts for 1.6% of the general population, despite a slight decrease in the last 2 years (Australian Institute of Health and Welfare 2021). The total adult prison population increased again in 2021 to 42,975 prisoners, of which 39,680 were males and 3290 were females (Australian Bureau of Statistics 2021). The age of people serving a prison sentence has changed over the past two decades, with a significant increase in older prisoners. In England and Wales in 2021, 3883 prisoners were aged between 15 and 20, 21,530 between 21 and 29, 25,211 between 30 and 39, 14,569 between 40 and 49 and 13,131 aged 50 years and over (Clark 2021). A similar pattern of the age of prisoners is observed in other countries, such as Australia, with 646 prisoners aged between 18 and 19, 11,932 between 20 and 29, 15,149 between 30 and 39, 9128 between 40 and 49 and 6120 aged 50 years and over (Australian Bureau of Statistics 2021). The following section will focus on the increase in the ageing prison population and identify a number of factors that may have contributed to these changes.

1.2 Ageing Prison Population The average age of a person serving a prison sentence (prisoner) is increasing, and older prisoners are the fastest growing group within prisons around the world. In the last two decades there has been a dramatic increase of older prisoners in England and Wales; between 2002 and 2020 there was an increase of 159% of prisoners aged 50–59 (Ministry of Justice 2020a, b) and an increase of 243% of prisoners aged over 60 (Ministry of Justice 2019, 2020a). In March 2020, the total percentage of adult prisoners in England and Wales over the age of 50 was 16% of the adult prison population (Ministry of Justice 2020a, b).

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A similar increase in older prisoners occurred in the United States and Australia. In the United States, between 2000 and 2009, there was a 79% increase in prisoners over the age of 55 (Williams et al. 2012). This trend continued, with older prisoners became the fastest growing group (Sharupski et al. 2018). The total percentage of adult prisoners over the age of 55 is currently 11.3% of the prison population (McKillop and Boucher 2018; Federal Bureau of Prisons 2022). In Australia, between 2001 and 2010, there was an 82% increase in prisoners over the age of 50, and a further 67% increase between 2010 and 2018 (Johnstone 2019). Despite the difference in proximity, these three Western regions have seen many similarities in their ageing prison populations, and it is therefore important to consider what factors may have contributed to these changes. These factors include the overall age of the general population, tough on crime sentencing and convictions of historical crimes.

1.3 Ageing General Population Worldwide the population is ageing as the average age of the general population increases. The World Health Organization (WHO) and US National Institute on Aging (2011) identified that there will be an increase of those over the age of 65 in 2050 from 8% of the world’s population (approximately 524 million people) to 16% of the world’s population (approximately 1.5 billion people). However, if those aged over 60 are considered, this group will increase to 22% of the world’s population in 2050 and will be larger than the group of people under the age of 5 years old (World Health Organization 2018). The Prison Service of England and Wales is separate to other member states of the United Kingdom, Scotland and Northern Ireland; however, general population figures are recorded for the United Kingdom. In 2019, those aged over 65 accounted for 20% of the UK population, approximately 12.3 million people (Lewis 2021). The increase of those over the age of 65 increased over three times the percentage of the United Kingdom’s overall population growth between 2009 and 2019 (Lewis 2021). The percentage of the population over the age of 65 in the United Kingdom is expected to rise to 24% by 2043, approximately 17.4 million people. An ageing population has also been recognised in the United States, and it is predicted that by 2034, for the first time in the nation’s history, there will be more adults over the age of 65 than children and young people aged under 18 (Medina et al. 2020). A decrease in the level of fertility at the same time as an increase in life expectancy is the main reason for the ageing population (Medina et al. 2020). The expected increase in the proportion of adults over the age of 65 has also been identified in Australia, which is expected to rise to 22% by 2057 and a further 3–25% by 2097 (Australian Bureau of Statistics 2014). A rationale for the increase of an ageing prison population may be due to the ageing populations around the world. As more people live longer, it increases the chance of being convicted of a crime at a later age or serve a sentence that would result in them being in prison at an older age. However, it is also important to

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consider what key factors are occurring specifically within the criminal justice system that may have impacted on the increase in older prison population.

1.4 Tough on Crime Sentencing The focus on being tough on crime through imprisonment is a key aspect in the way prison systems operate in England and Wales, the United States and Australia (Newburn 2007; National Research Council 2014; Mackay 2015). The need to be tough on crime was considered essential to tackle increasing rates of reported crimes. Over the past century the response to being tough on crime has been to change sentencing. These changes, which will be discussed below, have occurred within England and Wales, the United States and Australia, and it will be argued that these changes have influenced the increase in the ageing prison population. In England and Wales, sentencing guidelines determine the sentence for a specific crime. The guidelines have been developed and changed over time, which has often involved an increase in the severity of sentences, such as a longer minimum prison sentence. In the absence of death penalty, long prison sentences are the most severe punishment that can be imposed (Prison Reform Trust 2019). Due to the trend in increasing prison sentences, it has become common for prisoners to serve a minimum term of 10 years or longer (Crewe et al. 2019). The average length for a mandatory life sentence (excluding the whole-life tariff) has risen from 13 years in 2003 to 21  years in 2016 (Prison Reform Trust 2019). Longer prison sentences result in people being in prison for an extended period of time and ageing in prison. In the United States, sentencing changes occurred between 1984 and 1996, with a focus on being ‘tough on crime’, have had a long-lasting impact on how sentences are determined (Tonry 2013). Similar to England and Wales, the key changes included the implementation of mandatory minimum sentences (Sabol et al. 2002; Stemen et al. 2006), which reduces sentencing discretion, as courts have a minimum sentence to impose for the crime committed (Nelson 1992). Severe sentencing laws, with the inclusion of mandatory minimum sentences, which increase the length of time that a person serves in prison (Shahani 2017; The Sentencing Project 2017). Therefore, mandatory minimum sentences are largely responsible for the ageing prison population in the United States (Yorston and Taylor 2006). Sentencing practices in Australia have also focused on punishment (Tubex et al. 2015). Despite crime rates declining, there has been an increase in incarceration rates, and this is partially due to the introduction of mandatory sentences (Senate Legal and Constitutional Affairs Committee 2013). In Australia, mandatory sentences can be either a fixed sentence or a minimum term and are attached to certain crimes. For example, a conviction for murder in the Northern Territory, Queensland and South Australia results in a mandatory life sentence (Deckert and Sarre 2017). However, mandatory sentences vary depending on the offence and the states or territories where the offence occurred, which has led to some inconsistencies (Law Council of Australia 2014). The inconsistencies and implementation of mandatory sentencing are partially responsible for the ageing prison population in Australia.

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1.5 Convictions of Historical Crimes Crimes committed by older prisoners across England and Wales, the United States, and Australia fall into two main categories, sexual offences and violent offences, which are subject to long custodial sentences (Prison Reform Trust 2019). In England and Wales, 45% of prisoners aged over 50 were convicted of a sexual offence and 23% of a violent offence. The percentage of older prisoners convicted of a sexual offence increases with age, with 87% of those aged over 80 in England and Wales were  convicted of a sexual offence (Ministry of Justice 2017). In Australia, 64% of prisoners over the age of 65 were convicted of a sexual offence, whereas 17% of this age group were convicted of homicide or related offences (Australian Bureau of Statistics 2021). Over the past decade there has been an increase in potential historical sexual offenders being brought to trial. An historical sex offence refers to any offence that occurred either years or decades earlier. In the United Kingdom, the increase of convictions of historical sex offences is partially due to the aftermath of the identification of Jimmy Saville as a serial sex offender and the culture and practices within a number of institutions at this time. Due to the public outcry and pressure for justice, both the police and prosecutors have focused on pursuing convictions for historical sex offences (Mann 2012; Yorston 2015; Crawley and Sparks 2005). This pursuit has been supported by advances in forensic evidence and improved technology, which has led to older men being convicted and sentenced to long custodial sentences (Crawley and Sparks 2005). This has had a direct impact on the ageing prison population.

2 Sex and Gender of Prisoners This section will commence with WHO, Europe and UK government definitions of sex and gender, which, though used interchangeably, are two different concepts. This will be followed by a definition of transgender, and a discussion on the lack of understanding and recognition of transgender prisoners, which leads to further discrimination of this population through normative gender binarism and segregation by sex, which continues across prison services. Finally, the act of sex in prison will be defined and discussed, especially the implications, as in many countries the act of sex is illegal in prison.

2.1 Definitions of Sex and Gender The terms sex and gender are often used interchangeably; however, they are two distinct concepts. Sex is classified at birth and refers to the hormones, chromosomes and anatomy of the baby, and is a biological definition of male or female (WHO, Europe 2011). On occasion, there are instances when the biological sex of a baby is not exclusively male or female, which is referred to as intersex, but the baby will be

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assigned a sex by their doctor and family (Office of National Statistics [ONS] 2021). In comparison, gender is a social construction and is often referred to as gender identity, and it relates to the behaviours and attitudes of an individual that align with masculine or feminine characters of men and women (ONS 2021). However, gender identity may not always align with the sex a person is assigned at birth, often referred to as transgender, which is explored in the next section. However, an individual’s gender identity may not always align to that of a man or women and may lie somewhere in between the two, which is referred to as a non-binary gender (ONS 2021).

2.2 Transgender in Prison Transgender is a recognisable medical condition, with a diagnostic label of gender dysphoria (American Psychiatric Association 2013). The term transgender will be applied throughout this section, as this is the term used in prison policies and protocols. Transgender describes individuals whose gender identity is different from their biological sex assigned at birth (Drescher and Pula 2020). Treatments for transgender include both psychological support and counselling as well as medical interventions, such as hormonal therapy and reconstructive or genital removal surgeries (National Health Service 2020). However, transgender individuals experience social exclusion, direct and indirect discrimination, alongside abuse and harassment, which has led to a disproportionate representation of transgender individuals in prison (Lenning and Buist 2012). Transgender individuals in prison continue to experience discrimination from other prisoners, as well as prison staff and healthcare professionals (Grant et al. 2011). A cause of discrimination for transgender prisoners, especially those who are transgender women prisoners, is due to the normative gender binarism of prisons as prisoners are segregated by sex (Dziewanska-Stringer et al. 2019; Erni 2013). In England and Wales, as in many prisons around the world, prisoners are classified as male or female, depending on their biological or genital status, and then placed in a male or female prison (Sevelius and Jenness 2017). Further discriminations experienced by transgender women prisoners include harassment, abuse and physical violence from prisoners and prison staff, continuous sexual abuse from fellow prisoners, and they are frequently being placed in solitary confinement for their own safety, which is a form of punishment, or housed in special units with sex offenders (Brooke et al. 2022). The impact of discrimination on transgender prisoners has begun to be recognised, as transgender prisoners have higher rates of mental health problems, self-­harm and suicide (Bashford et al. 2017). In England and Wales, operational guidelines on the care and management of transgender individuals in prison were published in 2020 (HM Prison and Probation Service and Ministry of Justice 2020). Transgender individuals within the operational guidelines were classified as prisoners who expressed the wish to permanently live in the gender they identify, which is opposite to the biological sex assigned at birth, and either do not wish to have this recognised by law or have legal recognition of their new gender. The aim of the operational

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guideline is to ensure that all prison staff are provided with appropriate and clear direction to support and provide safe management for transgender individuals, including the management of risks to and from transgender individuals, so they are ‘managed safely with their rights properly respected and in accordance with the law’ (p. 7).

2.3 Sex in Prison The next section focuses on consensual sex between prisoners. However, it is acknowledged that coercive sex and abusive or violent sex also occurs in prisons around the world, and these acts are forms of interpersonal violence (Struckman and Struckman 2006). In England and Wales, the Crown Prosecution Service (CPS 2022) identify both rape and personal sexual violation in prison as interpersonal violence, which are prison-related offences and are referred to the police for investigation. Therefore, interpersonal violence will be discussed in-depth within the section on ‘violence in prison’. Consensual sex among prisoners is acknowledged to occur in prisons around the world. However, the rules governing sex among prisoners varies considerably. In the Prison Service of England and Wales, HMPPS states within the Prison Service Instruction 05/2018, which refers to prisoner discipline procedures, that: There is no rule specifically prohibiting sexual acts between prisoners, but if they are observed by someone who finds (or could potentially find) their behaviour offensive, a charge… may be appropriate, particularly if the act occurred in a public or semi-public place within the establishment, or if the prisoners were “caught in the act” during a cell search. But if two prisoners sharing a cell are in a relationship and engage in sexual activity during the night when they have a reasonable expectation of privacy, a disciplinary charge may not be appropriate. (HM Prison and Probation Service 2019, p. 63)

Sexual activity in prisons in England and Wales is therefore not illegal or forbidden, but there remains very little information on sex in prisons; this is partially due to the lack of openness and discussions of sex. Therefore, the Howard League for Penal Reform established an independent commission to explore sex in prison and completed interviews with statutory and voluntary agencies, lawyers, prison officers, former and serving governors (Stevens 2016). However, the then governing body (National Offenders Management Service [NOMS]) refused access to prisoners; therefore, former prisoners who were no longer under the supervision of NOMS were invited to participate to discuss their experiences of sex in prison. Qualitative interviews were completed with 26 former male prisoners who reported managing their sexual needs either by masturbation or discretely engaging in consensual sex with other male prisoners (Stevens 2016). In the United States, although laws across both Federal and States prisons are not consistent, it is illegal and forbidden for a prisoner to have consensual sex with a fellow prisoner (Tewksbury and Connor 2014). The offence is not just the act of sex but

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much wider with the inclusion of communications suggesting or planning to have sex and is defined under sexual misconduct. One example is from the state of Iowa: Proposes a consensual sexual contact or sexual relationship with another person through gestures, such as, kissing, petting, etc., or by written or oral communications or engages in a consensual sexual contact or relationship. (Iowa Department of Corrections 2017, p. 19)

Any prisoner who has been convicted of sexual activities with another prisoner will receive punishment, which can include being placed in segregation/solitary confinement, loss of the right to work, loss of the right to attend vocation or education programmes and/or religious services, as well as a loss of contact and visits from family and friends (Iowa Department of Corrections 2017). The punishment does not prevent prisoners from engaging in consensual sex, as prisoners have suggested that consensual sex occurs ‘all the time’ in prison, with an estimated 75–90% of prisoners contained in one wing involved (Lea et al. 2018). An accurate account of sex in prison is unknown due to the fear of both stigma and punishment (Arreola et al. 2015). However, the proportion of prisoners involved in sexual activity has been recognised for over two decades due to the high risk and disproportionate rate of sexually transmitted diseases and HIV among both male and female prisoners (Arriola et al. 2001; Chen et al. 2003; Mertz et al. 2002). The risk of HIV among prisoners had been identified as four to five times higher than observed in the general population (Maruschak 2009; McQuillan et al. 2006). In Prison Service of England and Wales, because of the legal approach to consensual sex between prisoners, condoms are available to support safe sex and a reduction in sexually transmitted diseases and HIV (Department of Health and NHS England 2013). However, the availability of condoms within male prisons remains inconsistent, especially across prisons and jails in the United States. In prisons in New South Wales, Australia, the distribution of condoms did not increase sex between men but increased safe sex (Butler et  al. 2013). Further evaluation of distribution of condoms in both prison and jail settings support the finding of Butler et al. (2013), as condoms did not increase sexual activity (Sylla et al. 2010) but did increase the practice of safe sex (Dolan et al. 2004; Harawa et al. 2010). Therefore, the provision of condoms is likely to support the reduction of both the risk and transmission of both sexually transmitted diseases and HIV (Leibowitz et al. 2012). An important element of sexual activity within prison, especially between male prisoners, is the need for sex, as male prisoners described sex as a physical need. Therefore, male prisoners, who identified as heterosexual and engaged in same-sex sexual activity while in prison in England and Wales, discussed that this was out of necessity and did not change or impact on their sexual identity (Stevens 2016). This finding is not unique to male prisoners in England and Wales, as male prisoners in the United States who identify as heterosexual reported engaging in same-sex sexual activity while in prison (Henley 2001). The terminology applied to heterosexual prisoners engaging in same-sex sexual activity within a prison is ‘gay for the stay’ or more appropriately situational homosexuality (Perdue et  al. 2011). Situational

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homosexuality describes consensual sex between prisoners as a result of living in a same-sex environment, such as a prison, and the need to meet their sexual needs, but these prisoners will return to heterosexual activities upon release (Ibrahim 1976).

3 Ethnic Diversity The overrepresentation of minoritised ethnicities on a large scale in prisons continues within England and Wales, the United States and Australia. This section will commence with statistics, which demonstrate the overrepresentation of minoritised ethnicities in prison, followed by a discussion on how this has and continues to occur. The term minoritised ethnicities will be applied within this chapter, due to the significant critiques regarding the term BAME (Black, Asian and Minority Ethnic) (Mistlin 2021). Minoritised ethnicities describes groups of people who have been defined by ‘minorities’ by a larger dominate group. Whilst the issue of grouping diverse people under a single heading still remains, it highlights how this chapter is drawing upon the experiences of those ethnicities that are the minority within their region. In 2020, in England and Wales, male prisoners from a minoritised ethnicity represented 27% (22,425) of all prisoners (Ministry of Justice 2020c), compared to 14% of the general population (GOV.UK 2020). In contrast, women from a minoritised ethnicity represented 18% of women prisoners, compared to 12% of the general population (Ministry of Justice 2016; Office for National Statistics 2016). Of the 27% male prison population who are from minoritised ethnicities, 13% identified as Black/African/Caribbean/British, 8% identified as Asian/Asian British and 6% identified as mixed/multiple ethnic groups (Ministry of Justice 2021). If the prison population of England and Wales represented the ethnic split of the general population, there would be over 9000 less people in prison (Kneen 2017; Lammy 2017). In England and Wales, the overrepresentation of minoritised ethnicities in prison costs the prison system an estimated £234 million per year (Kneen 2017). This overrepresentation stems from the increased chances of minoritised ethnicities being prosecuted and receiving a custodial sentence; for example, of those being prosecuted, 23% are from minoritised ethnicities (Yasin and Sturge 2020). Furthermore, people from minoritised ethnicities are more likely to be sentenced to prison for an indictable offence by the Crown Court, with a 53% heightened likelihood for Black people, 55%  for Asian people and 81% for other minoritised ethnicities (Kneen 2017). This overrepresentation is particularly high for those who identify as Black or Asian, as they are more likely to serve longer sentences than other prisoners; for example, 17% of Black people and 8% of Asian people in prison are serving a life sentence (Prison Reform Trust 2022). The overrepresentation of minoritised ethnicities within criminal justice systems also occurs in the United States. In a similar way to England and Wales, the ethnicity of prisoners in the United States is substantially different from their general

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population (Gramlich 2019). In 2017, Black people accounted for 12% of the general adult population, but 33% of the population serving a prison sentence (Gramlich 2019), whereas white people accounted for 64% of the general adult population, but only 30% of the population serving a prison sentence (Gramlich 2019). Recent figures identified 1 in 81 Black adults were held in a state prison (Penal Reform International 2022), which is five times more likely than white adults (The Sentencing Project 2021). However, there are disparities across the United States, the highest imprisonment rate of Black people was in Wisconsin with a ratio of 36 Black people to 1 white person (36:1), whilst Massachusetts reported 4:1 (The Sentencing Project 2021). The overrepresentation of minoritised ethnicities also occurs in Australia, as indigenous people continue to be overrepresentation within their prison population (Penal Reform International 2022). The Aboriginal and Torres Strait Islanders, Australia’s indigenous people, represent less than 3% of the general population, but more than 29% of the population serving a prison sentence (Korff 2022). The high incarceration rate of Aboriginal and Torres Strait Islanders is not new, and increased by 41% between 2006 and 2016, and a further 8% between 2020 and 2021 (Australian Law Reform Commission 2022; Penal Reform International 2022). Aboriginal and Torres Strait Islander women are imprisoned at a higher rate than non-indigenous women and at a higher rate than non-indigenous men (Australian Law Reform Commission 2022).

3.1 Reasons for Overrepresentation of Minoritised Ethnicities England and Wales, the United States and Australia all share similarities in terms of the level of overrepresentation of minoritised ethnicities within their prisons. Therefore, it is important to provide an overview of the predominant reasons for the overrepresentation of minoritised ethnicities. The following discussion will focus on racial discrimination, policing policies that increases targeting, and structural disadvantage and inequality. The first reason to be discussed is an acknowledgement of racial discrimination that is both historical and present within the modern day. This occurs through misperceptions of behaviour or characteristics of certain ethnicities, and these misperceptions can impact on criminal justice decisions. Racial discrimination therefore can have a negative impact on punishment applied. For example, minoritised ethnicities are often given harsher punishments due to the negative perception that they are a greater threat to public safety (Caravelis et al. 2013; Crawford et al. 1998). Black people are particularly subject to this discrimination due to the usage of negative language to describe them, such as ‘dangerous’ and ‘aggressive’ (Caravelis et  al. 2013; Crawford et  al. 1998). This discrimination increases the chance of an individual from a minoritised ethnicity being sentenced. A second reason, which leads to an overrepresentation of minoritised ethnicities within the prison system, is the enhanced opportunity to be found for an offence as a result of targeted policing. Hartney (2006, p.  1) notes that ‘crime rates do not account for incarceration rates’. Therefore, an overrepresentation does not mean that certain ethnicities are higher offenders, but rather that they have been targeted

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by the police. For example, locations with high volumes of people from minoritised ethnicities have been subject to enhanced drug policing programmes (Lum and Isaac 2016). However, targeted policing does not directly result in a prison sentence, but the presence of a criminal record from an arrest or conviction can lead to a future sentence from a subsequent conviction, especially for those from a minoritised ethnicity (The Sentencing Project 2021). There are further explanations that have been given for the overrepresentation of minoritised ethnicities in prison, but for the purpose of this chapter, the final reason to be discussed is the inequality and structural disadvantage. Both inequality and structural disadvantages include poverty, lack of employment and poor or no housing. These disadvantages impact minoritised ethnicities more than white people (Krivo et al. 2009). For example, Black people in the United States tend to have a higher chance of living in a poverty-stricken neighbourhood, which is compounded by other socio-economic challenges (Krivo and Peterson 1996). Due to heightened levels of inequality and structural disadvantage, minoritised ethnicities are more likely to live in environments where there is a lack of opportunity, which leads to a higher level of chance that crimes will occur, which may contribute to minoritised ethnicities engaging in crime. In England and Wales, the United States and Australia, minoritised ethnicities are still being imprisoned at disproportionate rates to the general population. Attention has been drawn to some of the reasons why the overrepresentation of minoritised ethnicities in prisons is still occurring. The reasons discussed identify the need to address racial discrimination within the criminal justice system, the appropriate use of language, the careful consideration of targeting policing policies and the need to continue to target minoritised ethnicities, who have historically always been targeted. Finally, there remains the need for a social movement to address the structural disadvantages and inequalities experience by minoritised ethnicities. All of these elements would need to be addressed to reduce the disproportionate rates of imprisonment of people from minoritised ethnicities.

4 Substance Misuse in Prison Substance misuse is one of the biggest challenges in prisons across the world. This section is an introduction to substance misuse, which will be discussed in more depth in the chapter “Substance Misuse in Prison”, as well as the role of the nurse in supporting prisoners with addiction. Substance misuse involves chemical substances that are either legal or illegal, which have the ability to adapt a person’s emotions and behaviour at a rate that can be harmful or problematic to themselves or others (Bennett and Holloway 2005). In the prison environment, substance misuse, which includes drugs and alcohol, contributes to self-harm, violence and crime. The following discussion will focus on the prevalence and reasons for high substance use by prisoners in England and Wales, followed by the identification of strategies that have been developed to address this ongoing issue. However, the experiences are similar across prisons in the Western World.

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4.1 Substance Misuse Substance misuse and availability of drugs within prisons is an ongoing widespread problem. Current figures show that approximately a quarter of people serving a sentence in England and Wales found it easy to obtain substances in their prison (HM Chief Inspector of Prisons 2021). These figures were closer to nearly a half of those serving a sentence found it easy to obtain substances prior to the pandemic (HM Chief Inspector of Prisons 2020). The availability of substances in prison is an important aspect of substance use, as in 2020, 14% of men and 12% of women reported that their substance use commenced whilst in prison (HM Chief Inspector of Prisons 2020). However, one in three people in prison in England and Wales entered prison with a substance addiction (Home Office 2020). Substance misuse treatment within prisons in England and Wales is monitored by the National Drug Treatment Monitoring System, which divides substance misuse into four groups: opiates, such as heroin; non-opiates, such as cannabis, crack and ecstasy; non-opiates and alcohol; and alcohol only. During 2020 and 2021, in England, over half the prison population, 43,255 prisoners, were receiving alcohol and drug treatment, with 55 deaths of prisoners receiving treatment during this time period (Office for Health Improvement and Disparities 2022). During 2020 and 2021, just over a third of prisoners were discharged from their treatment programme, which was an increase from just over a quarter of prisoners during 2019 and 2020. However, an important substance, which is not part of the substance misuse treatments but common in the prison environment, is a psychoactive substance commonly referred to as spice, which is a synthetic cannabinoid (Catch22 2018). Many prisoners’ first experience of spice is within prison, although positive tests for spice in England and Wales have begun to reduce the use of spice, the impact on the individual and prison system as a whole remains significant (Ministry of Justice 2020d). Spice is a substance that can be sprayed onto plant leaves, paper, cardboard or other materials and usually smoked, but can be sold as a liquid (National Institute on Drug Abuse 2020). Despite the similarity of spice to chemicals found in traditional cannabis, the effect is more powerful, unpredictable and life-threatening (National Institute on Drug Abuse 2020). Therefore, spice became an illegal substance in 2016, with the implementation of the Psychoactive Substance Act 2016. However, the make-up of substances, such as spice, are often adapted, and the Act needs to be amended to ensure the new compounds within the substances are illegal (National Institute on Drug Abuse 2020). Substance misuse in prison is a complex and multi-faceted problem, and a whole system approach to deal with both the supply and demand of the issue is required (HM Prison and Probation Service 2019a, b). The Prison Drug Strategy was created and implemented to address this issue, with three key focal points focusing on restricting supply, reducing demand and building recovery (HM Prison and Probation Service  2019a, b). These three objectives are addressed through five activities, including development of people (staff) with appropriate skills and support; procedural, the development of processes that are clear, fair and effective;

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physical, the development of safe and clean environments to promote well-being; followed by population, the enhancement of positive relationships and constructive activities; and finally, partnership, institutions working effectively together. However, the HM Chief Inspector of Prison in 2020 identified that a lack of an effective drug supply reduction strategy was in place.

4.2 Explanation of Substance Use Prison staff and prisoners have identified different explanations for substance use within prison (Mjaland 2016). Prison staff identified previous substance use and addiction and the troubled life trajectories of prisoners as the reasons for substance use within prison. Therefore, prison staff expected prisoners to use substances whilst in prison. Prisoners, on the other hand, identified different reasons for substance use in prison; whilst some prisoners identified addiction, other prisoners did not, instead they described substance use within prison as a deliberate process to alleviate the pains of being in prison. The possible psychological harm of prison is discussed further in the following paragraph. However, prisoners also identified substance use as an integral part of social life in prison, as well as a process of gaining status amongst other prisoners, and lastly, a process to demonstrate defiance against institutional rules (Mjaland 2016). Serving a prison sentence has been identified as causing possible harm to prisoners; this harm can be psychological and one of the reasons why substance use has become a large problem with prisoners. A psychological impact can occur due to the conscious experience of a loss of time, loss of personal autonomy and a loss of contact with family and friends, which can be psychologically painful (Medlicott 2001). Furthermore, the challenge of living in both a highly controlled and incredibly empty environment can cause psychological harm. The prison environment is highly contradictory in the sense that it is both routine and lacking in routine, therefore the prisoner is certain whilst being uncertain of their daily routine (Cope 2003). These are some of the challenges that may cause psychological harm, which leads individuals to abuse substances to support them to live within an environment that is both contradictory and unpredictable. However, as already acknowledged, the increase in substance use leads to both violence and crime within the closed environment of a prison.

4.3 Substance Use and Violence Substance use within prisons in England and Wales has been attributed to the increase rates of violence, assault rates and self-harm and suicide (HM Chief Inspectorate of Prisons 2019). Prisoners who are serving a sentence due to a drug offence or are known to use substances prior to their sentence are more likely to engage in violent acts whilst in prison (McGuire 2018). The increase usage of spice

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within prisons has been linked with the increased rates of violence in prison (Karila et  al. 2015; Zawilska and Andrzejczak 2015), despite the fact that the impact of spice on prisoners is more likely to cause sedation, relaxation and altered perception, in addition to volatile behaviour. The overall impact of spice within prison is disruptive as it contributes to violence through the bullying of prisoners, the need for prisoners to pay for spice and the development of debt among the more vulnerable prisoners.

5 Violence in Prison In this section, violence within prison will be introduced, even though recommendations and declarations worldwide reaffirm the human rights of prisoners to the right to a safe and healthy environment, which includes the right of protection from all forms of violence, including sexual assault. The definition and prevalence of violence within prison will be discussed, including the violence of prisoners towards fellow prisoners as well as prison staff and health and social care professionals. The characteristics of violent prisoners will also be identified and discussed. The final elements of this section will define sexual violence within both male and female prisons, as well as the influence of gender-based violence and the difficulty in determining the prevalence of sexual violence within prisons.

5.1 Prevalence of Violence in Prison The prevalence of violence within prisons is difficult to estimate, as any act of violence by a prisoner is both illegal and punishable and therefore occurs covertly. In addition, those who experience violence in prison are also unlikely to report a violent incident due to the fear of repercussions and retaliation (Modvig 2014). Retaliation is a genuine fear for prisoners due to the enclosed environment of a prison, which means there is no escape. This explains why only a quarter of prisoners who had experienced an assault in prison did not report the assault, as they believed this would not prevent further assaults, and a fifth of prisoners did not report the assault as they feared retaliation. Therefore, official statistics of violent offences or violent misconduct may be significantly less and underestimate the level of these offences within prisons (Byrne and Hummer 2007). The World Health Organization (2002) defines violence as: The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation (WHO 2002, p. 5).

The WHO (2002) categorises violence into three broad categories. The first category is self-directed, which includes both suicidal behaviour and self-abuse.

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Suicidal behaviour includes suicidal thoughts, attempted and completed suicides, and self-­abuse includes acts of self-harm. The second category is interpersonal violence, which includes community violence. This is any violence between individuals who are unrelated or who do not know each other and takes place outside of the home including institutions, such as prisons. Lastly, collective violence, which is violence committed to the advancement of a particular social agenda, may occur in prisons when prisoners collectively riot against their living conditions. Other acts of violence within a prison include attempted and completed suicide, self-ham, physical violence, psychological violence, such as threats and bullying, and sexual assaults, which occur between prisoners or between staff and prisoners (Modvig 2014). In prisons in England and Wales, during the period of October 2020 to September 2021, there were 20,049 assault incidents reported, which was a reduction of 18% from the previous year; however, in the last quarter of 2021, the number of assaults had increased by 9% (HM Prsion and Probation Service and Ministry of Justice (MoJ) 2022). The number of serious assault incidents reported in 2020/2021 was 2042, which was a reduction of 25% from the previous year. The number of assaults on staff during 2020/2021 was 7780, which was a reduction of 8% from the previous year; however, in the last quarter of 2021 the number of assaults had increased by 5%. Overall, in 2020/2021 the serious prisoner on prisoner assaults had decreased by 31% and serious assaults on staff by 12%. These figures were influenced by the COVID-19 pandemic, which has decreased the prison population due to reduced activity of the Criminal Justice Service (CJS) and the restricted regimes implemented to prevent the risk and spread of COVID-19 to both prisoners and staff (HMPPS and MoJ 2022). Violence towards healthcare professionals working in secure psychiatric and forensic settings has been explored (Gadon et al. 2006; Newman et al. 2021), but there is limited information on violence towards healthcare professions in prison. In the United Kingdom, the Joint Unions in Prisons Alliance (JUPA), which represents the trade unions of staff employed by HMPPS, private prison providers and staff working for contractors providing cleaning, maintenance, healthcare and education services, conducted a survey of all members to identify the level of verbal and physical abuse. Of those who responded, 1634, only 11.4% were members of the Royal College of Nursing, although the results of nurses were not separately presented (JUPA 2019). The survey identified 77% of staff reported verbal abuse and 26% reported physical violence in the last 12  months. One extreme act of violence was reported by a member of the Royal College of Nursing: Nov 2018 I was punched to the head x3 (times three). The prisoner continued to punch me when I was on the floor. (JUPA 2019, p. 4)

A study conducted in Australia has explicitly explored workplace abuse and violence amongst healthcare professionals working in a prison (Cashmore et  al. 2012a, b). The exploration of verbal abuse of healthcare professionals by prisoners

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identified the majority of reports were from nurses (84%), doctors (8%) and allied healthcare professionals (7%). Verbal abuse included being shouted and sworn at, and 33% of male and 19% of female healthcare professionals reported being threatened with physical abuse (Cashmore et  al. 2012a). Additionally, in Australia, a 3-year study reviewed 208 incidents within prison, the vast majority of which involved nurses (95%). The main activities engaged in when a violent incident occurred were preparing or dispensing medications, patient consultation, restraining or trying to calm an aggressive prisoner or observing or supervising a prisoner (Cashmore et al. 2012b).

5.2 Characteristics of Violent Prisoners The characteristics of prisoners in both federal and state prisons in the United States who are more likely to become involved in violent misconduct have been summarised in a comprehensive review by Schenk and Fremouw (2012). The most predominant predictor of violent misconduct was the age of a prisoner, with those aged 18–30 being significantly more likely to engage in violence than older prisoners. Prisoners who were convicted of a public order offence or a weapon crime were more likely to engage in violent misconduct than those convicted of murder. The length of a prisoner’s sentence has also been identified to correlate with violent misconduct, with those serving up to 5 years being more violent than those serving life without parole. One study identified that for each year added to the length of a prisoner’s sentence decreased their risk of violent misconducted by 1%. Finally, gang affiliation has also been identified to increase the risk of a prisoner becoming involved in violent misconduct (Schenk and Fremouw 2012). The characteristics of prisoners who are more likely to commit a violent assault in prison, as well as when and where the violence is likely to occur, have been explored across countries, including the United States, England and Wales, Switzerland, Slovenia and Spain (McGuire 2018 on behalf of HMPPS). Similar to the work of Schenk and Fremouw (2012), the characteristics of prisoners more likely to be violent were influenced by age, as younger prisoners are at a higher risk of committing a violent assault. However, further factors need to be considered, such as a prisoner’s history of pervious  violence in prison, convictions involving violence, as well as low self-control of anger and temper, mental health problems and antisocial attitudes. The prison environment is another element that also impacts on the level of violence among prisoners, including poor physical conditions, strict regimes and uneven application of rules. However, overcrowding was only weakly associated with violence, possibly due to staff interaction and availability of staff. When prisoners were engaged in purposeful activities, such as work and education, violence was less likely to occur, but when prisoners had fewer rules and less interaction with staff, such as free time, violence was more likely to occur (McGuire 2018).

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5.3 Sexual Violence in Prison Sexual violence within prison is underreported (Steiner and Wooldredge 2014) due to similar reasons for the underreporting of both verbal and physical violence, which includes the fear of retaliation. Prison culture and the unwritten convict code, of not reporting a crime, is evident for all violence in prison, although more so for sexual violence as prisoners who have witnessed an act of sexual violence are unlikely to report the incident. The underreporting of sexual violence is also due to embarrassment, self-blaming and not believing the incident was a sexual assault. More importantly, prisoners do not report sexual violence due to the fear of being transferred to segregation or solitary confinement or another prison. Segregation or solitary confinement is a form of punishment for prisoners who have committed a prison offence or have disrupted the prison regime. Prison authorities transfer a prisoner, who has been a victim of sexual violence, to either segregation/solitary confinement or another prison in the belief that this is for their own safety, but this is not necessarily the case (Miller 2010). The definitions of sexual violence, sexual assault and sexual victimisation vary, and these terms are often used interchangeably, which hinders the comparison of the limited data that is available. The WHO, Europe applies the definition of sexual violence as a behaviour that may include pressure to engage in sex, often referred to as sexual coercion, or aggressive intentions to have sex with another person (Modvig 2014). Sexual violence can also be described as sexual victimisation, which is defined as any non-consensual acts of sex, including oral, vaginal or anal penetration. Sexual victimisation also includes nonconsensual acts of sexual contact, which includes sexually threatening touching or grabbing of body parts (Wolff and Shi 2011). In the United Kingdom, the law defines and differentiates between rape, sexual assault and indecent assault as described by the Metropolitan Police: Rape is when a person intentionally penetrates another’s vagina, anus or mouth with a penis, without the other person’s consent. Sexual assault by penetration is when a person penetrates another person’s vagina or anus with any part of the body other than a penis, or by using an object, without the person’s consent. Indecent assault is an act of physical, psychological and emotional violation in the form of a sexual act, inflicted on someone without their consent. It can involve forcing or manipulating someone to witness or participate in any sexual acts. (Metropolitan Police 2022)

In England and Wales, the number of sexual assaults reported in 2021 have been identified by assailant and victim: 266 sexual assaults were prisoner on prisoner, 85 sexual assaults were prisoner on prison officer, 26 sexual assaults were prisoner on other, which includes other members of staff and volunteers working within the prison (Clark 2022). Sexual violence within prisons in England and Wales accounts for only 2% of reported violence. Data of sexual assaults in prisons in England and Wales from 2002 to 2014 identified 20% involved non-genital contact, 16% genital contact, 11% rape, 10% non-penile penetration, 2% sexual harassment, 1% sexual

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activity without consent, whilst 40% of sexual assaults had insufficient information recorded to categorise (Sondhi et  al. 2018). Of the 11% rape, 96% involved the allegation of a prisoner assaulting another prisoner; however, of the 20% of the non-­ genital contact assault, 69% involved the allegations of a prisoner assaulting someone who was not a prisoner (Sondhi et al. 2018). A further element, perhaps unique to prisons in England and Wales, is the classification of a sexual assault, which is decided by the victim; therefore, this may also add to the issues of underreporting of sexual violence. In the United States, the Prison Rape Elimination Act (PREA) was introduced in 2003, and as a result, information on both rape and sexual assault is collected from federal prisons and jails by law. PREA  includes specific  elements to support the elimination, reduction and prevention of both sexual violence and harassment in prison, which include zero-tolerance for any form of sexual abuse, prevention of sexual abuse as a priority, the implementation of the National Standards to Prevent, Detect, and Respond to Prison Rape (PREA Standards 2012) and accurate collection of data regarding incidence and prevalence of sexual abuse (U.S. Department of Justice 2013). Date gathered under PREA indicated 4% of prisoners in state and federal prison have experienced one or more incidences of sexual assault, which were committed by another prisoner or prison officer (Beck et al. 2014). Prisoners who have experienced sexual violence in England and Wales were, on average, aged 28 and of white ethnicity (73%) (Sondhi et al. 2018). This is similar to the profile of those who experienced sexual violence in prisons in the United States, as they were younger, those aged up to 34, of white ethnicity, higher education and/or convicted of a violent sex offence (Beck et al. 2010). A contemporary study in the United States, which explored the profile of prisoners who were perpetrators of sexual violence, identified perpetrators were Black (87%), unmarried (90%), no high school education (76%), no job whilst in prison (87%), convicted of a violent offence (80%), no prior sex offence (92%), but did have a higher number of previous admissions to prison and had been in prison longer than those who did not commit sexual violence (Hilinski-Rosick and Freiburger 2021).

5.4 Women Prisoners, Violence and Abuse Many women in prison have experienced either domestic violence or abuse, which may be an underlying reason for drug and alcohol misuse and/or self-harm (MacDonald 2013). Violence against women by men is referred to as ‘gender-based violence’ and is defined by the UN Declaration on the Elimination of Violence Against Women (1993) as: … any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life. (Article 1, p. 1)

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Gender-based violence within the UN Declaration encompasses domestic abuse, sexual violence, rape, stalking, harassment, trafficking of women, female genital mutilation, intimidation, or harassment at work, in education or in public, forced prostitution, forced marriage and honour crimes. The inclusion of gender-based violence in the UN Declaration highlights violence against women is usually due to gender inequality. The inequality of women has occurred as a result of the discrimination in opportunities, but also due to the limitations to and control of resources compared to men (Krantz and Garcia-Moreno 2005). Women’s experience of gender-based violence may be a direct cause of their engagement in crime. In the United States, 60% of women serving a life sentence had experienced sexual abuse and 80% had experienced both physical and sexual abuse (Leigey and Reed 2014). In England, 57% of women in prison had experienced some form of domestic violence, although this is likely to be only a fraction of the true prevalence of violence, as the charity women in prison identified that 79% of women who used their services had experienced domestic and/or sexual abuse (Prison Reform Trust 2017, 2021). The coercive nature of both physical and sexual abuse by a partner was discussed by 60% of women in prison. The coercive nature of these relationships led to the fear of further abuse if they did not comply with their partners wishes, which directly led to their involvement in criminal activity (Prison Reform Trust 2017). The fear instilled in these women prevented them from being able to report offences to the appropriate authorities, which ultimately led to the women becoming both a victim and perpetrator and serving long prison sentences. In all prisons, the understanding of a woman’s history of gender-based violence is essential, as women who have been a victim and become a perpetrator may be traumatised by both experiences. Therefore, elements of a prison environment may be very distressing for these women, such as unexpected loud noises, including shouting by prisoners and prison staff, which may be interpreted as aggressive and provoke unpleasant and traumatic memories (Jewkes et al. 2019). An element that may be particularly difficult and distressing for these women is physical contact with officials such as physical and strip searches (Elliot et al. 2005). Because of past abusive and coercive relationships, it is possible that when women enter prison, they begin reflecting on their actions, including the crimes they committed, which may cause feelings of guilt and regret, possibly leading to self-harm and suicide (Crewe et al. 2017). In England, in 2016, 12 self-inflicted deaths in prison involved women (Independent Advisory Panel on Deaths in Custody 2017). In prisons across 21 states in the United States, between 2003 and 2015, there were 176 self-inflicted deaths involving women, referred to as suicide completion, 93% of which were death by hanging (Mennicke et al. 2021). Finally, women in prison may continue to be sexually abused by the people who are there to ensure their safety, prison guards/officers. In prisons in England and Wales, information on the abuse of women prisoners by prison staff is difficult to obtain, and it ‘is not known whether abuse by prison staff is rare, widespread or systemic’ (The Howard League for Penal Reform 2014, p. 7). In the United States,

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sexual abuse against women in prison by male prison guards is endemic (Stern 2018). In both the United States and England and Wales, the majority of female prisons are staffed by male prison guards/officers, who have complete control over the women and their movements, and therefore it is to be expected that any abuse that may occur will not be reported. Women in prison have nowhere to hide from prison guards/officers who hold all the power because of power dynamics of the prison, which may explain their fear of retaliation and their silence of the abuse that occurs.

6 The Culture of Prisons The last section of this chapter will introduce prison culture to support the reader to place all the information presented in the proceeding chapters in the context of the unique culture within prisons. Prison culture will be explored through the prison code, which defines behaviours, beliefs and interactions of prisoners with both fellow prisoners and prison guards and officers. A further element of prison culture is the development of a hierarchy of prisoners by prisoners, which is reinforced by prison guards and officers, the hierarchy will be introduced and the implications for prisoners will be discussed. Whilst reading this section, it must be acknowledged that prison culture varies not only between prisons but also within prisons, varying from wing to wing. The changes in prison culture may be due to the specific population of prisoners within a prison or more specifically within a wing, the ethos and focus of the leaders or governors of the prison, the security level of the prison and the relationships been prison staff and prisoners (Crawley 2004; Bryans 2007). Lastly, prison slang will be introduced, many of the terms applied within prison correspond to criminal behaviour, life in prison, legal cases or different types of prisoners. A list of slang and definitions will be included, which are used within Prison Service of England and Wales. Once again, it must be recognised both prison slang and varies across prisons, regions and countries.

6.1 The Prison Code Prison culture is a concept, which has been developed over many decades, and involves both the values and norms of prisoners as well as their beliefs. The understanding of prison culture is imperative for new prisoners, as the culture of the prison will dominant their life whilst in prison. Prisoners will need to both belong and comply with prison culture through the unwritten convict, inmate or prison code. The prison code has developed throughout history as a result of prisoners’ experiences of serving a prison sentence and interacting with prison staff. Prisoners experience oppression from prison staff and the prison regime, as well as a lack of freedom, autonomy, material items, security and intimate relationships (Mitchell et al. 2021). From these experiences, prisoners have tried to create or restore a sense of meaning and status through the development of their own rules in their own code.

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The prison code also provides prisoners with a sense or guidance on how to behave whilst in prison. The most recent definition of the convict code is by Mitchell (2018): An inmate-defined and -regulated culture consisting of a set of values that govern behaviours and interactions with inmates and correctional staff (p. 3).

Elements of the prison code include the importance of never informing on other prisoners, for prisoners to do their time respectfully, to mind their own business, not let anyone take advantage of them, and never be too friendly with a prison guard or officer (Mitchell 2018; Mitchell et al. 2021). Prisons where regimes are strict and oppressive are prisons where the prison code flourishes, as the code provides prisoners with a sense of solidarity, but also the feeling of a sense of power over their individual choices and actions. Adherence to the prison code does vary amongst prisoners, and there is a wealth of information on factors that impact on adherence, although this data was prior to mass incarceration and may be out of date as it was conducted in the 1960s and 1970s. However, this body of work has been summarised by Mitchell (2018), who identified that prisoners were more likely to adhere to the prison code if they were older, had less education, came from a lower-class background, had a criminal history, and had a higher number of previous arrests (Mitchell 2018).

6.2 The Hierarchy of Prisoners The prison code expands beyond behaviours and includes both status and mutual respect, which informs an unwritten code of the status or hierarchy of different prisoners. For example, prisoners who are convicted of more serious and violent crimes and have served longer in prison are provided with more respect. In the United States, older prisoners who have been on the same wing for a long period of time are perceived by other prisoners as both more powerful and influential, as local knowledge is important in gaining status (Kreager et al. 2017). In contrast, prisoners who have informed on other prisoners are towards the bottom of the hierarchy, with prisoners convicted of child sex offences at the bottom (Weinrath 2016; Meško and Hacin 2018). However, another element that informs the hierarchy of prisoners is due to the sex segregation of prisons and places prisoners who identify as non-­ heteronormative, including transgender prisoners, at the bottom of this hierarchy, which leaves these prisoners open to abuse (Jenness and Fenstermaker 2014, 2016).

6.3 Prison Slang Prison slang develops and changes over time, between wings, prisons and countries. The below list is just an example of some of the slang used within prisons (Table 1), and this information is from personal experience and the work of (Mulvey 2022). This work included the exploration of lexical terms in one session with six prisoners in HMP Winchester, of which a full glossary contained over 1000 items.

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Table 1  Slang words and terms Slang words or terms A four, a seven or an eight All dayer All dayer and a night Animals, wrong-uns, bacon or bacon-head, beast, nonce Bang or banging weights Bang or banging out Bare Bash or knock one out or knocking one out Basic or put on basic Bend or bending up Wrap or wrapping up Bird and doing bird Blag or blagging Bomb squad Brew Burn, snout, batts, skins, veras Cage Carpet Catching a ride Cell or winda warrior Chin check Chow or nosh in the mess or mess hall Cowboy Down the brink Drum or drumming Echo E-Man Ghost, ghosting or to be ghosted Gov

Meaning These terms represent the length of a prisoner’s sentence A prisoner who is serving a life sentence A prisoner who is serving a life sentence without parole All refer to prisoners who have been convicted of sexual offences with children Prisoners in the gym lifting weights or working out One prisoner punching or hitting another prisoner, with the aim to knock them down When a prisoner has a lot of something, such as ‘I have bare biscuits’ Refers to the act of masturbation When prisoners are confined to their cell and all privileges are removed, such as television and books The process of restraining a prisoner in their cell before moving him to either another part of the prison or out of the prison Bird is simply time in prison, and doing bird is to spend time in prison To steal or stealing The squad in this context is a set of prisoners sent to clean up after excrement has been thrown from prison windows Alcohol Burn and snout refers to tobacco, whereas batts are cigarettes, skins or veras refer to cigarette papers, veras is from the cockney rhythm of Vera Lynn A prisoner’s cell This refers to either a 3-month or 3-year sentence, and originates from the time for prisoners to make a rug for their cell A prisoner is high on drugs that were given to them by another prisoner A cell warrior is a prisoner who is loud and shouts when in his cell or through a window, but in face-to-face interactions is perceived as a coward When a prisoner is perceived as not adhering to the prison code, another prisoner may punch them on the jaw Food may be referred to as chow or nosh, and served in the mess or mess hall This is a term that is sometimes used to refer to a new prison guard or officer A prisoner has been removed from their cell and has been placed in segregation These words refer to a house and burgling a house The allocated space for prisoners to exercise, also referred to as the exercise yard This term is applied to a prisoner who has tried to escape from custody Ghost or ghosting refers to the removal of a prison without warning, whereas to be ghosted refers to a prisoner attending the visitor centre, but their visitor did not attend Refers to a prison officer, not necessarily the governor of the prison (continued)

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Table 1 (continued) Slang words or terms Grass or snitch Jam or jam roll Jammer or shank or shiv

Meaning A prisoner who informs on illegal activity of other prisoners This is from the cockney rhythm of jam role and refers to parole A form of homemade knife made from varies objects including toothbrushes Kanga This is from the cockney rhythm of kangaroo, which rhythms with screw, and refers to prison officers Lock or locking down All prisoners are locked in their cells, and this may be due to the usual prison regime or due to an incident or a lack of staff to support prisoners’ movements Nicker This is from the cockney rhythm for vicar Nosh This term may refer to either food or a blow job Rub or rubbing down or spin, These terms refer to the searching of a prison cell by prison spinning guards Rush or rushing in The act of prison guards entering a cell to restrain a prisoner prior to being moved Shipped or shipping out When a prisoner is transferred to another prison without any warning Sweeper This refers to a prisoner who collects cigarette butts Swing or swinging a line A means of prisoners communicating between cells by swinging a message on string Tear or tearing up, whack or These terms refer to either the beating up of a prisoner by whacking up, raze or razing another prisoner or the cutting or stabbing of a prisoner drawing blood up, wet or wetting up Vanilla This is from the cockney rhythm vanilla fudge, which refers to a judge

7 Conclusion This chapter explored current prison population, including how many people are in prison, their age, sex, gender and ethnicity, and worldwide ageing prison population due to longer prison sentences and the convictions of historical offences. The definitions of sex and gender have been discussed and the implications for prisoners identified, as well as the impact of a binary system for prisoners who identify as transgender. Overrepresentation of minoritised ethnicities in prison has been introduced and the reasons why this continues in the twenty-first century. The final sections of this chapter have discussed the culture of prison environments, unwritten rules created and adhered to by prisoners, as well as some prison slang.

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Struckman C, Struckman D (2006) A comparison of sexual coercion experiences reported by men and women in prison. J Interpers Violence 21(12):1591–1615 Sturge G (2021) UK Prison population statistics. https://researchbriefings.files.parliament.uk/ documents/SN04334/SN04334.pdf. Accessed 15 June 2022 Sylla M, Harawa N, Grinstead Reznick O (2010) The first condom machine in a US jail: the challenge of harm reduction in a law and order environment. Am J Public Health 100(6):982–985 Tewksbury R, Connor DP (2014) Who is having sex inside prison? Deviant Behav 35(12):993–1005 The Howard League for Penal Reform (2014) Sex in prison: experiences of former prisoners. https://howardleague.org/wp-­content/uploads/2016/03/Sex-­in-­prison-­web.pdf. Accessed 15 June 2022 The Sentencing Project (2017). Still life: America’s increasing use of life and long-term sentences. https://www.sentencingproject.org/wp-­content/uploads/2017/05/Still-­Life.pdf. Accessed 20 June 2022 The Sentencing Project (2021) The color of justice: racial and ethnic disparity in state prisons. https://www.sentencingproject.org/wp-­content/uploads/2016/06/The-­Color-­of-­Justice-­Racial-­ and-­Ethnic-­Disparity-­in-­State-­Prisons.pdf. Accessed 20 June 2022 Tonry M (2013) Sentencing in America, 1975-2025. Crime Justice 42(1):141–198 Tubex H, Brown D, Freilberg A, Gelb K, Sarre R (2015) Penal diversity within Australia. Punishment Soc 17(3):345–373 U.S. Department of Justice (2013) Implementing The Prison Rape Elimination Act: a toolkit for jails. https://s3.amazonaws.com/static.nicic.gov/Library/026880.pdf. Accessed 15 June 2022 UN Declaration on the Elimination of Violence Against Women (1993). http://www.un-­documents. net/a48r104.htm. Accessed 15 June 2022 Weinrath M (2016) Behind the walls: inmates and correctional officers on the state of Canadian prisons. University of British Columbia Press, Vancouver Williams BA, Stern MF, Mellow J, Safer M, Greifinger RB (2012) Ageing in correctional custody: setting a policy agenda for older prisoner health care. Am J Public Health 102(8):1475–1481 Wolff N, Shi J (2011) Patterns of victimization and feelings of safety inside prison: the experience of male and female inmates. Crime Delinq 57:29 World Health Organization (2002) The World report on health and violence. https://www.who.int/ publications/i/item/9241545615. Accessed 15 June 2022 World Health Organization (2018) Ageing and health. https://www.who.int/news-­room/fact-­ sheets/detail/ageing-­and-­health. Accessed 17 June 2022 World Health Organization and US National Institute on Aging (2011) Global health and ageing. https://www.who.int/ageing/publications/global_health.pdf?ua=1. Accessed 17 June 2022 World Health Organization, Europe (2011) Gender and health. https://www.who.int/health-­topics/ gender#tab=tab_1. Accessed 15 June 2022 Yasin B, Sturge G (2020) Ethnicity and the criminal justice system: What does recent data say on over-representation? https://commonslibrary.parliament.uk/ethnicity-­and-­the-­criminal-­justice-­ system-­what-­does-­recent-­data-­say/. Accessed 16 June 2022 Yorston GA (2015) Managing aggression and violence in older people. The Royal College of Psychiatrists, London Yorston GA, Taylor PJ (2006) Commentary: older offenders – no place to go? J Am Acad Psychiat Law 34(3):333–337 Zawilska JB, Andrzejczak D (2015) Next generation of novel psychoactive substances on the horizon – a complex problem to face. Drug Alcohol Depend 157:1–17

Healthcare in Prison Joanne Brooke

This chapter contains a case study of primary and mental health care provision in HMP Birmingham.

1 Human Rights of Prisoners to Healthcare This section will commence with a brief over of the Universal Declaration of Human Rights (1948) as established by the United Nations (UN), and the International Convention on Elimination of All Forms of Racial Discrimination (1965), International Covenant on Civil and Political Rights (1966), the International Covenant on Economic, Social and Cultural Rights (1966) and the Convention on the Elimination of All Forms of Discrimination Against Women (1979). However, this section will focus on the Standard Minimum Rules for the Treatment of Prisoners [The Nelson Mandela Rules] (United Nations 2015). The Standard Minimum Rules for the Treatment of Prisoners were first introduced in 1955 and remained unchanged for 60 years. The main focus of this discussion involves section B of part two of the Nelson Mandela Rules (2015), which defines the human rights of prisoners who require access to healthcare.

1.1 Universal Declaration of Human Rights (1948) The Universal Declaration of Human Rights (1948) is a statement of principles. The Declaration of Human Rights (1948) is not legally binding, but the principles within the declaration are agreed by all countries who are members of the United Nations J. Brooke (*) Centre of Social Care, Health and Related Research, Birmingham City University, Birmingham, UK e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 J. Brooke (ed.), Nursing in Prison, https://doi.org/10.1007/978-3-031-30663-1_2

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(UN). Originally, there were 51 member states or countries of the UN, which has grown to 193. The development of the UN was formed following the second world war with the aim of supporting the human rights of all individuals, through “peace, dignity, and equality, on a healthy planet” (UN 2022). The Declaration of Human Rights (1948) was the first document to state all human beings are equally entitled to rights and freedoms and has subsequentially become the gold standard for measuring human rights. This document is now the most translated in the world and has been translated into 512 languages (UN 2018). The Declaration of Human Rights (1948) contains 30 statements, which are referred to as articles, a brief overview of each article is provided in Table 1, however, it is important to remember: Because they (human rights) are inherent to every woman, man and child, the rights listed in the 30 Articles are indivisible—they are all equally important and cannot be positioned in a hierarchy. No one human right can be fully realised without realising all other rights (UN 2018). Table 1  Overview of the Declaration of Human Rights (1948) Article Article 1

Definition We are All Born Free and Equal This article recognises we are all born free and equal, and therefore we all entitled to the same respect and rights, whilst simultaneously showing respect and recognising the rights of our fellow human beings. Article 2 Freedom from Discrimination This article recognises all human beings have the right to all articles within this declaration without any form of discrimination. This includes the right not to be discriminated against because of a human being’s gender, ethnicity, colour, but also national or social origin, language, religion and political beliefs. Article 3 Right to Life This article reinforces the right of all human beings to life, and a life that is free and secure. Article 4 Freedom from Slavery This is a specific article against slavery, and clearly states no human being is to be held as a slave, and the slave trade to be banded in all countries. Article 5 Freedom from Torture This is a specific article against torture, and clearly states no human being will be tortured or receive a punishment that is cruel or degrading. This article refers to all circumstances, including those who are serving a prison sentence. Article 6 Right to Recognition Before the Law This article states each human being has the right in every country to be recognised as a person in the law of that country. Article 7 Rights to Equality Before the Law This article reinforces all human beings are equal, and this includes being equal before the law and equally protected by the law without any form of discrimination. Article 8 Right to Remedy This article refers to the right of all human beings to both support and protection by the law when one of their human rights has been violated. Article 9 Freedom from Arbitrary Detention This article identifies no human being can be arrested, imprisoned or exiled due to the choice or possible whim of another human being. Article 10 Right to a Fair Trial This article reinforces the right of each human being as equal, and therefore all human beings are entitled to a fair and public trial, which is overseen by an independent and impartial judge and a jury.

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Table 1 (continued) Article Definition Article 11 Presumption of Innocence and International Crimes There are two elements to this article: first, the right of each human being to be presumed innocent of a crime prior to being found guilty in a court of law following the provision of an adequate defence. Second, the time of the offence must be considered as no human being can be found guilty of an offence that was not an offence at the time it was committed, which allows for changes in the law over time. Article 12 Right to Privacy This article enforces the right of each human being of the right to privacy, which includes privacy for their families, correspondence, but also their reputation. Article 13 Freedom of Movement This article identifies the right of each human being to the freedom of travel, which includes movement within their own country, but also the freedom to leave their country and then return, with no negative consequences. Article 14 Right to Asylum This article identifies the right of each human being to seek and obtain asylum when they are being persecuted in their own country. This does not apply if the person has been involved in non-political crimes that contradict others human rights. Article 15 Right to Nationality This article states each human being has a right to a nationality, and they cannot be deprived of this status. This article also encompasses the right of a person to change their nationality. Article 16 Right to Marry and to Found a Family There are two elements to this article: first, both men and women, who are of legal age, may marry freely and have a family, without limitations, such as race, nationality or religion. Second, those who enter into a marriage only do so once they have provided free and full consent. Article 17 Right to Own Property This article reinforces each human being is equal, and therefore states each human being has the right to own property, and once owned, whether alone or with other people, will not be deprived or denied the property. Article 18 Freedom of Religion and Belief There are two elements to this article: first, the right of each human being to the freedom of thought and to engage in either religious or other beliefs at home or within their community. Second, the right and freedom of each human being to change their religious or other beliefs. Article 19 Freedom of Opinion and Expression This article refers to the right and freedom of each human being to hold their own opinions, but also the right and freedom to express these opinions. Article 20 Freedom of Assembly and Association There are two elements to this article: first, each human being has the right and freedom to form groups and engage in peaceful meetings, and second, nobody should be forced to belong to a group or to attend a meeting. Article 21 A Short Course in Democracy There are two elements to this article: first, each human being has the right to be involved in the government of their country, either through being an active member or through a voting system, which supports representation. Second, each government is elected for a defined period by an election, which involves secret voting of the country’s population. Article 22 Right to Social Security This article refers to the right of each human being to social security, including access to work, social and cultural activities, which enables each individual to do their best and the freedom to develop their own interests, views and personality. (continued)

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Table 1 (continued) Article Definition Article 23 Right to Work There are three elements to this article: first, the right of each human being to work, but also to choose their occupation, where they work, in conditions that are favourable, and without the risk of losing their job. Second, the right to equal pay for the same work. Third, the right for each working human being to have the right and freedom to join a trade union to both support and project them. Article 24 Right to Rest and Leisure This article identifies the right of each working human being to both rest and leisure time, supported through limitations of hours worked and holidays with pay. Article 25 Right to Adequate Standard of Living There are two elements to this article: first, each human being has the right to resources to maintain an adequate standard of living, to enable access to sufficient food, clothing, housing and healthcare. Resources include financial support for those who cannot work due to unemployment, sickness, disability, bereavement or retirement. Second, the need for specific care and support for expectant mothers and babies, and all babies when born have the same rights as all human beings. Article 26 Right to Education There are two elements to this article: first, each human being has the right to education, and this article further identifies education for children of primary school age should be free. However, all education should support the development of each student providing them with an understanding of human rights and both tolerance and understanding of different people, countries and religions. Second, all parents have the right and freedom to choose the type of education their children receive. Article 27 Right to Cultural, Artistic and Scientific Life There are two elements to this article: first, each human being has the right and freedom to be involved in cultural activities, arts and science and benefit from advances. Second, each human being has the right to both the moral and material interest resulting from their work. Article 28 Right to a Free and Fair World This article identifies the need for a social and peaceful world for rights and freedoms defined within this Declaration of Human Rights to be fully realised by each human being. Article 29 Duty to Your Community This article identifies the importance of community, and each human being has not only the right, but the duty to support their community and in turn this will support them to reach their full potential. The only occasion when rights and freedoms of individuals may be limited is when this is necessary to maintain both morals and laws in a democratic society. Article 30 Rights are Inalienable The final article identifies that the rights and freedoms of human beings need to be considered and no acts or plans to act should interfere with the rights and freedoms as stated within this Declaration of Human Rights. This includes acts or plans to act by individuals, governments or collective groups. Adapted from UN Universal Declaration of Human Rights (2015)

The Declaration of Human Rights (1948) has informed the development of four important legally binding conventions/covenants, which are: First, under the International Convention on Elimination of All Forms of Racial Discrimination (1965), members/countries of the UN are legally

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bound to proactively address and eliminate all forms of racial discrimination, whilst also promoting an understanding of differences and promotion of tolerance. Second, International Covenant on Civil and Political Rights (1966a), which supports the human rights of individuals to identify and progress their own life, including goals of employment, social, cultural and political activities, and the ability to dispose of their income as they wish. This Right can only be restricted during a national or an international emergency, for example  to prevent the spread of COVID-19, when movement, and social and cultural activities of people were restricted by law. Third, the International Covenant of Economic, Social and Cultural Rights (1966b), which supports the rights of all human beings to an adequate standard of living, education and working environment, through social security and parental leave to enable engagement in cultural activities. Fourth, the Convention on the Elimination of All Forms of Discrimination Against Women (1979), which enforces all governments of the UN to support and advance the equality of women, and ensuring their rights are developed and respected within employment, political, public and cultural activities. This was the first law to identify discrimination against women as illegal, and states their rights to education, employment and health and social benefits.

1.2 Standard Minimum Rules for the Treatment of Prisoners [The Nelson Mandela Rules] (2015) The first Standard Minimum Rules for the Treatment of Prisoners was introduced in 1955 and the Rules were not changed or amended until 2015. A review of the Rules was essential due to the implementation of various human rights declarations and conventions in the 1960s and 1970s, as described above. The review commenced in 2011 and the new rules were agreed in 2014 and published by the UN in 2015. The new rules are referred to as the Standard Minimum Rules for the Treatment of Prisoners [the Nelson Mandela Rules] (2015). The new name of the Rules was to honour the legacy of Nelson Mandela, who spent 27 years in prison. The Nelson Mandela Rules (2015) contain eight areas of guidance including respect for prisoners’ inherent dignity, medical and health services, disciplinary measures and sanctions, investigations of deaths and torture in custody, protection of vulnerable groups, access to legal representation, complaints and independent inspection and training of staff. Not all of these areas will be discussed, only those relevant to prisoners’ health, social and well-being; however, it must be acknowledged the Nelson Mandela Rules (2015) are: …not intended to describe in detail a model system of penal institutions. They seek only on the basis of the general consensus of contemporary thought and the essential elements of the most adequate systems of today, to set out what is generally accepted as being good principles and practice in the treatment of prisoners and prison management (United Nations 2015).

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The Nelson Mandela Rules (2015) are divided into two parts with 122 rules. The first part contains rules (1–85) regarding the general management of prisons and is applicable to all types of prisoners, such as those on remand, and those who have been convicted of a crime and are serving their sentence. The second part is divided into further sections, rules (86–108) are specifically for supporting prisoners who have been convicted and serving their sentence, rules (109–110) are specifically for prisoners with health conditions, including both physical and mental health conditions and disabilities, rules (111–120) regard prisoners on remand, those awaiting in prison for a trail, rule (121) regards civil prisoners and the final rule 122 for prisoners who have been detained in prison without a charge.

1.3 Section 1: Rules of General Application The first five rules stating the basic principles of the Nelson Mandela Rules (2015) will be explored below, the understanding of these rules and principles is essential as all further rules are underpinned by these principles. The basic principles of the Nelson Mandela Rules (2015) can be directly mapped onto the Declaration of Human Rights (1948). This approach reinforces the rights of each human being, including those who are currently prisoners, and identifies only specific rights have been removed, such as freedom of movement. Rule 1  This rule states each prisoner is required to be respected and treated with dignity due to their value as a human being, whilst ensuring the safety and security of all prisoners, those who work in a prison and the prisoners’ visitors. Treating a prisoner with respect and dignity enforces an important part of this rule which is “no prisoner shall be subjected to, and all prisoners shall be protected from, torture and other cruel, inhuman or degrading treatment or punishment, for which no circumstances whatsoever may be invoked as a justification” (p.  2). This principle underpins each interaction by staff with a prisoner, including prison staff, volunteers and health and social care professionals. Rule 2  This rule is to ensure all the rules are applied impartially and without discrimination, which includes “race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or any other status” (p. 2). Furthermore, the rule states religious, spiritual and moral beliefs of prisoners will be respected. This rule requires prison administrations to identify individual prisoner’s needs and to implement measures to protect and promote the rights of prisoners without discrimination, especially prisoners who may be considered vulnerable. Rule 3  This rule recognises the suffering inflicted on prisoners due to removing the individual from society and their place in society, depriving them of the right of independence, autonomy and freedom. Therefore, prison administrations should not exacerbate a prisoner’s suffering, unless there is an explicit reason to justify further separation to maintain the discipline within the prison.

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Rule 4  This rule emphases the purpose of a prison sentence, which is both the deprivation of a person’s freedom to protect society and to reduce recidivism. The term recidivism refers to the rate of reoffending of prisoners on release from prison. Recidivism and reintegration into society upon release from prison can only be achieved if prison administrations work collaboratively with other external institutions, and together “offer education, vocational training, and work, as well as other forms of assistance that are appropriate and available, including those of a remedial, moral, spiritual, social and health- and sportsbased nature” (p.  3). Programmes offered within prisons need to encompass individual treatment needs of prisoners, which may include programmes to address crimes such as child sexual offences or an uncontrollable impulse to start a fire. Rule 5  This rule emphases the need for prison administration to ensure the prison regime minimises the difference between prison life and life in society, especially elements of prison life that may remove further responsibilities of the prisoner or impact on the respect and dignity provided to prisoners. This rule encompasses elements of reasonable adjustments for each prisoner with regards to their physical and mental health and any other disabilities, to ensure they have full and equal access to programmes and amenities within the prison. Rules 6–23  encompass practical elements of prison administration and the rights of prisons such as prisoner file management, separation categories, accommodation, personal hygiene, clothing and bedding, food, and exercise and sport. Rules 24–34 explicitly relate to healthcare services for prisoners and are discussion in depth below. All healthcare professionals working in a prison, or students attending a clinical placement within a prison, should be aware of the rights of prisoners to healthcare and ensure these standards are met. Rule 24  The provision of healthcare services for prisoners is not the responsibility of the prison but the responsibility of the State. Prisoners are entitled to access and receive the same standard of healthcare that is available in the community, which should be both free of charge and discrimination. The provision of healthcare services is required to be organised in collaboration with community healthcare services to support continuity of care when prisoners have completed their sentence and released. Rule 25  Healthcare provision should be in place in each prison and include “a health-care service tasked with evaluating, promoting, protecting and improving the physical and mental health of prisoners, paying particular attention to prisoners with special health-care needs” (p. 8). Therefore, healthcare provision will need to be staffed by an interdisciplinary team, who have expertise in primary health care, forensic health, including psychiatrists, psychologists and dentists.

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Rule 26  All healthcare services are required to maintain accurate, current and confidential medical notes for each prisoner. A prisoner can request access to their medical notes during their prison sentence, or a prisoner can nominate a third party to access their medical notes on their behalf. On the release of a prisoner, their medical notes should be transferred to the relevant health authority, subject to confidentiality agreements. Rule 27  In the case of medical emergencies, each prisoner will have access to prompt medical attention. Prisoners who may require surgical or specialised treatment will be transferred to the most appropriate institution, either a prison hospital or a civil hospital. If this is a prison hospital, the hospital will be both adequately staffed and equipped to provide the same standard of care as a civil hospital. An important element of this rule involves the recognition only a healthcare professional can make a clinical decision regarding a prisoner’s health and their need for urgent medical care. Once this decision has been made, it cannot be overruled or ignored by a member of the prison staff. Rule 28  All women prisoners who are pregnant will receive appropriate prenatal and postnatal care and treatment. When possible or practicable the birth of all children should be planned to occur outside of the prison. However, if this is not possible, and a child is born within a prison, this fact will not be entered on their birth certificate. Rule 29  In some circumstances a decision based on the best interest of a child may allow the child to stay with a parent in prison. When this occurs, specific provisions are required, which include childcare facilities either inside or outside of the prison, which are staffed by qualified professionals, and a place where the child can be placed when not with their parent, but also child-specific healthcare services, for screening and monitoring of the child’s development by appropriate healthcare professionals. Children who are with their parents in prison “shall never be treated as prisoners” (p. 9). Rule 30  Each prisoner who enters a prison will be reviewed by a physician or a qualified healthcare professional as soon as possible. The review of each prisoner on entering the prison is to identify healthcare needs, including current prescribed medications, identify any ill-treatment of the prisoners prior to their arrival and to identify any signs of psychological stress due to entering a prison, which may include a risk of self-harm, suicide or withdrawal from substances. Prisoners on entering the prison should be screened for contagious diseases and provided appropriate precautions, and this is particularly important due to the COVID-19 pandemic. Finally, the review will support the identification of prisoners’ ability to work, experience and possible engagement in other prison activities. Rule 31  When prisoners become ill, a physician or a qualified healthcare professional will review the prisoner daily. All medical examinations of prisoners, whether for physical examinations or mental health assessments, will be completed in full confidence between the healthcare professional and the prisoner.

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Rule 32  The relationships of physicians or other qualified healthcare professionals and prisoners are governed by the same ethical and professional standards applied in the community. First, the prevention, diagnosis and treatment based on the prisoner’s clinical needs. Second, respecting a prisoner’s autonomy with regard to decisions regarding their own health and obtaining their informed consent for any procedures. Third, the maintenance of confidentiality of medical information, unless there is a risk of imminent threat or danger to the prisoner or to others. Fourth, this has been included due to the history of medical abuse of prisoners “an absolute prohibition on engaging, actively or passively, in acts that may constitute torture or other cruel, inhuman or degrading treatment or punishment, including medical or scientific experimentation that may be detrimental to a prisoner’s health, such as the removal of a prisoner’s cells, body tissues or organs” (p. 10). However, prisoners may be involved in health research if these studies have gained all the necessary ethical approvals in law, and prisoners provide free and informed consent to participate. Rule 33  A physician or other qualified healthcare professional is responsible to report to the prison governor when they have identified that a prisoner’s health, either physical or mental, has been or will continue to be negatively impacted on by being in prison. Rule 34  During an examination of a prisoner, if a physician or other qualified healthcare professional identifies signs of torture or other cruel, inhuman or degrading treatment or punishment, this will be documented and reported to the prison administration and the appropriate judicial authority. During this process, safeguards will be implemented to maintain the confidentiality of the prisoner or associated others to prevent any further harm. Rule 35  Healthcare professionals or a public health representative are involved in regular inspections of the provision of appropriate food, cleanliness of the prison, including sanitation, temperature, lighting and ventilation, clothing and bedding, as well as access to physical exercise and sports. The inspections are reported and discussed with the prison service to ensure any concerns are addressed. The remaining rules (36–85) within section 1 encompass restrictions, discipline and sanctions, instruments of restraint, searches of prison cells, information to and complaints by prisoners, contact with the outside world, books, religion, retention of prisoners’ property, notifications, investigations, removal of prisoners, institutional personnel, internal and external inspections. Healthcare professionals working in a prison should be aware of the remaining rules within section 1, within their role of duty of care to each prisoner.

1.4 Section 2: Rules Applicable to Special Categories Section 2 is divided into sections from A to E.  Section A focus on prisoners under sentence (rules 86–108) and includes guiding principles, treatment of prisoners, classification and individualisation, privileges, work, education and

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recreation, social relations and after care. Section B focus on prisoners with mental disabilities and/or health conditions, and only contains two rules (109–110), but both are important for healthcare professional to understand. First, prisoners who are found to be not criminally responsible for their crime, or whilst during their prison sentence are diagnosed with a severe mental illness or health condition, especially illnesses or conditions that are exacerbated by being in prison, should not continue to be detained in prison. These prisoners should be transferred to an appropriate specialised facility for care, support and treatment by healthcare professionals. Second, healthcare services need to provide adequate facilities and provide psychiatric treatment for all prisoners who require this specialised support. This approach is required to support the continuation of psychiatric care, support and treatment following prisoners official release from prison.

2 Organisation and Delivery of Healthcare Within Prisons This section will commence with the 12 key elements of healthcare in prisons as suggested by the World Health Organization (WHO), Europe (2014) and explore how these has been implemented in England. NHS England has been responsible for the provision of healthcare for prisoners since 2013, through a collaboration with Her Majesty’s Prison and Probation Service (HMPPS), Public Health England (PHE) and, more recently, the Ministry of Justice (MoJ) and the Department of Health and Social Care. The delivery of healthcare within prisons in England is guided by the National Partnership Agreement for Prison Health 2018–2021 (HM Government and NHS England 2018), which will be discussed. However, there are elements of healthcare provision to prisoners that still require further development, which will be identified, and recommendations discussed. Finally, an example of healthcare within a prison within England will be presented to provide an overview of services in one prison.

2.1 Principles of Healthcare in Prison The WHO, Europe (2014) identified 12 essential elements of healthcare services in prisons, which are closely aligned to both the Declaration of Human Rights (1948) and the Nelson Mandela Rules (2015). The 12 elements include: 1. The State is responsible for the provision of healthcare services for those detained in prison to ensure all prisoners’ human right to health is achieved. 2. Primary healthcare must be provided within all prisons and be accessible to all prisoners, and this must include appropriate healthcare professions, resources and facilities, and the standard of this provision needs to be at least the same standard of primary healthcare provided in the community.

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3. All healthcare professionals working within a prison will be employed by a local health authority and have total independence from the prison administration, and the prison administration will need to accept and expect healthcare professionals to practice within the code of conduct of their regulatory body. 4. All prison staff are required to understand that prisoners are treated as patients by healthcare professionals, and this treatment is the same as healthcare professional would provide to a patient in the community. 5. When a prisoner becomes a patient, they have the right to confidentiality, treatment and care that is provided by healthcare professionals following informed consent. 6. The importance of initial health screening and evaluation of prisoners on arrival at a prison is essential, and this service must be resourced by healthcare professionals, who are able to divert prisoners to other appropriate or specialised institutions if necessary. 7. The continuity of care of prisoners should be facilitated by both prison administration and healthcare professionals to ensure continuous access of care when the prisoner is moved to another prison and on completion of their sentence. 8. The health of prisoners should be protected by ensuring they are not exposed to hazards that may impact on their health. 9. The health of prisoners is not the sole responsibility of healthcare professionals; all prison staff are required to have appropriate training in health and understand how their role can support the work of healthcare professionals and enable healthy prison environments and regimes. 10. The concept of health resilience needs to be addressed and included in healthcare provision to support prisoners’ health following release from prison and to reduce their health inequalities when compared to those living in the community. 11. Healthcare services within prisons need to influence the health of prisoners when they are released, including both attitudes and behaviours towards a healthy lifestyle. 12. Healthcare services within prisons cannot work in isolation and need to be integrated into national healthcare systems to ensure continuity of care for prisoners.

2.2 Healthcare in Prisons in England Healthcare provision in prisons in England is outlined in the National Agreement for Prison Healthcare in England 2018–2021 (on writing this agreement is in the process of being updated) and occurs through the inclusion and collaboration of five partners: NHS England, PHE, Department of Health and Social Care, MoJ and HMPPS. The National Agreement for Prison Health in England identifies three core shared objectives of all five partners: to improve the health and well-being of prisoners and to reduce the current health inequalities that exist between prisoners and those living in the community; to support a reduction in re-offending through rehabilitation and changing health-related drivers of re-offending, such as substance

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dependence; and to support both access and continuity of care by prisoners through the prison estate and back into the community. Ten key priorities were identified from the core objectives of the National Agreement for Prisons in England 2018–2021, four of which were directly related to healthcare service provision and included the reduction of incidents of self-harm, self-inflicted deaths and substance misuse; the improvement of the mental health and well-being of prisoners; and the improvement of health and social outcomes for older prisoners. A further three key priorities focused on the development of a whole prison approach to health and well-being, preventative, diagnostic and screening programmes, and an alignment with community healthcare provision. However, an evaluation of the National Agreement for Prison Health is now required; in 2017–2018, data were collected from 112 prisons in England and Wales, which identified that prisoners were not accessing healthcare of equitable standards as compared to the general population (Davies et al. 2020). The findings also identified the following: • Prisoners used hospital services less and missed more hospital appointments than the general population. When prisoners were compared to people of the same age and sex who were living in the community, they had 24% less hospital admissions and outpatient appointments, 45% fewer visits to an emergency department, and the non-attendance at outpatient appointments was double than those living in the community. • Prisoners had specific health-related needs due to violence, drugs and self-harm, for example injury and poisoning accounted for 18% of attendances compared to 6% of those living in the community, whilst psychoactive substance use was documented in over 25% of prisoners who were admitted to hospital. • There were elements of care that were particularly poor for prisoners, for example, one in ten women who gave birth during a prison sentence did so either in prison or on their way to hospital. Another example is the care and treatment of diabetes, as 39 prisoners were admitted to hospital as a direct result of diabetic ketoacidosis, which is due to a lack of insulin and is both avoidable and life threatening (Davies et al. 2020). The recommendations from the analysis of this data suggest there is a need for an understanding of prison escorts, such as the availability and how prisoners are prioritised to attend hospital appointments, as well as how to  increase access to hospital services via telemedicine. However due to the COVID-19 pandemic, healthcare services within prisons had to rapidly implement digital technology to support telemedicine, although it is still unknown if the use of telemedicine in prisons has been an effective approach during and after the pandemic (Edge et al. 2020).

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2.3 Case Study: An Example of Prison Healthcare This section provides an example of prison healthcare in one prison, which is situated in the West Midlands, England, HMP Birmingham. This prison has been identified as an example, due to the provision of both primary care and inpatient care, although there is the need to recognise not all prisons have inpatient healthcare services, and prisoners requiring inpatient care may be transferred to another prison or healthcare institute. The information presented to support a detailed example of healthcare services within HMP Birmingham has been obtained from a Health Needs Assessment, which was completed in 2015 and published in an open report (Offenders Health Needs Assessment [OHNA] 2015). Therefore, there is the need to acknowledge that this information was correct in 2015, although service provisions may have changed in the following years. HMP Birmingham, a male prison, holds prisoners who are classed as a category B and category C security level. Category B includes prisoners who are a risk to the public, and therefore escape must be made difficult, but maximum security is not required. In contrast, category C includes prisoners who are unlikely to escape but cannot be trusted in open prisons. HMP Birmingham was first opened in 1849, and many of the original Victorian buildings remain, although an extensive refurbishment was completed in 2004. The refurbishment also included the construction of new buildings, one of which includes a healthcare centre and two inpatient wards. Other new buildings included an education centre, further workshops and a gym. The capacity of HMP Birmingham at the time of refurbishment was 1450 prisoners across 11 wings, but since this time and disruptive incidents by prisoners in 2016 and 2017, partially due to the conditions they were living in, current capacity is 1028 prisoners across 11 wings. An important factor within any prison is the turnover or change of prisoners, a high turnover also referred to as a population churn can disrupt any prison. The population churn of HMP Birmingham was high due to the number of prisoners being held on remand and those serving short sentences.

2.4 Primary Health Care Healthcare professionals, including general practitioners (GPs) and nurses, who provide primary healthcare in HMP Birmingham are directly employed by Birmingham Community Healthcare NHS Foundation Trust. The provision of primary healthcare in prison is through a GP led practice, which is both equitable and comparable to that of a GP practice in the community. Therefore, clinics within the prison are held on both the morning and afternoon from Monday to Thursday, with only a morning clinic on Friday. The morning clinics are facilitated by two GPs, with approximately 36 appointments available each day, although the afternoons are facilitated by only one GP, with approximately 14 available each day. The waiting time for prisoners to see a GP, at the time of the publication of the OHNA (2015) report, varied from 6 to 15 days. Alongside these clinics, both GPs and the nurses

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support evening reception, which is typically the time new prisoners are transferred to the prison, and both GPs and nurses support the assessment of these new prisoners. Nurses within primary care work autonomously and lead on a number of clinics, which are delivered in different locations within the prison to support the needs of the prisoner, so these may be in the health centre but also on various wings throughout the prison. The clinics are diverse and incorporate a number of specialities, including the provision of vaccinations, wound care, sexual health care, treatment and advice, assessment and support of older prisoners, palliative care and clinics for specific diseases such as diabetes, asthma, COPD and respiratory rehabilitation, as well as mental health clinics delivered by mental health nurses. The provision of primary care is also supported by other healthcare professionals, for example, a physiotherapist runs a clinic twice a week, a podiatrist twice a week, an optician once a week and dentists, similar to GPs, have clinics both in the morning and afternoon Monday to Thursday, and on a Friday morning.

2.5 Two Inpatient Wards The healthcare services within HMP Birmingham are supported by two inpatient wards, both with a capacity for 15 patients. One ward focuses on the physical health care of prisoners and the other ward focuses on mental health care, both wards will be discussed simultaneously in this paragraph. The HM Chief Inspector of Prisons report (2018) following an announced visit identified these wards provided a calm environment for prisoners and a good standard of care through the integration of healthcare officers (prison staff) and nurses. All patients were individually assessed by nurses and provided with a regime to support their physical and mental health needs. Both wards were supported by a full-time occupational therapist, who supported patients with different therapeutic activities that could be completed within their cells. Similar to hospital management, all patients were assessed to ensure they were admitted to one of the wards for clinical needs, rather than behavioural needs, and reviewed on a weekly basis to review each patient’s progress and manage the discharge process. Bed management meetings were also held regularly to ensure the appropriate use of these facilities. Each ward was staffed by two qualified nurses and three healthcare officers during the day and one nurse and healthcare officer during the night.

2.6 Mental Health Care Similar to primary healthcare, all healthcare professionals supporting the mental health of prisoners at HMP Birmingham are directly employed, and for mental health services this is by the Birmingham and Solihull Mental Health NHS Foundation Trust. Healthcare professionals, although employed by an NHS Trust, work permanently within HMP Birmingham. The service provision to support prisoners’ mental health is both comprehensive and complex, and includes both primary and inpatient care, as well as dual diagnosis and forensic mental health

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services, which require extensive cooperation and collaboration with justice mental health services and other diversions and external agencies. Over a period of 12  months, OHNA (2015) estimated the mental health care team at HMP Birmingham completed 125 new mental health assessments and provided inpatient care for 112 prisoners each month. An important element to acknowledge is the need for a learning disability nurse within the mental health care team, which has occurred more recently at HMP Birmingham to support the identification, referral and support of prisoners with learning disabilities and those with an autistic spectrum disorder.

2.7 Planned and Unplanned Secondary Care Both planned and unplanned secondary care for prisoners in HMP Birmingham are supported by the healthcare teams described above. Staff are allocated each week to support and escort prisoners to hospital appointments, the maximum visits supported per week is fifteen, which is divided into three appointments in the morning and two appointments in the afternoon. However, fifteen appointments per week for a population of just over 1000 prisoners may not always be sufficient, and managing and prioritising appointments is a complex task. HMP Birmingham have been proactive in addressing this issue, by trying to reduce the need for visits to hospital. This has involved working closely with Birmingham City Hospital to support the ability to X-ray prisoners by qualified radiologists within the prison. The need for hospital visits continues as some prisoners require kidney dialysis, to attend fracture clinics if a fracture is identified, and if an acute medical emergency occurs.

3 Health of Prisoners The last section of this chapter will focus on the health of prisoners and introduce the common physical and mental health conditions of prisoners. Physical health conditions include communicable diseases such as TB and HIV and non-­ communicable conditions, also referred to as long-term conditions, such as hypertension, diabetes and arthritis. Older prisoners are at a greater risk of a diagnosis of osteoarthritis, asthma, hearing loss and ischemic heart disease (Hayes et al. 2012). Mental health conditions include depression, posttraumatic stress disorder, anxiety and psychotic illnesses, with adverse outcomes of self-harm and suicide (Fazel et al. 2016). The following section will explore some of the possible reasons for the poor health of prisoners, including alcohol and drug use (Fazel et al. 2006), as well as significant family problems such as abuse and neglect (Schnittker et  al. 2012), which has been recognised to be associated with the development of poor health behaviours and the onset of mental health conditions (Non et al. 2016; Green et al. 2010). The final element within this section will include the exploration of the impact of mental and physical health on recidivism (Link et al. 2019; Wallace and Wang 2020).

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3.1 Communicable Diseases The prevalence of communicable diseases, such as HIV, tuberculosis, hepatitis B and C, and other sexually transmitted diseases are acknowledged to be higher in prisons than in the general population in countries around the world (Dolan et al. 2016; Kamarulzaman et al. 2016). Globally, the prevalence of HIV in prisons and other closed settings has been reported by the Joint United Nations Programme on HIV/AIDS (UNAIDS), with an estimated 4% of this population living with HIV/ AIDS, which is six times more than adults in the general population (UNAIDS 2021). In the United States, the percentage of prisoners in both federal and state prisons diagnosed with HIV is 1% (U.S. Department of Justice 2022). Similar to the United States, in 2018/2019 in the United Kingdom, an increase of HIV testing of prisoners as they arrived at a prison or were transferred between prisons identified a prevalence of 1% (Public Health England 2019). In the United Kingdom, the opt-­ out approach of testing prisoners for HIV has supported the testing of individuals who may not otherwise have been tested. The prevalence of latent tuberculosis infection (LTBI) in prisons in the United States and England is also similar. In a prison in New York City the prevalence of LTBI has been estimated to be 6% following the introduction of interferon gamma release assay (IGRA) screening rather than skin testing (Katyal et al. 2018). In inner city prisons in England, the prevalence of LTBI has been estimated between 7 and 11.5% (Gray et  al. 2020; Aldridge et  al. 2015). The risk factors that increase the likelihood of a prisoner requiring treatment for LTBI included a previous prison sentence, history of drug abuse and the lack of a BCG vaccination (Gray et al. 2020). However, in the state of Victoria, Australia, the prevalence of prisoners diagnosed or treated for LTBI was 0.04%, with no differences identified between treatment and outcomes of those in prison and those living in the community (Moyo et al. 2018). The prevalence of hepatitis B has been estimated to be between 1 and 11.4% in prisons in the United States (Smith et al. 2017). In one prison in London, the prevalence of hepatitis B both past and current was 8% (Aldridge et al. 2015), although in one maximum-security prison in England the prevalence was zero (Nakitanda et al. 2021). A recognised problem of the detection of prisoners with hepatitis B is the asymptomatic nature of the disease, again, the opt-out approach of testing prisoners has been implemented (Nakitanda et al. 2021). Transmission of hepatitis B in prison has been associated with the injection of substances not only due to the sharing of needles but also due to being stabbed or engaged in violent interactions with other prisoners (Li et al. 2020). Therefore, recommendations to reduce transmission focus on developing safe behaviours, such as safe approaches to injecting substances including ink for tattoos, as well as the availability of condoms, personal hygiene toiletries and a robust immunisation programme (Smith et al. 2017; Li et al. 2020). These approaches are also likely to reduce the spread of other blood-borne and sexually transmitted diseases. The prevalence of prisoners with hepatitis C antibodies, which demonstrates if they have had a past or have a current infection, has been estimated to be 16% of prisoners in Western Europe, 20% of prisoners in Eastern Europe and 15% in

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North America (Dolan et  al. 2016). However, the prevalence of prisoners with hepatitis C antibodies in UK prisons has been estimated to be between 5 and 24% of this population (Aldridge et al. 2015; Kirwan and Evans 2011). The prevalence of hepatitis C within prisons in the United Kingdom has begun to be addressed. In prisons in Wales, an opt-out testing policy of prisoners for hepatitis C antibodies was introduced, which supported the increase of testing, although the prevalence of positive results, 11%, remained the same (Perrett et al. 2020). In the North East of England, following testing for hepatitis C virus prisoners received notification and treatment via  telemedicine clinics, which identified a prevalence of 6%, of 49.5% of prisoners tested had an active infection and were commenced on antiviral therapy (Morey et al. 2019). The high prevalence of communicable diseases in prisons may be due to the high-risk prison environment. For example, the increase of communicable diseases such a tuberculosis and the increased transmission rates within prisons have been attributed to a number of factors, such as overcrowding within cells, the high turnover of prisoners, especially in remand prisons, the already high percentage of prisoners with tuberculosis and the late detection and treatment of cases (Baussano et al. 2010). The risks of an individual prisoner contacting a communicable disease include a low level of education, high risk behaviours, such as substance misuse and unprotected sex, as well as a poor diet and hygiene (Kamarulzaman et al. 2016). A further and important element, which has impacted on the continued high prevalence of communicable diseases in prison, has been the lack of comprehensive programmes to support the identification and treatment of prisoners with a communicable disease (Kuncio et al. 2015; Begier et al. 2010). However, in many countries including England, a focus on reduction of LTBI and communicable diseases has begun to address both the identification and treatment of prisoners with communicable diseases (Public Health England 2013). The management of tuberculosis in prisons within England has been developed by Public Health England (2013) and includes the need for any prisoner who has had a cough for more than 3 weeks to be assessed for tuberculosis to support identification of cases. When a prisoner is either diagnosed or suspected of pulmonary tuberculosis, isolation in a single cell is essential, and the need for the prisoner to remain isolated until they are no longer considered to be infectious. The local NHS Trust tuberculosis service must be involved in the care and treatment of the prisoner and perform any necessary contact, tracing and screening. All prisoners receiving treatment for tuberculosis are observed whilst taking their medication to ensure compliance, until the prisoner is no longer considered to be infectious. However, both the continuity and completion of treatment for tuberculosis is essential, and therefore there is a need for collaboration with community NHS healthcare to ensure the prisoner is supported to continue treatment on leaving the prison.

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3.2 Long-Term Conditions The following section introduces the prevalence of non-communicable diseases, which are known as long-term conditions (LTC) in the United Kingdom, as defined by The Kings Fund (2022): Long-term conditions or chronic diseases are conditions for which there is currently no cure, and which are managed with drugs and other treatment, for example: diabetes, chronic obstructive pulmonary disease, arthritis and hypertension.

The understanding of LTCs and the increasing prevalence of LTCs in the ageing prison population is essential. A recent survey of LTCs and associated risk factors in two prisons in England identified 46% of prisoners reported at least one LTC, such as respiratory disease (17%) and hypertension (10%), which were associated with increasing age or drug dependence (Wright et al. 2019). Due to the ageing prison population and the correlation of LTCs, the definition of an older prisoner is required to support the commissioning of healthcare services. In many documents around the world, an older prisoner is defined as any prisoner over the age of 50, and in England and Wales, HMPPS have implemented this definition. The classification of a prisoners as old from the age of 50 is due negative impact of prison on the ageing process. Grant (1999) identified a 10-year differential between a prisoner’s chronological age and their physical health compared to people living in the community. Therefore, a prisoner aged 50 will have the healthcare needs of a person aged 60 living in the community. However, if a prisoner is sentenced to prison for the first time later in life, his or her health may be significantly better than that of a prisoner of the same age who has been in or in and out of prison for many years. The prevalence of older prisoners, those aged 50 or over, with at least one LTC in prisons in England and Wales is estimated to be up to 90%, and the prevalence of older prisoners with three or more LTCs is estimated to be up to 50% (Commons Select Committee, Justice 2020; HMPPS 2018). The most common LTCs of older prisoners in the United Kingdom have been identified as osteoarthritis (35%), hypertension (32%), hearing loss (21%), diabetes (19%), ischemic heart disease (18%) and asthma (17%) (Hayes et al. 2012). Similar results have been identified for prisoners in the United States, as older prisoners were more likely to be diagnosed with hypertension, diabetes, arthritics, heart and kidney diseases (Sharupski et 2018). Data from the United Kingdom focuses on male prisoners. However, in the United States, older female prisoners have also been estimated to be diagnosed with up to four LTCs, including arthritis, hypertension, menopause-related problems, heart conditions and hearing problems (Sharupski et al. 2018). An important consideration is the impact of LTCs on the functional abilities of older prisoners, which may be further impacted by the prison environment. Multiple LTCs have been identified to be associated with increased functional limitations of prisoners. Gates et al. (2018) classified three patterns of LTCs within prisoners that impacted on their functional ability: the first category included diabetes, hypertension and high cholesterol, of which 60% of older prisoners had at least one, and 34% had all three. The second category included LTCs and the outcome of a LTC, which

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specifically impacts on a prisoner’s functional ability, and included joint problems, fractures and dementia, of which 70% of older prisoners had at least one. The third category included substance misuse, mental health disorders and neurological conditions, of which 61% of older prisoners had at least one. The three categories support identification of a prisoner’s functional ability, a prisoner who is significantly at risk of functional impairment is someone who has three LTCs from the first category or one condition from the second category (Gates et al. 2018). Although these categories supported the identification of functional impairment of prisoners, the main variable that predicted a significant risk of functional impairment was age (Gates et al. 2018).

3.3 Mental Health Conditions Mental health conditions of prisoners will be briefly introduced, but for more in-­ depth information including interventions and support within prison will be provided in chapter “Mental Health Care”. Prisoners have a higher rate of mental health disorders compared to the general population (Fazel et al. 2016). The prevalence of psychotic illness has been estimated to be present in 4% of both male and female prisoners, and major depression has been estimated to be present in 10% of male prisoners and 14% of female prisoners (Fazel et al. 2016). When considering a lifetime mental health diagnosis, the five most prevalent in those in prison are: personality disorder, 20% of males, and 35% of females; anxiety disorder, 26% of males and 28% of females; mood disorder, 52% of males and 73% of females; post-­traumatic stress disorder, 21% males and 18% females, and finally, psychotic disorders, 14% of males and 5% of females (Tyler et al. 2019). High co-morbidity was also identified as almost half of the prisoners were estimated to have two or more mental health disorders, and female prisoners were estimated to have more mental health disorders than male prisoners (Tyler et al. 2019). An important element to acknowledge is the high risk of both suicide and self-­harm by prisoners, which is significantly higher than the general population (Fazel et  al. 2016). Prisons around the world have varying prevalence of suicide, this is due to the difficult in accurately recording the cause of a death, due to misclassified as an accident or unknown, or not acknowledged as suicide due to the religion of the country. For example, France has a high prevalence of suicide in their prisons compared to other countries, whereas the United States has a low prevalence of suicide in their prisons, although the difference may be due to the high rates of African Americans and Hispanics in US jails and prisons, and the low rates of suicide within these ethnicities in the general population (Fazel et al. 2016). Risk factors that identify prisoners who are more likely to commit suicide include those who have expressed suicidal ideation, are in a single occupancy cell, history of suicide attempts, current diagnosis of a mental health condition and on psychotropic medication, although further factors may include serving a life sentence, for a violent crime and substance misuse (Fazel et al. 2016). In comparison to suicide, both attempted and completed, self-harm in prison has become common in prisons in England and Wales, over a 12-month period it was estimated that 5–6% of male prisoners and 20–24% of female prisoners self-harmed

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(Hawton et  al. 2014). The rate of self-harm by prisoners in England and Wales between 2012 and 2020 has increased in all ethnic groups, the largest increase of 226% was in prisoners who identify as mixed ethnicity, which increased from 136 to 443 incidents of self-harm per 1000 prisoners. Although white prisoners have the highest rate of self-harm, and 823 incidents of self-harm per 1000 prisoners (Ministry of Justice 2021). Risk factors that identify prisoners who are more likely to self-harm include those who are younger, serving a sentence of under 12 months or a life sentence, or are prisoners who are detained or under remand (Fazel et al. 2016). The risk factors for serious self-harm, which could lead to a near death incident, include those who have low education, previous prison admissions, in prison for less than 30 days, mood or anxiety disorders, psychoses, drug use and current diagnosis of two or more mental health conditions (Fazel et al. 2016).

3.4 General Poor Health of Prisoners The reasons for prisoner’s poor health need to be considered, as well as why a prisoner’s physical age, and hence health, is 10 years advanced of their chronological age (Grant 1999). This process has been defined as accelerated ageing and is especially evident in older prisoners. Factors that impact on accelerated ageing of prisoners will be discussed, and these include poor health and life-style choices, adversities, such as grief and loss, especially in childhood, and social disadvantages. Poor health and life-style choices include a lack of engagement with healthcare services, a poor diet and a lack of exercise, as well as the use of both alcohol and drugs. The prevalence of the use of alcohol by prisoners prior to entering prison has been estimated to be between 18 and 30%, whilst the use of drugs was estimated to be between 10 and 40% (Fazel et  al. 2006). Adversities, especially those that occurred in childhood, are more commonly experienced by prisoners than those in the general population, which include both abuse and neglect by their family (Schnittker et al. 2012). The impact of childhood adversities is associated with poor health behaviours in later life, thus confounding the impact on the health of prisoners (Non et al. 2016; Green et al. 2010). Lastly, the impact of social disadvantage and being involved in crime have been acknowledged to be associated with poor health, although the evidence for this association remains weak. Social disadvantage refers to a lack of social and economic resources compared to other communities. The majority of prisoners have a socially disadvantaged background, however, the majority of people from a socially disadvantaged background do not become prisoners. Therefore, the association between social disadvantage and becoming involved in crime is complex. A significant factor is childhood disadvantage, which influences the risk of a child being exposed to criminal activity and poor behaviour and health choices of adults in their family (Wilkstrom and Treiber 2016). Childhood disadvantage also encompasses education, and the completion of minimal education increases the risk of unemployment, poorly paid and seasonal jobs, which may lead to crime. The completion of minimal education by prisoners is negatively associated with increased health

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needs, however, the implementation of education programmes within prisons can begin to address this issue (Nowotny et al. 2016).

3.5 Impact of Poor Health on Recidivism Prisons are required to provide healthcare to prisoners. However, there is no obligation of prisoners to engage with healthcare services, or adopt health behaviours, such as exercise, diet and addressing substance misuse. However, prisoners’ health on release from prison, especially poor physical and mental health, has been identified to be linked to increased recidivism (rate of reoffending). A study in Australia identified higher reincarceration rates of prisoners with mental health conditions, which included a history of self-harm (55%), an intellectual disability (62%), and the reincarceration rates of prisoners with physical health conditions, which included two or more chronic illnesses (50%) and low physical functioning (50%) (Thomas et al. 2015). A pathway for the impact of poor health on reincarceration has been identified, where physical health limitations lead to a lack of employment, financial problems, crime and reincarceration, whereas a mental condition, such as depression, leads to family conflict, financial problems, crime and reincarceration (Link et  al. 2019). The relationships between prisoners’ health within and on release from prison, and recidivism has been identified, a reduction in reincarceration  is associated with improvement of a prisoner’s mental health both in prison and on release from prison, although, the greatest reduction in reincarceration was identified when a prisoner’s mental health significantly improved upon release from prison. However, prisoners whose physical health improves in prison and continues to improve on release from prison are more likely to reoffend (Wallace and Wang 2020).

4 Conclusion This chapter has introduced the human rights of all human beings and those currently serving a prison sentence, and the relevant human right declarations including the Universal Declaration of Human Rights (1948) and the United Nations Standard Minimum Rules for the Treatment of Prisoners [The Nelson Mandela Rules] (2015). The focus of this chapter is the implementation of the Nelson Mandela Rules (2015) and the WHO, Europe principles of prison healthcare to understand the rights of prisoners to healthcare. This if followed by how the provision of healthcare is implemented within prisons in England, supported by the National Partnership Agreement for Prison Health 2018–2021 (HM Government and NHS England 2018). The remaining of this chapter has explored the poor physical and mental health of prisoners and the prevalence of both long-term conditions and infectious diseases.

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The Kings Fund (2022) Long-term conditions and multi-morbidity. https://www.kingsfund.org. uk/projects/time-­think-­differently/trends-­disease-­and-­disability-­long-­term-­conditions-­multi-­ morbidity. Accessed 14 August 2022 Thomas EG, Spittal MJ, Taxman FS, Kinner SA (2015) Health-related factors new approaches predict return to custody in a large cohort of ex-prisoners: new approaches to predicting re-­ incarceration. Health Justice 3:10 Tyler N, Miles HL, Karadag B, Rogers G (2019) An updated picture of the mental health needs of male and female prisoners in the UK: prevalence, comorbidity, and gender differences. Soc Psychiat Psychist Epidemiol 54:1143–1152 U.S. Department of Justice (2022) HIV in Prisons, 2020 – Statistical Tables. https://bjs.ojp.gov/ content/pub/pdf/hivp20st.pdf. Accessed 14 Aug 2022 United Nations (2015) Standard Minimum Rules for the Treatment of Prisoners [The Mandela Rules] (2015). https://cdn.penalreform.org/wp-­content/uploads/1957/06/ENG.pdf. Accessed 14 Aug 2022 United Nations (2022). https://www.un.org/en/about-­us#:~:text=The%20United%20Nations%20 is%20an,contained%20in%20its%20founding%20Charter. Accessed 14 Aug 2022 United Nations Human Rights Office of the High Commissioner (1948) 30 Articles of the Universal Declaration of Human Rights (1948). https://www.un.org/en/about-­us/universal-­declaration-­ of-­human-­rights. Accessed 14 Aug 2022 United Nations Human Rights Office of the High Commissioner (1965) International Convention on the Elimination of All Forms of Racial Discrimination (1965). https://www.ohchr.org/en/ professionalinterest/pages/cerd.aspx. Accessed 14 Aug 2022 United Nations Human Rights Office of the High Commissioner (1966a) International Covenant on Civil and Political Rights (1966). https://www.ohchr.org/en/professionalinterest/pages/ccpr. aspx. Accessed 14 Aug 2022 United Nations Human Rights Office of the High Commissioner (1966b) International Covenant on Economic, Social and Cultural Rights (1966). https://www.ohchr.org/en/professionalinterest/ pages/cescr.aspx. Accessed 14 Aug 2022 United Nations Human Rights Office of the High Commissioner (1979) Convention on the Elimination of All Forms of Discrimination Against Women (1979). https://www.ohchr.org/ EN/ProfessionalInterest/Pages/CEDAW.aspx. Accessed 14 Aug 2022 United Nations Human Rights Office of the High Commissioner (2018) Universal Declaration of Human Rights at 70: 30 Articles on 30 Articles. https://www.ohchr.org/en/press-­ releases/2018/11/universal-­declaration-­human-­rights-­70-­30-­articles-­30-­articles?LangID=E& NewsID=23856. Accessed 14 Aug 2022 Universal Declaration of Human Rights Office of the High Commissioner (2015) Universal Declaration of Human Rights. https://www.un.org/en/udhrbook/pdf/udhr_booklet_en_web. pdf. Accessed 14 Aug 2022 Wallace D, Wang X (2020) Does in-prison physical and mental health impact recidivism? SSM – Population Health 11:100569 Wilkstrom P-OH, Treiber K (2016) Social disadvantage and crime: a criminological puzzle. Am Behav Sci 60(10):1232–1259 World Health Organization (2014) Prisons and health. https://www.euro.who.int/__data/assets/ pdf_file/0005/249188/Prisons-­and-­Health.pdf. Accessed 14 Aug 2022 Wright NMJ, Hearty P, Allgar V (2019) Prison primary care and noncommunicable diseases: a data-linkage survey of prevalence and associated risk factors. BJGP Open 3. https://doi. org/10.3399/bjgpopen19X101643

The Role of the Nurse in Prison Joanne Brooke

This chapter contains a case study of a nurse’s reflection, thoughts and experiences of working collaborating with prison officers.

1 History of Prison Nursing Nursing practice within prison has only begun to be developed and recognised alongside the development of systems to provide healthcare to prisoners (Schoenly 2011). Therefore, the development of nursing in prison is entwined with the progression of healthcare services for prisoners. Examples within this section will be drawn from different countries, including the United States and how civil litigation, such as the 1976 Supreme Court decision of Estelle versus Gamble, established the obligation of the government to provide healthcare to prisoners. The discussion of the development of healthcare within prisons in England and Wales will commence from 2000, when the responsibility of healthcare became the responsibility of the Department of Health (Hayton and Boyington 2006). Finally, this section will conclude with how the role of the prison nurse has developed in the twenty-first century, both in the United States and England.

1.1 Civil Litigation in the United States In the United States, litigation has supported prisoners’ rights to healthcare, in particular the case of Estelle v. Gamble, 429 U.S. 97 (Marshall 1976). This case arose from an injury that occurred when a prisoner was allocated to the work in a J. Brooke (*) Centre of Social Care, Health and Related Research, Birmingham City University, Birmingham, UK e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 J. Brooke (ed.), Nursing in Prison, https://doi.org/10.1007/978-3-031-30663-1_3

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textile mill, which involved loading and unloading cotton bales from a truck. In the Texas Department of Corrections on 9 November 1973, J.W. Gamble sustained an injury when one of the 600-pound cotton bales fell unexpectantly. Gamble continued working for a couple of hours until his back began to spasm, and he was allowed to attend the hospital unit within the prison. The doctor checked Gamble for a hernia and sent him back to his cell, but later that day the pain became unbearable, and Gamble returned to the hospital unit. On this occasion, Gamble was prescribed and given analgesia, but no further treatment. The following day Gamble was assessed by a different doctor and analgesia was again prescribed and administered. On this occasion, Gamble was provided a ‘cell-pass cell-feed’ routine, which was a pass to state he was unfit to work, and supported Gamble to rest in his cell, apart from mealtimes. When the ‘cell-pass cell-feed’ routine ended, Gamble was declared fit to work. However, his back pain had not improved and he was disciplined for refusing to work and the prison administration placed him in administrative segregation, which is similar to solitary confinement. This process was repeated on many occasions over the next 3 months. Gamble also complained of chest pain, for which he was treated for an irregular heartbeat in hospital, but later he was denied any further requests for treatment by the prison administration. During these 3 months, Gamble was assessed on 17 occasions by healthcare professionals. Gamble submitted a civil rights action on 11 February 1974 against the medical director of the state corrections department and two prison officers. Gamble claimed he has been subjected to cruel and unusual punishment, which was in violation of the Eighth Amendment. Gamble considered the inadequate treatment of his back injury, which was sustained whilst he engaged in prison work, to be cruel and unusual punishment. The District Court dismissed Gamble’s action. However, the Court of Appeals reinstated the action for two reasons: first, due to insufficient medical treatment provided to Gamble, specifically the lack of a diagnostic examinations such as an X-ray. Second, due to the use of solitary confinement by the prison administration rather than the provision of adequate healthcare. The decision on 30 November 1976 by the Court of Appeals was to uphold Gamble’s action, as the “deliberate indifference by prison personnel to a prisoner’s serious illness or injury constitutes cruel and unusual punishment contravening the Eight Amendment” (Marshall 1976). However, Gamble’s action against the medical director was not upheld as “the failure to perform an X-ray or to use additional diagnostic techniques does not constitute cruel and unusual punishment, but is, at most, medical malpractice” (Marshall 1976). This case established that the principle of cruel and unusual punishment included the failure of prison administrations to address the healthcare needs of prisoners (Dimitrakopoulos 2007).

1.2 Development of Health and Social Care in England and Wales Prison Service The provision of healthcare in England and Wales Prison Service became the responsibility of the Department of Health in 2000 (Hayton and Boyington 2006).

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This was due to a highly critical report of the provision of healthcare by the Prison Service by Her Majesty’s Chief Inspector of Prisoners in 1996, which led to the development of a Joint Prison Service and National Health Services Executive Working Group in 1999. The working group identified inconsistencies of healthcare provision across prisons in England and Wales, which lacked both strategic planning and clear lines of accountability. Good practice by healthcare professionals was identified by the working group, but many healthcare professionals lacked appropriate knowledge, training and continued supervision. The Joint Prison Service and National Services Executive Working Group recommended the joint responsibility of healthcare provision for prisoners, to include both the Prison Service and the National Health Service (NHS), and the development and implementation of primary healthcare within prisons by NHS Trusts and access to secondary care within local NHS hospitals. Important changes, developments and implementation of healthcare within prisons in England and Wales have occurred since 2000, below is a timeline outlining these changes. The timeline ends with the National Partnership Agreement for Prison Healthcare in England 2018–2021 (HM Government, NHS England 2018), which is discussed in more depth in chapter “Healthcare in Prison”: 2001—the introduction and implementation of in-reach mental health care service for prisoners in England and Wales following the publication of the new health policy by the Department of Health. 2003—the development of the National Partnership Agreement, including the Home Office and the Department of Health, and the responsibility of the Department of Health for the funding of primary care in prisons in England. 2006—the commissioning of primary care services was transferred to Primary Care Trusts, who partnered with Prison Partnership Boards of their local prisons to commission services that addressed the needs of individual prisons and national agreements. 2007—a reform of services occurred with the implementation of new services, such as the Integrated Drug Treatment Programme, and a new National Partnership Agreement between the Department of Health and Her Majesty’s Prison Service for both the Accountability and Commissioning of Health Services for Prisoners. 2008—the Prison and Probation Services were transferred from the Home Office to the Ministry of Justice, and then to the National Offender Management Service (NOMS). 2011—the Department of Health and the Ministry of Justice co-commissioned and implemented a programme to treat and support the mental health of prisoners through the Dangerous and Severe Personality Disorder Programme. Other changes included the responsibility for commissioning non-clinical substance misuse services, which became the responsibility of the Department of Health, rather than the NOMS. 2013—the commissioning of primary care services was transferred from Primary Care Trusts to Clinical Commission Groups, following the Health and Social Care Act (2012).

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2013—a further update of the National Partnership Agreement occurred to include development of the tripartite agreement of NHS England, NOMS and Public Health England (PHE) to identify priorities, commissioning and delivery of healthcare in prisons in England. 2016—the impact of the commissioning of healthcare services by the NHS was explored by PHE, in a rapid review of the evidence, which identified positive impacts, although areas that required further improvement included further community engagement and partnerships. 2017—NOMS became Her Majesty’s Prison and Probation Service (HMPPS). 2018—a further version of the National Partnership Agreement for Prison Healthcare in England was developed, which included the Ministry of Justice, HMPPS, PHE, the Department of Health and Social Care and NHS England. This agreement expired in 2021, however, a new version has yet to be published at the time of writing. 2019—Primary Care Networks were implemented, to remove the divide between primary and community health services, primary care provided within a prison, should be linked to a Primary Care Network. The purpose of PCNs is clear in the title of the first section of Chap. 1, “we will finally dissolve the historic divide between primary and community health services”, and they have been designed to help achieve a series of goals from addressing profound challenges in general practice to acting as the building blocks on which integrated care systems (ICSs) will function successfully. 2022—the commissioning of primary care services was transferred from Clinical Commission Groups to Integrated Care Groups. The provision of healthcare within prisons and the access of healthcare by prisoners in England has significantly improved over the past two decades, especially in the last decade with the introduction of the National Partnership Agreement. Improvements occurred due to the introduction of NHS healthcare services for prisoners, which are provided by appropriately qualified healthcare professionals. Other systems embedded within NHS Trusts have also supported improvements, such as the introduction and implementation of the patient advice and liaison services and national standards defined by the National Institute for Health and Care Excellence (NICE). However, there remains the need for specialist education and training of qualified healthcare professionals to understand the complex healthcare needs of prisoners, as well as further clarity and development of collaborative working of healthcare professionals, prison officers and prison administration.

1.3 The Role of the Nurse in Prison The first prison to develop and implement a hospital and pharmacy in the United States was the New York City Newgate Prison in 1797, and this was led by Thomas Eddy, the warden at the time (American Nursing Association [ANA] 2013). The implementation of a hospital required nurses to care for the prisoners, and therefore,

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the year 1797 has been recognised as the beginning of the specialism of correctional/prison nursing. During the 1800s, a nurse, Dorothea Lynde Dix advocated for the need to provide support and care for prisoners who were experiencing mental health issues and petitioned for reform, which in 1845 included the separation of different types of prisoners. However, it was not until 1976 that an amendment to the constitutional rights of prisoners to receive healthcare was implemented. The amendment occurred following the Supreme Court ruling on the case of Estelle v. Gamble (1976). The rights of prisoners encompassed three specific elements of healthcare provision: first, the right to access care, which focuses on the responsibility of the prison to provide healthcare services, to support medical emergencies, and  the continuation of medical management. Second, the right to professional judgement, access to healthcare, and the timely provision of prescribed treatment. Third, the right to prescribed healthcare treatment, and the right of prisoners to be provided healthcare by qualified healthcare professionals with appropriate medical equipment within medical units (ANA 2013). The amendment of the constitutional rights of prisoners in 1976 supported the need and development of correctional or prison nursing as a specialism (Schoenly 2011). In 1985 the American Nursing Association published the Scope of Nursing Practice in Correctional Facilities, which has now been updated on a number of occasions, most recently in 2013 and 2020. The latest edition, Correctional Nursing: Scope and Standards of Practice, Third Edition (2020), defines the scope of practice of correctional nurses and more widely the environment of healthcare within prisons, the unique education requirements to become a correctional nurse, as well as issues and trends within prison healthcare and the ethical bases of correctional nursing. The Scope and Standards of Practice (2020) describes 16 standards and within each standard specific competencies, a correctional nurse is required to understand and adhere to the standards and demonstrate the specific competencies. The development of healthcare within prisons in the United Kingdom also commenced in the late 1700s, which was led by John Howard, who was appointed High Sheriff of Bedfordshire in 1773, which involved the responsibility of the county prison. On visiting the prison, John Howard was appalled by the conditions of the prison, the degrading treatment of prisoners, and the approach of prisoners paying for their basic amenities, such as bedding and food. John Howard travelled and visited prisons across England and Europe to further understand the conditions and treatment of prisoners. On his travels between 1775 and 1780, John Howard found appalling conditions of prisons and treatment of prisoners, which he detailed in his book The State of the Prisons in England and Wales (Howard 1777). Following this work, John Howard campaigned for the reform of healthcare within prisons and was instrumental in an Act of Parliament in 1774, which required prisoners who were sick to be placed in separate rooms and each prison was required to appoint a prison surgeon. This reform led to the development of healthcare units and hospitals within prisons in England. A charity formed in 1866 continues this work today, which is the Howard League for Penal Reform. The implementation of healthcare and hospitals in prisons in the early 1800s in England and Wales did not support the role of the nurse within prisons. Although a

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few nurses did work in the prison hospitals, the Prison Service implemented ‘hospital officers’, who were prison officers who had been chosen to work in the prison hospital. Therefore, it was not until the implementation of new policies, such as the National Partnership Agreement in 2003 and the transfer of healthcare in prisons to the NHS, were qualified nurses routinely employed to permanently work within prisons. The ongoing development of prison healthcare in England and Wales through the policies outlined above has further supported the specialist role of the nurse in correctional or prison healthcare. The development of prison nursing has also been supported by different forums, such as the Nursing in Justice and Forensic Health Care Forum, hosted by the Royal College of Nursing, and the provision of clinical placements in healthcare in prisons for nursing students. Unlike the United States, in England and Wales there are no specific scope, standards or competencies for nurses working within prison. The NHS describes the requirements of a prison nurse, which include the need to be a qualified nurse registered with the Nursing and Midwifery Council, and demonstrate essential generic skills of resilience, communication and conflict management, as well as an understanding of the criminal justice system. However, there is currently no regulation or guidance for specialist training or the completion of specialist qualifications as training is provided through comprehensive induction programmes and prison-­ specific training. The role of the prison nurse within prisons in England and Wales in the twenty-first century is highly skilled and varied and includes nurses from different specialities such as mental health, psychiatry, learning disability and general nurses, although many nurses have post-registration qualifications, including specialisms such as primary care, trauma or substance misuse.

2 Professional Identity This section will commence with a definition of professional identity as applied within nursing, and how this has changed over time (Johnson et al. 2012), followed by the development of an individual nurse’s professional identity throughout her career (Larson et al. 2013). This will lead to a discussion on the professional identity of a nurse working within a prison (Goddard et al. 2019; Choudhry et al. 2017a; Stephenson 2018), as well as the concepts of emotional labour and moral distress, which impact on all nurses, especially nurses working within this unique setting (Humblet 2020; Walsh 2009; Walsh and Freshwater 2009; Walsh et al. 2013; Lazzari et al. 2020).

2.1 Professional Identity of Nursing Professional identity of nursing and nurses continues to evolve. The original concept and identity of nurses as a doctor’s assistant from the early twentieth century has been challenged. Nurses are now qualified autonomous practitioners who are active members in the decisions and provision of patient care (Johnson et  al. 2012). A

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professional identity refers to a person’s occupational identity and is only one element of a person’s self and has been described as the “self-conception of requirements, values, tributes, and norms concerning a profession or a vacation” (Mao et  al. 2021). There is an association between the professional identity of a nurse, their satisfaction with nursing and/or their commitment to nursing, and their likelihood of remaining in nursing (Lu et al. 2019; Sabanciogullari and Dogan 2015). Therefore, the development of both nurses and nursing students’ professional identity is important to understand, as globally, including within NHS England, there remains a significant shortfall of nurses, which is predicted to continue, increase and negatively impact on the delivery of healthcare (Buchan et al. 2020). The development of a professional identity involves a number of processes, including socialisation into the profession and the acquisition of knowledge, skills, attitudes and values of the profession (Miller 2010; Rose et al. 2018). The development of a professional identity as a nurse has been described as an iterative process involving both education and practice, which must occur within the values, ethics and code of conduct of the professional regulatory body of nursing (Larson et al. 2013), which in the United Kingdom is the Nursing and Midwifery Council. Others argue the professional identity of a nurse is developed through a combination of the integration of their own values and ethics, alongside the development of both knowledge and practice, as well as socialisation into their profession (Hercelinskyj et al. 2014). However, the professional identity of nurses by nurses can be influenced both positively and negatively by the same factors, including public image, media representation, doctors, and other nurses (Goddard et al. 2019). An example of a professional identity pathway and factors that influence professional identity throughout the career of a nurse has been developed by Johnson et al. (2012): • The first stage of the pathway, ‘initiating the professional identity pathway’, commences prior to nursing students start their nurse education programme, and their beliefs and values at this time, which may include images of a nurse and nursing. • The second stage of the pathway, ‘academic content, teachers and mentors’, commences during nursing students’ education programme and involves both a deconstruction and then a reconstruction of their understanding of the professional identity of nurses and nursing. During this stage, nursing students are influenced by both lecturers and mentors, from whom they commence their understanding of professional values and the skills and competency required by nurses. • In the third stage of the pathway, ‘clinical placements and their effects’, clinical placements are essential to support nursing student’s socialisation into nursing and the development of their own professional identity. Clinical placements support nursing students to being to link theory and practice and organise their newly acquired knowledge with the values and practices of becoming a nurse. • The fourth stage of the pathway, ‘professional identity and the transition to practice’, is the stage when nursing students transition to qualified nurses. However, this stage involves more than successful graduation, as a nurse may

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experience dissonance between their expectations of becoming a nurse and their experiences. Therefore, the support of newly qualified nurses is essential through comprehensive preceptorship programmes. • The fifth and final stage of the pathway, ‘evolving professional identity within a changing world of healthcare’, is essential as the healthcare needs of the population continue to change, for example the COVID-19 pandemic. However, other changes may include advances in technology and the development of new and advanced techniques to treat diseases, which require expertise. The development of professional identity of nursing students has recently been explored and defined following a review of contemporary published literature (Vabo et al. 2022) and a research study (Wu et al. 2020). Two main themes were identified from the literature review: first, ‘a caring practice–academic partnership’, with subthemes of clinical supervisors, self-confidence, ethical competence and preparation. This theme identifies nursing students’ need for support and consistency across learning in the classroom and clinical practice. Second, ‘support in the learning environment’, with subthemes of predictability and safety, structure and cooperation, and reflective space. This theme identifies nursing students’ need to learn in a safe consistence space to support their professional identity as a nurse (Vabo et al. 2022). These findings consolidate the identification of positive influences on the development of nursing students’ professional identity, which include long clinical placements and positive perceptions of the clinical learning environment (Wu et al. 2020). The two themes and subthemes identified by Vabo et al. (2022) and the two elements identified by Wu et al. (2020) support and develop the second and third stage of the professional identity pathway identified by Johnson et al. (2012). The contemporary studies support the need to understand the complexities of developing a professional identity that occurs across education and clinical practice, including an organised robust partnership between academic education and clinical practice. Professional identity is also influenced by factors outside of nursing and nursing students’ education. Further concepts, which may influence the development of both nurses and nursing students’ professional identity, include individual’s self-­ efficacy and resilience (Mei et al. 2022), as well as coping styles, especially during extremely stressful healthcare events, such as COVID-19 (Zhao et al. 2021). A significant increase of psychological stress was identified by one cohort of nursing students due to studying and caring through the COVID-19 pandemic. However, this experience influenced their professional identity, which improved significantly and reinforced their reasons for choosing nursing as a profession (Zhao et al. 2021). Although this study did not involve nursing students studying in England, the events during COVID-19, and the identification of the NHS workforce as frontline staff, the clapping and support of staff, including nurses, may have contributed positively to students nurses professional identity. A further element that has only just begun to be explored and may significantly impact on nurses’ professional identity is social media (Alharbi et al. 2020). Nursing students identified the use of social media to both understand and share their understanding of the professional identity of nursing, which supported them to develop

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their sense of belonging to the nursing profession. Nursing students also used social media to share their experiences of nursing, with the aim of influencing outdate images and concepts of the role of the nurse (Alharbi et al. 2020). However, this study appeared to lack a discussion of the possible negative impacts of social media on nursing students and the development of their professional identity as nurses who are disillusioned with nursing may post negative experiences and portray negative values towards nurses. The professional identity of nurses, student nurses and nursing continues to develop and evolve, and involves many complex constructions, all of which need to be understood and addressed through nursing education.

2.2 Professional Identity of a Nurse in a Prison Setting Nursing within healthcare in a prison setting is a specialised and highly skilled role, due to the provision of care and treatment for diverse conditions in a challenging environment, which is largely unseen, unacknowledged, undervalued and under-­ resourced (Goddard et al. 2019). Nurses working in healthcare in prison experience emotional labour and moral distress, which will be discussed in-depth in the next section. However, these feelings can impact negatively on nurses and lead to burnout, which is more common in nurses working in healthcare in a prison and may be enhanced by a lack of a strong professional identity as a prison nurse. Therefore, the professional identity of prison nurses has begun to be explored (Choudhry et  al. 2017a). Five factors that positively and negatively influenced the development of prison nurses’ professional identity included relationships with colleagues, the prison regime, autonomy, delivery of patient care and prison culture (Choudhry et al. 2017a). The negative impact of the prison regime, prison culture and autonomy on the professional identity of nurses is important to understand and address. First, nurses have identified the security of the prison and the prison regime is always a priority; although this is recognised as a necessity, security and the prison regime takes precedence over the provision of healthcare (White and Larsson 2012; Solell and Smith 2019). The priority of the prison regime creates a conflict between custody and care, as the prison regime influences how nurses provide assessment, treatment and care for prisoners (Weiskopf 2005; Dhaliwal and Hirst 2016). The conflict between custody and care requires nurses to negotiate their provision of care within the boundaries of the prison regime, which is imposed by prison authorities. The complex challenge of negotiating care for prisoners includes obtaining physical access to prisoners, which may be limited to providing care for a prisoner behind bars or a door, or whilst they are shackled and in front of prison officers (Foster et al. 2013). Further difficulties arise for nurses due to the inflexibility of the prison regime; for example, if a nurse has been assessing a prisoner with complex needs and requires more time to finish the assessment, this may not be possible. The prison regime also impacts on how a nurse organises her work; for example, a nurse may identify the need to implement a vaccination clinic. However, depending on the prison regime, the nurse may have to collect the prisoner from their cell and bring them to the clinic

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(Powell et al. 2010). These aspects impact on the professional identity of a prison nurse, as they have identified the inability to provide appropriate care in a timely way in an appropriate environment. Second, the prison culture impacts negatively on nurses’ professional identity because nurses identified the need to be cautious with prisoners since some prisoners attempted to manipulate them and had an ulterior motive for their need to see a healthcare professional. For example, prisoners may try to obtain medication they do not require, or to simply have time out of their cell and enjoy a social interaction with someone other than a prisoner or prison officer (Weiskopf 2005; Peternelj-­ Taylor 2004; Choudhry et al. 2017b). Nurses found this behaviour particularly difficult to both understand and provide appropriate support and advice (Choudhry et al. 2017a). However, nurses’ approach of being firm, fair and consistent helped to prevent prisoners from taking advantage of them. This approach also supported an understanding by prisoners that nurses were there to provide care and support following an accurate assessment of their needs. The professional identity of prison nurses was supported by this approach, as they remained focused on providing appropriate treatment to prisoners by acknowledging, understanding and addressing prison culture (Solell and Smith 2019). Third, the element of autonomy had a positive impact on nurses’ professional identity compared to the prison regime and the culture of the prison, as nurses recognised the autonomy within their role as a prison nurse, which was described as more autonomous than working outside of a prison (Walsh 2009). Nurses identified the need to work within the prison regime, and this supported their autonomous practice, as they could visit prisoners within their cells (Powell et al. 2010). Nurses were able to develop their knowledge and skills whilst working in a prison; for example, nurses became specialists in bloodborne viruses and sexual health, as well as the implementation of diagnostic techniques such as dry blood spot testing (Stephenson 2018). Both the autonomy of prison nurses and the ability to develop specialist skills supported the development of their professional identity. Two elements that impact on nurses, especially prison nurses, and influence their professional identity are emotional labour and moral distress, which are discussed in the next two sections.

2.3 Emotional Labour This section will commence with a description and impact of emotional labour with relevance to the role of the nurse, and specifically prison nursing. Emotional labour has been described as the process of how an individual copes with their feelings and expressions within the requirements and expectations of their job (Hochschild 2003). Emotional labour is demonstrated through how a person acts, and this may be through surface level acts or deep level acts. A surface level act is when an individual acts in a way his or her colleagues would expect, although the individual is not demonstrating their true beliefs or values. In contrast, a deep level act may involve the individual acting in a way that demonstrates their true beliefs or values, or the individual is emotionally adopting the beliefs or values of their organisation

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or workplace, which involves emotive effort (Hochschild 2003). The impact on an individual of controlling how they act, whether their actions demonstrate their true values or not, creates high levels of emotional labour. In nursing, emotional labour consists of therapeutic interactions between nurses and patients, collegial interactions with other nurses and colleagues, and instrumental interactions, which involves nurses’ skills and confidence in performing clinical tasks (Theodosius 2008). The three forms of emotional labour identified in general nursing, i.e. therapeutic, collegial and instrumental, are relevant to prison nursing and maybe more poignant and prevalent in the prison environment. A comprehensive review of the literature exploring each of these forms of emotional labour in nurses has been completed by Delgado et al. (2017), and the following section will be informed by this work and explore the three forms of emotional labour and discuss these with relevance to prison nursing: 1. Therapeutic interactions include emotional labour through the suppression of frustration when trying to support and care for a patient who may be uncooperative, demanding, aggressive or threatening to self-harm. Emotional labour may also occur due to the suppression of feelings of rejection or offence when a patient is expressing their personal views. Encounters such as these occur in prison healthcare, as prisoners may be experiencing withdrawal from alcohol, drugs or under the influence of an illegal substance such as spice, or prisoners may be frustrated and angry with their situation and their only method of control is to self-harm. 2. Collegial interactions include emotional labour when nurses needed to instigate conversations regarding treatment decisions for patients, or when care was identified to fall below nursing expectations or standards, or when unprofessional behaviour was demonstrated by a colleague. In the prison healthcare environment, these interactions can occur between nurses and prison staff, which are discussed in more depth in a following section. 3. Instrumental interactions include emotional labour when an invasive or intrusive clinical intervention, assessment or treatment was required that would cause pain, but was necessary. During these tasks, nurses focused on the technical aspect of the task to emotionally distance themselves and manage their feelings of fear and distress. In the prison environment, nurses providing invasive or intrusive interactions with prisoners in shackles may focus on the task to emotionally distance themselves from their negative feelings of preforming such a task under these circumstances. The impact of emotional labour on nurses, including student nurses, has been identified to be positively correlated with emotional exhaustion, stress, burnout and intention to leave the profession (Kinman and Leggetter 2016; Delgado et al. 2017; Theodosius et al. 2020). There is a lack of studies exploring the impact of emotional labour within the prison nursing workforce. However, due to the impact of custody versus care, prison nurses may experience higher emotional labour than those working in non-custodial settings. A number of factors have been identified to reduce the

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impact of emotional labour on nurses, including clinical supervision, resilience, job satisfaction and perceived organisational support (Delgado et al. 2020; Gulsen and Ozmen 2020; Lartey et al. 2019). The implementation of initiatives to reduce the impact of emotional labour of nurses, especially prison nurses, is essential to support the care provided to prisoners and retain the prison nursing workforce.

2.4 Moral Distress This section will commence with a description and impact of moral distress with relevance to nursing, and specifically prison nursing. The concept of moral distress was developed and defined by Jameton (1984) and occurs to a healthcare professional “when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action” (p. 6). The immediate impact of moral distress on a nurse is a painful sensation due to psychological dissonance, and this occurs due to the nurse’s knowledge of the morally appropriate care that should have been provided to a patient, but this did not occur due to institutional constraints. A number of institutional constraints have been identified and include a lack of time, managerial support, limitations due to institutional policies and the contractual role of the nurse (Corley 2002; Negrisolo and Brugnaro 2012). The concept of moral distress has been expanded to include moral decisions made by healthcare professionals, which inadvertently have a negative impact on the patient. Therefore, a nurse may be able to make a moral decision and act on this decision with institutional support, but moral distress occurs due to elements within the situation rather than the institution (Tigard 2018). The long-term impact of moral distress on nurses is important to acknowledge and understand, as it may include both physical and psychological symptoms. Physical symptoms may include sleeplessness, reduced appetite, as well as palpitations and headaches (Austin et al. 2005; Fard et al. 2020), whereas psychological symptoms may include guilt, loss of self-esteem, avoidance behaviours and an emotional detachment from work, leading to an intention to leave (Austin et al. 2005; Borhani et al. 2014; De Villers and De Von 2014). The moral distress of nurses working in prisons in Italy has been explored, and a moderate level of moral distress was identified, which was not influenced by the length of time they had worked in a prison setting (Lazzari et al. 2020). The mean length of prison nurses experience in this study was 6 years, suggesting the prison environment contains numerous situations that are potentially a source of moral distress for nurses. Therefore, within a short period of time, nurses working in the prison environment develop high levels of moral distress, which influences their intention to leave prison nursing (Lazzari et al. 2020). On many occasions, nurses do not recognise when they experience moral distress (Wilson et al. 2013). Therefore, there remains the need for all healthcare services, especially those within prison settings to support their staff, including nurses, to identify moral distress and the implementation of interventions to support those experiencing moral distress. Interventions need to consider all aspects of the organisation, and for healthcare professionals working in prison this needs to involve both the prison regime and prison culture. Interventions need to address the causes of

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moral distress, as preventing or acknowledging these causes can impact on the moral distress of nurses and provide an explanation for their professional performance, increase job satisfaction and retention (Lazzari et al. 2020). An example of an intervention to reduce moral distress is the implementation of a resiliency bundle, which was identified to reduce moral distress in healthcare professionals working in a paediatric intensive care unit (Davis and Batcheller 2020). The bundle included an ethical issue resolution process, mindfulness reminders through a phone application and a patient death process, which included case conferences and discussions, structured debriefings with pastoral care, discussions with colleagues, as well as social events and educational courses aimed at healthcare professionals’ well-being (Davis and Batcheller 2020).

3 Therapeutic Relationships This section will focus on the therapeutic relationships between a nurse and a patient, who is also a prisoner within the prison. The therapeutic relationship within a prison setting requires all healthcare professionals, including nurses, to understand the balance between care and custody (Nolan and Walsh 2012; Foster et al. 2013). Further aspects that impact on the therapeutic relationship between a nurse and a patient-prisoner will also be explored, such as practice dilemmas and the emotional impact of a nurse knowing or imagining the patient’s crime, and finally the concept of ethical caring (Crampton and de Turner 2014).

3.1 Care Versus Custody An important element of the provision of care and support by nurses is the development of a therapeutic relationship with prisoners and within the context of the prison setting. A therapeutic relationship has been defined by many scholars, which encompasses a supportive, caring, non-judgmental relationship between a nurse and a patient within a safe environment (Mottram 2009). A therapeutic relationship continues throughout the provision of care and support, which may be brief or continue over time (Priebe and McCabe 2006). This is especially important within the prison setting due to prisoners’ limited interactions with others, as therapeutic relationships with nurses facilitates effective communication and can support their physical, mental and emotional well-being (Step et al. 2009). Elements of a therapeutic relationship in an acute hospital environment include therapeutic listening and responding to both a patient’s emotions and unmet needs from a patient-centred approach (Kornhaber et al. 2016). These elements are also essential to develop therapeutic relationships between nurses and prisoners to develop trust and support prisoners to engage with healthcare and begin to address the health inequalities of prisoners. The development of a therapeutic relationship between a nurse and a patient can be influenced by a number of factors, some of which may be more prevalent in healthcare in a prison environment. In mental health  care services, factors which

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impact negatively on the development of a therapeutic relationship can be classified as nurse-related, patient-related and organisational-related (Pazargadi et  al. 2015). Nurse-related factors may relate to the personal characteristics of a nurse, which may include a nurse’s natural response to patient presenting with anger towards them and are unable to commence a therapeutic relationship with the patient. Other nurserelated factors may be due to overwork and exhaustion, leading to job dissatisfaction, which may impact on a nurse’s motivation to develop therapeutic relationships with their patients. Whereas organisational-related factors include a continued lack of staff and the recommended patient capacity exceeded, which will negatively impact on the development of therapeutic relationships. Further organisational factors may include a lack of appropriate clinical supervision for healthcare professionals, which may impact on the development of their skills and resilience. This approach demonstrates the responsibility of organisations to both support and develop their staff, rather than the identification of nurse-related factors that impact negatively on the development of therapeutic relationships (Pazargadi et al. 2015). In secure forensic settings, similar internal and external constructions were identified to impact on a therapeutic relationship, but also further elements related to the nature of a secure setting (Stevenson and Taylor 2020). For example, external factors included security, as within forensic and prisons settings, nurses are not working within the care principle of the least restrictive option, as patients are serving a custodial sentence. Whereas,  nurses adhere to the Mental Capacity Act (2005) “before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action”. Another important element to consider within custodial settings is the boundaries imposed to maintain both security and safety of those within the prison, which restrict both nurses and patients from developing a therapeutic relationship. First, the boundaries implemented by secure settings restrict nurse’s expressions of caring (Weiskopf 2005). Second, the usage of shackles or handcuffs on prisoners, which has an impact on their dignity, autonomy and privacy, and  reinforces the restrictive practice of the prison (Bayuo 2018). The development of a therapeutic relationship within a secure setting needs to incorporate or at least acknowledge the custodial aspects experienced by patients, and for nurses to understand how the issues of safety and security impact on the development of a therapeutic relationship. An important aspect that needs further consideration is the difficulty in developing a therapeutic relationship if the nurse is concerned that the patient may become aggressive or violent, as this impacts on the nurse’s ability to engage empathetically (Moreno-Poyato et al. 2016; Stevenson and Taylor 2020; Pazargadi et al. 2015). However, nurses, and other healthcare professionals, have identified when they feel fear, this is reduced by their understanding of the security and prison regime, which demonstrates the complex relationship between safety and security and the impact on therapeutic relationships.

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3.2 Practice Dilemmas A practice dilemma identified by prison nurses regards the need to know or not to know a prisoner’s crime and the consequences if they did know a prisoner’s crime, such as how would this knowledge impact on the care and support they provided. However, Crampton and Turner (2014) identified nurses held different beliefs and reasons for wanting or not wanting to know a prisoner’s crime: • A reason nurses did not want to know a prisoner’s crime was the concern it might impact on the care and support they provided to that prisoner, as one nurse stated, “I’ve never ever known what the patient (prisoner) has done, and I’d probably prefer not to. I would be concerned that it might affect the way I care for them. If I know they’ve hurt little children or raped innocent women or beat up the elderly, it would just make me not want to help them as much, it might make me feel funny” (Crampton and Turner 2014, p. 114). • A reason nurses wanted to know a prisoner’s crime was due to their concern for their own safety, as one nurse stated, “I’m always curious about what they’ve done. Some people say that you shouldn’t know because it can interfere with your care for the patient. But I don’t discriminate, no matter what. Sometimes for my safety it’s been something I’ve wanted to know about, especially when they’ve been looking mean and tough and I’m thinking I could get a broken jaw or something out of it. I’d like to know whether I should keep at arm’s length ‘cause sometimes the guards don’t pay enough attention” (Crampton and Turner 2014, p. 115). • However, on occasions, even when nurses did not want to know a prisoner’s crime, they became aware of the crime due to media attention. When this did occur, nurses described an inner turmoil of not wanting to care for the prisoner, as one nurse stated, “a prisoner was awaiting trial for terrorism charges. and I did look at that patient quite differently. And I did find it quite difficult, to look after this patient, because I knew the story. I knew this person and others were planning to potentially kill a lot of people in my own country. I just didn’t feel like I wanted to look after that person because of that and I did find it difficult to overcome” (Crampton and Turner 2014, p. 115). Nurses working within healthcare in a prison setting need support to work through their beliefs and attitudes towards providing care and support for prisoners, who may have committed crimes that are contrary to their own personal beliefs. Therefore, nurses require continuous support and supervision from their organisation and/or experienced prison nurses to reflect on these practical dilemmas and develop their professional practice. Prisoners need support from healthcare professionals within prison and on release. However, it also important to recognise the impact of discrimination on prisoners by healthcare professionals, as 42% of male prisoners who had recently been released from prison stated they experienced discrimination by healthcare professionals in primary care settings (Frank et al. 2014). Ex-prisoners who experienced discrimination were older, had served a long sentence and were more likely to have a college education. The impact of

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discrimination on ex-prisoners was a lack of engagement with primary care provision on release and a higher attendance at emergency departments (Frank et  al. 2014), which suggests a negative impact on the health outcomes of ex-prisoners. A further practice dilemma identified by healthcare professionals working within a prison setting is confidentiality and when does it become necessary for healthcare professionals to breach a patient’s confidentiality. The dilemma occurs when prisoners engage in or seek voluntary care and support rather than court-ordered therapies, as prisoners are informed that the results or outcomes of these therapies will be shared with the court. Confidentiality within a closed prison setting is difficult, as healthcare professionals collaborate closely with prison officers, who are involved in the movement of prisoners to healthcare. Confidentiality is especially difficult to maintain if healthcare professionals are treating prisoners with infectious diseases, such as tuberculosis, hepatitis or HIV/AIDS, as these involve long-term regular treatment, which can include specialists outside of the prison (MacDonald 2006). Although the process of trying to maintain a prisoner’s confidentiality differs from the dilemma of when should healthcare professionals breech the confidentiality of prisoners. The dilemma for healthcare professionals is when should medical information be shared with anyone outside of the healthcare team. There are clear exceptions to maintaining confidentiality, for instance when healthcare professionals identify risk, such as the safety of the prisoner, other prisoners, prison staff, or disruption to the prison regime. However, there is the need for healthcare professionals to decide when they need to breech confidentiality if they consider this to be in the best interest of the prisoner. Healthcare professionals have been identified to adopt their own approach to addressing this dilemma and applying one of four approaches (Elger et al. 2015): 1. Healthcare professionals reminded the prisoner of the limits of confidentiality with a prison setting and gained informed consent to share information. 2. Healthcare professionals reminded prisoners that all medical information would remain confidential except in certain situations, and these were explained. 3. Healthcare professionals believed that information should be shared in the best interests of the prisoner, and this approach was not discussed with the prisoner. 4. Healthcare professionals dealt with the dilemma on an individual basis with each prisoner. However, breaches of confidentiality by healthcare professionals without informed consent from competent prisoners, unless a risk has been clearly identified, remain an unethical practice. Healthcare professionals, including nurses, need clear guidance and support to understand how to support prisoner’s confidentiality and when it is necessary to break confidentiality. Policies, guidance, training and supervision should be provided jointly by the prison administration and health and social care NHS Trusts. Confidentiality is a practice dilemma for healthcare professionals working in a prison and has also been identified by prisoners as a concern. Prisoners

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tend to believe that prison staff, including prison officers, have access to their medical records since all records are stored on a secure sever to which prison officers have access. One prisoner explained “they (prison officers) say they won’t check but that’s bullshit, they can go into any computer and access whatever they want” (Crowley et  al. 2018). The process of attending healthcare appointments was also identified by prisoners as breeching their confidentiality, as they would be called on the landing to attend healthcare for a certain blood test or hospital appointment, so prisoner officers were aware of their medical history and other prisoners were made aware due to this process (Crowley et al. 2018). The issue of confidentiality of prisoner’s medical history is complex, and there is a need to share information appropriately and when necessary, but there is also the need to protect prisoners’ confidentiality and this can only be achieved through the collaboration of healthcare professionals, prison administration and prison staff.

4 Collaborative Working with Non-healthcare Professionals This section will explore and discuss the need for multi-disciplinary team collaboration of both healthcare and non-healthcare professionals supporting the health and social care needs of prisoners. First, the need for collaboration between nurses and prison officers will be discussed, and examples will include the support of nurses to reduce prison officer’s stigmatisation of prisoners with mental illness (Melnikov et  al. 2017) and the continued need to improve interprofessional collaboration between nurses and prison officers (Hean et  al. 2017). The final element of this section will commence with reflections, thoughts and experiences of a nurse working in a prison and collaborating with prison officers. This will be followed by an exploration of the need for collaboration between nurses and prisoners who provide care for other prisoners, with examples such as Gold Coats in the United States and buddies in the United Kingdom (Berry et al. 2016; Brooke and Rybacka 2020; Moll 2013). Lastly, a discussion on the need for collaboration between nurses and third sector or charitable organisations, such as the Alzheimer’s Society to support prisoners (Purewal 2020).

4.1 Collaborative Working of Nurses and Prison Officers Nurses working in a prison environment are required to collaborate closely with prison officers due to the need to provide care within a secure regime. For example, when a nurse is delivering a clinic, the prison officers are responsible for unlocking each prisoner and escorting them to the clinic, which needs to occur within a specific timeframe to ensure all prisoners on the clinic list are seen. The process and protocols of the provision of assessments, care and treatment of prisoners reiterate the requirement of prison officers to be present or in close proximity. However, the relationships

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between nurses and prison officers have been identified to be difficult, as the priority of prison officers is safety and security, whilst the nurse’s priority is the provision of healthcare. Difficulties occur when prison officers question the legitimacy of the need for a prisoner to attend healthcare and the nurse’s decision regarding the care needs of a prisoner. When these circumstances occurred, nurses avoided conflict with the prison officer as they acknowledged that they continued to require their cooperation and support, as well as protection if the need arose (Almost et al. 2013). Nurses have identified that the attitudes and presence of prison officers whilst providing care can be a barrier to appropriate empathetic care, due to the relationship between the prison officer and the prisoner and the power imbalance (Solell and Smith 2019). Nurses have also reported a lack of insight of mental health conditions by prison officers, such as self-harm, and their adoption of a medicalisation approach to self-harm, which causes tension when providing care to prisoners (Marzano et al. 2015). The approach of medicalisation of self-harm focuses on the prescription of medication to prevent self-harm, which is often unnecessary, but from the perspective of prison officers would support the prison regime (Marzano et al. 2015). An approach to challenge prison officers’ attitudes and for prisoners to view prison officers as supportive of their healthcare needs has been to include prison officers as members of the multi-disciplinary team. This approach enables prison officers to understand both the physical and mental healthcare needs of prisoners, and how they can support individual prisoners within the prison regime (Powell et al. 2010). There remains the need to continually improve interprofessional collaboration between nurses and prison officers (Hean et al. 2017; Brooke and Jackson 2019; Brooke and Rybacka 2020, 2021). The perspectives of prison officers current and desirable levels of interprofessional collaboration have been explored, with the identification of desirable and highest levels of collaboration with primary care nurses (Hean et  al. 2017). Although the largest difference between current and desirable collaboration occurred with mental health specialists, including nurses and doctors, especially when prison officers needed support with a prisoner who needed support with their mental health. Prison officers have also identified their lack of understanding of other health conditions, such as dementia and psychosis, and how to identify if a prisoner is experiencing poor health or the effect of an illegal substance (Brooke and Jackson 2019). As one prison officer stated, Sometimes we have problems identifying whether it is mental health or dementia or learnt behaviour, because we are not trained in that type of stuff… we don’t know, with the older guys, is it because they have been in prison for years or is it drug induced, or alcohol induced, or an illness, we don’t know… (Brooke and Jackson 2019, p. 813).

The needs of the prison officers, as well as the nurses, are essential to understand to support interprofessional collaboration and deliver healthcare within a prison. Nurses working in prison are optimally placed to support prison officers understanding of the healthcare needs of prisoners. Nurses have begun to implement initiatives to challenge and develop prison officers’ perceptions and knowledge of both physical and mental health conditions, including mental illness, dementia and ageing (Melnikov et al. 2017; Brooke and Rybacka 2020). For example, one nurse-led initiative involved

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a 6-day workshop to address prison officers’ negative attitudes to mental health illness (Melnikov et  al. 2017). The workshop explored cognitive, psychoeducational and behaviour components of negative attitudes, alongside the opportunity for prison officers to observe care and treatment on an acute mental health ward, as well as case reviews, formal lectures and simulation learning. The evaluation suggests that prison officers who attended the 6-day workshop demonstrated a decrease in negative attitudes and an increase in knowledge of mental health conditions. Another example involved the development and implementation of a brief (2  h) nurse-led prison dementia education programme (Brooke and Rybacka 2020). The nurse-led programme was developed specifically to support prison staff and prisoners to identity and support prisoners with dementia. Three phases were included in the development of the programme: first, the current understanding of prisoners and prison officers’ knowledge of dementia; second, understanding prisoners and prison officers’ experiences of supporting prisoners with dementia; and third, the development of a programme to include and address the elements identified in the first and second phase. The dementia education programme included barriers identified and an explanation of current initiatives, a short PowerPoint presentation, videos, handouts and group activities. The programme was evaluated positive by both prisoners and prison offices, who engaged fully in discussions that challenged their misconceptions. Case Study: A Nurse’s Experiences of Working in a Prison and Collaborating with Prison Officers

The officers are actually one of the biggest challenges to healthcare within the environment. A good officer will facilitate the clinic you are trying to run, bring your patients to and from their areas within the establishment and allow you adequate time to make your assessments, or discuss treatment. However, a less agreeable officer can cause missed appointments, may try to impose time limits upon your consultations, or even interfere in the schedule and offer their own advice as to how the patient needs treating. The mood of your patient may well depend upon the attitude of the officer who has accompanied them to the appointment, a friendly professional officer usually indicates a productive pleasant healthcare appointment. A moody, tired or arrogant officers will most definitely reflect his feelings, and this is likely to impact upon the attitude of the inmate when he arrives in your consultation room. Working in a prison is an interesting experience, a lot of people have concerns around safety, but I think it is far safer than a lot of community environments. Nurses have an emergency radio, there are alarm bells, security cameras and officers. Nurses can get ‘burnt out’, it is a violent oppressive environment with lack of respect, care, empathy and understanding you must challenge poor practice from officers and nurses otherwise you risk being part of it.

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4.2 Collaborative Working of Nurses and Prisoners Nurses working within the prison environment also support prisoners who care for other prisons. Two examples will be discussed, one implemented in the United States, the Gold Coats (Berry et al. 2016), and another in the United Kingdom, the buddies (Brooke and Rybacka 2021; Moll 2013). The two examples presented identify the need to support older prisoners, especially those with cognitive impairment, and how this can be successfully implemented for both the older prisoner requiring care and the prisoner providing care. Prisoners who provided care are supported through the completion of recognised training schemes that enable them to engage in worthwhile employment in prison, which may lead to employment on release. Nurses may not be directly involved in training of prisoners to provide care, but require an understanding of these roles, including both the responsibilities and limitations of care prisoners can provide. Nurses need to support these prisoners and be aware of the emotional impact of caring within a prison setting and ensure the needs of prisoners requiring care are met. Nurses also need to support and empower prisoners providing care to become involved in multidisciplinary team meetings, as they will be able to give an accurate description of a prisoner’s needs, identify if these needs are changing and/or their condition is deteriorating.

4.3 The Gold Coats The Gold Coat programme was developed and implemented in a state prison in the United States, the California Men’s Colony. The prison was opened in 1954, holds up to 3414 prisoners and is a minimum to medium security male prison. The name of the programme ‘Gold Coat’ is due to the uniform provided to prisoners who have completed the programme, which is a gold-coloured smock. A bright colour was chosen to ensure these prisoners were easily identifiable. The programme was developed to provide training, education and support to prisoners to empower and enable them to support and care for older prisoners with cognitive impairment (Berry et al. 2016). An important element of the Gold Coat programme and the role of prisoners who have completed the Gold Coat programme is to protect older prisoners, and especially those with cognitive impairment, from bullying and victimisation from other prisoners. Any prisoner may apply to complete the Gold Coat programme; however, the inclusion criteria is necessarily restrictive and includes only prisoners with no disciplinary actions within the last 10 years, still have a long sentence ahead of them, do not have any psychological or mental health problems and have completed the necessary rehabilitation that accompanied their original sentence. The Gold Coat programme is comprehensive and is provided over 3–4 months by a clinical psychologist within California Men’s Colony prison. The focus of the programme is to provide the necessary skills to a prisoner to enable them to support and care for an older prisoner with cognitive impairment, including:

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• Communication skills to respond to a prisoner who may become agitated or aggressive, including how to either redirect or deescalate a situation • Cognitive focusing techniques, such as cognitive exercises and cognitive simulation therapy • Providing care to a prisoner to assist with their activities of daily living • Coaching or supporting involvement in physical exercise and sports activities • Supporting involvement in social interactions and recreational activities • Providing companionship at meals, and supporting nutritional intake • Further support as necessary, such as reading or writing of letters. The Gold Coats role is to support and care for older prisoners with cognitive impairment and to ensure their health and social care needs are met, and potentially slow the progression of the prisoner’s cognitive impairment, but their role is not to replace a healthcare professional. Prisoners who become Gold Coats also need ongoing support from both the clinical psychologist and other healthcare professionals such as nurses, as the impact on providing care in the enclosed environment of prison can be emotionally draining. As one Gold Coat expressed: My first client was an angry, disabled patient who would not eat. Staff tried to bribe him to eat but it only made him angry. I sat with him, and he finally said he liked coffee. I was able to get him coffee but told him he had to eat a little first. He did and then started eating regularly. We became very close, and I cared for him for a long time—I cleaned up when he soiled himself, helped him shower etc. all the while trying to protect his dignity. Eventually, he ended up in the hospice, where I continued to visit him. Just before he passed, he told me ‘Thank you for everything.’ I cried like a baby (Berry et al. 2016 p. 65).

4.4 Buddy Support Worker England has a similar programme to that of the Gold Coats and is referred to as the Buddy Support Worker programme, and on completion of the training within this programme, prisoners are referred to as ‘buddies’. This programme has been implemented across prisons in the South West of England (Moll 2013) and supports any prisoner who has health and social care needs, not just older prisoners with cognitive impairment. The training within this initiative is led by the charity RECOOP (Resettlement and Care of Older ex-Offenders and Prisoners) and has been adapted from the standards for health and social care workers in England. The training includes a series of modules, all of which need to be successfully completed to be awarded a National Care Certificate. The modules encompass an understanding of the role, duty of care, equality and diversity, and how to maintain a prisoner’s dignity and privacy. However, the modules also focus on how to support a fellow prisoner from a person-centred approach, including the development of communication and advocacy skills, safeguarding, health and safety, handling confidential information and awareness of mental health and learning disabilities. Buddies are also trained to support a prisoner in a wheelchair, as well as to provide adequate fluids and nutrition. However, buddies are not allowed to support a prisoner with their

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personal hygiene, and there is a strict no contact rule, which simply stated as no physical contact from a prisoners nipples to their knees. Once a prisoner has completed the training element of the Buddy Support Worker programme, a probation period needs to be successfully completed. The probation period includes observations of the prisoners providing care and support by trainers from RECOOP, and written statements from the prisoners they have supported. The probation period may last for a couple of months, until both the trainer and the prisoner are assured of the competence of the care and support provided (Brooke and Jackson 2019). An important element of the Buddy Support Worker programme is the ongoing support through monthly meetings with trainers to discuss any concerns or difficulties and to share good practice. The buddies have described these meetings as essential as they may be moved to another prison without notice, and therefore they believed it was essential to share good practice. The needs of buddies to share good practice demonstrates their commitment to caring for and supporting fellow prisoners. As one buddy stated: “It is about best practice; we tell each other what we have been doing, what is working well for us because at the end of the day if I get shipped out to a different jail they have got to step in, it kind of alleviates the teething problems” (Brooke and Jackson 2019, p. 814). The Buddy Support Worker programme has been awarded the Health Service Journal Patient Safety Award in 2019, which is an award judged by experts from both health and social care sectors.

4.5 Collaborative Working of Nurses and Third Sector or Charitable Organisations Nurses working within the prison also need to collaborate with third sector or charitable organisations supporting prisoners, such as the Alzheimer’s Society (Purewal 2020). The Alzheimer’s Society has provided training for prison officers to enhance their understanding of dementia and how to support prisoners with dementia, and have delivered ‘dementia friends’ sessions to prisoners and trained prisoners to become ‘dementia champions’. Therefore, prisoners will be able to facilitate ‘dementia friends’ sessions for fellow prisoners and sustain a basic understanding of dementia amongst prisoners. The development of prisoners as dementia champions has created a sense of community within individual prisons, some of which have begun to discuss and address wider aspects of mental health. The Alzheimer’s Society have also developed criteria for ‘dementia-friendly communities’ (DFC), which have begun to be applied in prisons (Treacy et al. 2019) with the support of prison administration. However, it is essential for prison nurses to have an oversight of these initiatives to ensure the information and provision of advice is both accurate and appropriate. Nurses caring for prisoners also need to understand the charities and the process of referring prisoners to access support from different charitable organisations working within prisons, these vary depending on the prison, and may not be directly related to health, but may include the following:

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• PACT—Prison Advice and Care Trust, a charity in England and Wales, which supports prisoners, people with convictions and their families across each stage of the criminal justice process. PACT supports those in prison through initiatives such as the first night and early days in custody and a prison-based social worker who support mothers during their sentence and their children. • Koestler Arts—Although based in West London, the charity has partnered with other organisations across the United Kingdom. Koestler Arts supports and works with prisoners to express themselves through art and support them to lead more positive lives. • Story Book Dads—A UK charity, which supports prisoners who are Dads to record bedtime stories for their children, and these recordings are edited by prisoners who are completing training/work experience in audio software. There are also many other creative initiatives to support Dads to remain in touch with their children. • Fine Cell Work—A UK charity, which supports prisoners to develop skills and earn money through high-quality needlework. The aim is to engage prisoners in rehabilitation through meaningful activities, develop accountability and hope for independent living on release. • Prisoner Education Trust—A charity in England and Wales, which supports prison education by funding distance learning at levels and subjects not available in prisons. The courses are completed in prisoners own time and from within their cells. • Shannon Trust—A charity in England, Wales and Northern Ireland, which supports prisoners who can read to support and teach those who cannot read. The charity provides support and resources, and learning occurs outside of formal education provided by prisons. Learning to read is an essential skill that can transform a person’s life.

5 Conclusion This chapter commenced with the introduction of the history of prison nursing, both in the United States and England, with an explanation of the United States 1976 Supreme Court decision of Estelle versus Gamble, which identified the lawful requirement of healthcare for prisoners. In England, healthcare for prisoners was implemented in 2000 with the transfer of responsibility of healthcare to the NHS. A brief timeline of the changes in the responsibility of healthcare provisions within English prisons has been presented. The development of the professional identify of a nursing has been discussed, as well as the professional identify of a nurse in a prison setting, which includes both emotional labour and moral distress. This chapter also explored the ethical dilemma of care versus custody and the development of a therapeutic relationship with a prisoner. Lastly, this chapter also explored the need for nurses working in a prison to work collaboratively with non-healthcare professionals, including prison officers and charities.

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Primary Care in Prison Joanne Brooke and Nina Shamaris

This chapter contains three case studies of a primary care nurse’s reflection, thoughts and experiences of working in primary health care in a male prison, including ‘Holistic care’, ‘Autonomous decision-making’ and ‘Patients’ best interest’.

1 Primary Care Primary care is usually the first point of contact for people who have concerns regarding their health. The provision of primary care in general practices in England and Wales has changed and developed since the implementation of the NHS in 1948. Primary care is predominantly provided in general practices by healthcare professionals including general practitioners (GPs), community, primary and practice nurses. Primary care services are also provided outside of general practices, which are equally important and need to be acknowledged, although not the focus of this chapter, and include community pharmacists, opticians and dentists. Important landmarks in the development of primary care services include the development of the Royal College of General Practitioners (RCGPs) in 1972 and GP training in 1976, which only became mandatory in 2007, when a national training programme was developed and implemented. The inclusion of health promotion as a role of primary care was implemented in 1978, and in the late 1990s and early 2000s, nurse-led personal medical services began to be implemented to support primary care provision (King’s Fund 2001). J. Brooke (*) Centre of Social Care, Health and Related Research, Birmingham City University, Birmingham, UK e-mail: [email protected] N. Shamaris School of Nursing and Midwifery, Birmingham City University, Birmingham, UK e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 J. Brooke (ed.), Nursing in Prison, https://doi.org/10.1007/978-3-031-30663-1_4

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The core purpose of primary care has not changed over time, which is a commitment to the provision of a service that supports general health, and healthcare professionals that are generalists. Primary care healthcare professionals need to understand a broad range of mental, physical and social problems that a patient may be experiencing, rather than specialising in one disease. The responsibility of the GP and primary care nurse is to ensure patients are referred to appropriate specialists, whilst supporting and coordinating care for patients with multiple or complex conditions. Therefore, GPs and primary care nurses may support patients with common minor conditions and the management of long-term conditions such as diabetes, but also engage in health promotion through education, vaccination and screening programmes. Over the last decade, primary care services have become responsible for treatment, care and follow-up appointments that were previously provided within secondary care services (acute hospitals). The development of primary care services has influenced the role of the primary care nurse, who has a range of responsibilities, which previously would have been undertaken by a GP (King’s Fund 2011). Due to the development of primary care services in England to support the growing population and people who are living longer with long-term conditions, primary care networks (PCNs) have been developed and implemented (NHS England 2022). PCNs support GP practices to work together with other primary care services in their community such as mental health and social care, as well as voluntary services and charities, providing ‘proactive, personalised, coordinated, and more integrated health and social care for people close to home’ (NHS England 2022). Currently, there are 1250 PCNs across England, which are formed around general practices in local communities and serve between 30,000 to 50,000 patients. The majority of general practices (99%) in England are part of a PCN. Each PCN is led by a board of clinical directors, which includes a GP, primary care nurse, pharmacist and other relevant healthcare professionals who work within services of each PCN. A requirement of PCNs is the development and delivery of services across seven specific areas, the first three areas were identified in 2020 and 2021 with the introduction of structured medication reviews, enhanced health in care homes and support for early cancer diagnosis. The remaining four, which are yet to be implemented, include anticipatory care, personalised care, cardiovascular disease case-finding and services to address local inequalities in healthcare (King’s Fund 2020). The involvement of PCNs within primary care in prison is essential, as this approach enables wider commissioning to support prisoners access to broader services and the continuity of care for prisoners on release (NHS England and NHS Improvement 2020). There has been an increased focus on the provision of primary care in prisons since the transfer of commissioning and provision of healthcare services to the NHS (Condon et al. 2007). The importance of primary care within prisons has been recognised since the beginning of the twenty-first century, due to the identification that the majority of prisoner’s healthcare needs can be met by primary care. However, the role of primary care, including the role of the primary care nurse, needs to recognise and adapt to the specific needs of prisoners, as well as how prison may

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impact on prisoners’ health. This is essential as there are many similarities between the provision of primary care in prisons and the community, but there are also differences that need to be recognised. The differences occur due to the impact of the loss of freedom experienced by prisoners and how healthcare can be provided in prison. These differences have been defined by the World Health Organization, Europe (Frazer 2014) and are discussed below within the role of the primary care nurse in prison: –– A negative impact on prisoners’ health is the loss of social contact, including the loss of social support from family and friends, which impacts on how a prisoner accesses or obtains information regarding their health. Therefore, it is essential for primary care nurses to be aware the information they provide to prisoners, may be the only information prisoners have access to or are able to obtain, as they will not have the opportunity for timely conversations with those they would normally turn to and whose opinions they respect. –– The prison environment may impact negatively on prisoner’s mental health. Therefore, it essential for primary care nurses to engage in holistic assessments of prisoners in order to support the identification of mental health issues and concerns and determine whether they can be addressed within their consultation or whether further support or referral is required. –– The prison environment may impact on a prisoner’s understanding of their decision-­making ability, as prisoners may perceive their right to make decisions has been removed. Therefore, it is essential for primary care nurses to ensure prisoners are aware of their rights, especially their rights to healthcare, which includes the right to decline treatment and care if they wish. –– A further element of the prison environment that impacts on the provision of primary care for prisoners is the length of a prisoner’s sentence or the movement of a prisoner from one prison to another, which impacts on the provision of courses of treatment and the therapeutic relationship between healthcare professionals and the prisoner. Therefore, it is essential for primary care nurses to endorse the motto of Public Health England and NHS England ‘make every contact count’ (2016). –– A prisoner is unable to choose their primary care team, and primary care teams working in prison are unable to choose their patients. This is similar to the provision of primary care in England and Wales, although in other countries the choice is available for both patients and primary care teams. Therefore, it is essential for primary nurses to focus on developing therapeutic relationships with prisoners to ensure optimal healthcare provision. Primary care services within prison have begun to be explored to understand the necessary components to support positive outcomes for prisoners and positive working environments for healthcare professionals, including those of primary care nurses. An early model developed to support primary care services in a prison in England highlights three essential elements: the first element identifies the importance of prisoner involvement and the collaboration between

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prisoners, prison staff and healthcare professionals (Cowman and Walsh 2013). The second element identifies the need for prisoners to be aware of and understand primary care provision within prisons, as well the need for prisoners to trust both prison staff and healthcare professionals, and the third element identifies the need to empower prisoners to adopt healthy behaviours and to support other prisoners with their health. The development of the role of healthcare representatives for prisoners who were interested in supporting primary care services was implemented. This new role supported and improved relationships between healthcare representatives and healthcare professionals, including primary care nurses, and increased prisoners’ engagement with primary care services (Cowman and Walsh 2013). The last essential element of this model, and possibly the most important, is the need to recognise and continually address the organisational culture of the prison and the power imbalance between prisoners and prison and healthcare staff. The implementation of this model has supported primary care nurses, who identified an increase in job satisfaction and intention to stay (Cowman and Walsh 2013). New models are beginning to be implemented in prisons and support collaborative healthcare provision across primary and secondary care provision to support the health of prisoners. A contemporary example from Australia includes the introduction of a nurse navigator as part of the primary care provision in prison to support a reduction in the number of prisoners requiring transfer to local emergency departments (Collett et al. 2022). The role of the nurse navigator encompasses four strategic objectives: 1. Capacity building within primary care provision in prison, which includes effective and comprehensive multi-disciplinary team meetings for prisoners with complex health needs, with the inclusion of a problem-solving approach on how care can be provided within prison. 2. Engagement with senior clinicians from local emergency department to support their understanding of the complexities of primary care provision in prison and develop a collaboration to improve prisoners health. 3. Involvement of emergency department representatives within prison administration and health services executive meetings to support the governance of new clinical pathways and possible operational risks both within the prison and the emergency department. 4. Implementation of regular informal meetings between clinical healthcare professionals within the prison and emergency departments to build trust and transparency. The evaluation of this model identified a significant reduction in the need for prisoners to attend an emergency department, through the development of collaborative holistic care. The development and role of a primary nurse as a nurse navigator, who works across primary and secondary care, can enable the complex and challenging health care needs of prisoners to be addressed (Collett et al. 2022).

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2 Primary Care Nurse This section will focus on the broad and diverse role of a nurse within primary care provision in prison, which falls within the three categories of supporting the general health of prisoners, management of long-term conditions and health promotion (Condon et al. 2007). This section will commence with a discussion on supporting the general health of prisoners, with a focus on the importance of continuity of care through reception screening, administration of medication and emergency care. The following section will explore how the role of the primary care nurse has developed to support patients who are prisoners with the management of long-term conditions, such as the implementation of a tool for Tracking and Assessing Chronic Illness Care in Prison (ACIC-P) (Wang et al. 2014). Lastly, this section will discuss the need of health promotion for prisoners, which can be delivered by primary care nurses, and will include an example of the implementation of a health promotion intervention in a prison in England (Finnie 2018).

2.1 General Health The general health needs of prisoners are greater than that of their community dwelling counterparts (Prison Reform Trust 2005), due to health inequalities, social disadvantages and a lack of engagement with healthcare services. A core objective of NHS England and HM Government partnership (2018) is the continuity of care for people entering prison, including before, during and after serving a prison sentence. Therefore, primary care nurses within prisons are optimally placed to support holistic assessment, referral and treatment. An important process is the understanding of a prisoner’s health as they enter prison, and this process commences in reception on the day prisoners arrive at the prison. A primary care nurse will complete a reception screening questionnaire with each prisoner and ensure that the appropriate referrals are completed. Referrals may include next-day appointments with a GP if a prisoner has a long-term condition, or to a detox team if a prisoner has identified either alcohol or drug use/dependence. Prisoners may also be referred for first night appointments, such as the first night GP list, if medications need to be prescribed, or to the mental health first night team, if a prisoner is considered to be at risk or requires a depot injection. Reception screening continues to  occur over two days following a  prisoners arrive, and during this time the prisoner will remain in a cell in reception, which is usually referred to as the first night wing, until the screening process is completed. If prison officers notice or have concerns regarding a prisoner’s health, whilst they are on the first night wing, this concern is raised, and the prisoner will be reviewed by a GP or primary care nurse the following morning. The second day in reception supports another opportunity for primary care nurses to capture further health information and complete physiological measurements, as well as offer vaccinations and support, such as referral to a stop smoking clinic. The World Health Organization, Europe have identified specific screening, which should occur on reception and

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within the first few days of a prisoner entering a prison; see Box 1 for an overview of ‘Reception Screening’ and Box 2 for an overview of ‘Follow-up Screening’ (Frazer 2014). Box 1 Reception Screening

The following questions need to be explored by healthcare professionals, either a GP or a primary care nurse, for all prisoners each time they enter the reception of a prison: –– What are the main health problems of the prisoner, are all appropriate medications prescribed, do they have any outstanding hospital appointments or procedures? –– Does the prisoner have any conditions that could lead them to being at risk to themselves? Consider if the prisoner will experience withdrawal from substance misuse, both illegal or prescribed medications, and if the prisoner is a risk of self-harm or suicide. –– Does the prisoner have any current injuries, which may have occurred during their arrest or previous detention and a sign of ill-treatment? –– Does the prisoner present or pose a risk to others? Consider if the prisoner has an infectious disease or other health issues that may impact on the risk of a prisoner becoming violent. Adapted from the World Health Organization, Europe (Frazer 2014) Box 2 Follow-up Screening

Follow-up screening can occur the following day (within 24 hours), which is the process in prisons in England and Wales, or after a short period when the prisoner has settled into prison. This usually involves a follow-up of health issues identified and the collection of further detailed information, and is completed by a GP or primary care nurse, and includes the following: –– Are the main health problems of the prisoner identified on reception screening under control, and all appropriate medication prescribed and received? –– Does a prisoner require further in-depth assessment of their current health problem and the development of a treatment plan? –– The completion of a comprehensive health assessment of each prisoner, including vaccinations, such as Hepatitis B and COVID-19. –– Does a prisoner require any specialist assessment, further reports or the development of a treatment plan for a new diagnosis? –– Does a prisoner require an integrated care plan for complex health issues, such as mental health problems and substance dependence, and if so, who is responsible and will action the care plan? –– Are there any further key determinants that will impact and influence a prisoner’s health? Consider housing, sentencing and family matters.

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Adapted from the World Health Organization, Europe (Frazer 2014) The role of the primary care nurse also includes the administration of prescribed medication to prisoners. This process traditionally occurs via medication hatches, through which a primary care nurse administers the appropriate medication to prisoners. Each prison contains a number of hatches to support timely administration of medications across the prison, which usually occurs twice a day, unless there is an exceptional circumstance for more regular medication. During this process, it is essential that the primary care nurse witnesses the prisoner taking their medication due to the possible abuse of certain medications in prison. This traditional method has been challenged due to the ageing prison population and increased healthcare needs of prisoners (Peek 2022). The impact of increased demand and the provision of medication through hatches has increased waiting times for prisoners, bullying of prisoners whilst waiting and the possibility of missed doses due to the strict structure of the prison regime, resulting in negative experiences by prisoners (King’s Fund 2020). Issues regarding administration of medications to prisoners have led to the implementation of in-possession medications, where prisoners are supported to administer and store their own medications, following the completion of a risk assessment (Peek 2022). Only certain medications can be managed by prisoners; for example, controlled drugs are managed by healthcare professionals due to the potential of misuse, trading and bullying. There are many benefits of in-possession medications in prison, for example the benefits for prisoners include the promotion of self-care and the responsibility to take their medication as prescribed. The benefits of in-possession medications for primary care nurses include less time administering medications and more time supporting prisoners with long-term conditions, which increases both job satisfaction and retention while also reducing the omission of doses and medication errors (Shropshire Community Health NHS Trust 2022). In one prison in England, 16% of prisoners were supported to manage their in-­ possession medications, and all stakeholders reported improvements in prisoners’ access to medications, reduced omissions and delays in receiving medication, as well as improvement in the management and control of long-term conditions (Peek 2022). The role of the primary care nurse in prison is diverse, because the role also includes responding to health emergencies within the prison. In prisons in England and Wales, primary care nurses carry an emergency radio, which has only two codes, ‘code blue’, which indicates that an emergency may include one of the following: breathing difficulties, chest pain, choking, seizures, possible stroke or the prisoner is unconscious. Whereas ‘code red’ informs the nurse that there is significant blood loss, these calls may include self-harm, drug overdose, hanging, or incidents that have occurred through violence. The role of the primary nurse in emergency situations is to arrive with appropriate medical equipment and comprehensively assess the patient, who might be a prisoner or a member of staff. The recognised ABCDE (Airways, Breathing, Circulation, Disability, Environment) approach is applied to systematically identify the needs of the patient, whilst obtaining a history from anyone who witnessed the incident. The nurse is not the sole responder to an emergency but may be the only healthcare professional present.

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Following the assessment and provision of emergency treatment, the nurse informs prison administration if the patient needs urgent transfer to a hospital emergency department. The transfer of a prisoner to hospital will require prison staff to escort the prisoner, which may impact on delivery of the prison regime and therefore be opposed by the prison administration. The case study provided at the end of this chapter includes an example of the responsibilities of a primary care nurse attending a ‘code red’, and how the nurse had to advocate for the patient, a prisoner, to be transferred to an emergency department for further treatment.

2.2 Management of Long-Term Conditions The role of the primary care nurse in prison also includes the management of long-­ term conditions, which include conditions that can be controlled by medications, lifestyle behaviours, or other forms of treatment, but cannot be cured (Department of Health 2012). The risk factors for an onset of a long-term condition disproportionately impact on prisoners than the general population (Wright et al. 2019). The risk factors for and the development of long-term conditions have an impact on prisoners’ needs to attend primary care, which is three times higher than those living in the community (Marshall et al. 2001). Therefore, an important element of primary care services within prisons is to support the continuity of care for long-term conditions, which is supported by primary care nurses, and commences within reception and the screening process as prisoners enter prison (as described earlier in this chapter). The process is also supported by obtaining confirmation from the prisoners GP, called ‘GP confirmation’, which provides information on previous and current healthcare conditions and medication, as well as outstanding primary and secondary healthcare appointments. A recent study identified the responsibility of obtaining GP confirmations varied from prison to prison in England, and in some prisons, it was the responsibility of the primary care nurse (Wright et al. 2021a, b). A Prison Service Order (PSO), number 3050, entitled ‘Continuity of Healthcare for Prisoners’ was implemented in 2006 (HMPS 2006), which provides mandatory guidance on how to ensure the continuity of care for prisoners during reception, transfer and release. The consideration of continuity of care when transferring prisoners between prisons is important. In 2018 it was estimated that almost 66,000 prisoners in England and Wales were transferred from one prison to another prison, which equates to the movement of 275 prisoners a day (Healthcare Safety Investigation Branch 2019). Transfer of prisoners between prisons occurs to support not only the needs of prisoners, who may be required to attend specific training courses that are only delivered within certain prisons, but also the needs of the prison estate, for example, if a prisoner is deemed to be a high security risk. When prisoners are transferred to a new prison, they are also transferred to a new primary care team, which creates challenges for continuity of care. The guidance of PSO number 3050 is to ensure the current healthcare needs of prisoners are assessed prior to transfer and a plan created to support continuity of care. Each plan should

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include an overview of a prisoner’s current physical and mental health, current mediations and any outstanding primary and secondary care appointments. A supply of medication should accompany the prisoner to ensure that medications are continued until a new GP prescription can be obtained. The primary care nurse will be involved in both the transfer and reception of prisoners and ensuring the continuity of care for these prisoners. In two prisons in England the prevalence of prisoners living with long-term conditions was significantly higher than those living in the community, with 46% of prisoners reporting at least one long-term condition (Wright et al. 2019). A tool to support the continuity of care of long-term conditions in prison has begun to be explored in the United States (Wang et  al. 2014) through the development of an existing tool, the Tracking and Assessing Chronic Illness Care [ACIC] (Bonomi et  al. 2002), although the terminology applied is different to that of the United Kingdom, the overarching elements of the tool are transferable. The ACIC is a tool to support primary care services to assess and understand their provision of care for individuals with long-term conditions. The tool contains six components focusing on self-management support, linkage to community resources, decision support, delivery system design, clinical information systems and organisation of the health system. Each component contains a number of questions with set answers that are scored from 0 to 11, with the scores representing the level of support for individuals with long-term conditions. A score of 0 to 2 identifies little to no support, 3 to 5 basic or intermediate support, 6 to 8 advanced support and 9 to 11 optimal, comprehensive or integrated support (Bonomi et al. 2002). The tool identifies areas of care for long-term conditions, which require improvement. The Assessing Chronic Illness Care in Prison (ACIC-P) tool (Wang et al. 2014) has been amended to include specific elements of the prison setting, such as the movement of prisoners across different primary and secondary care settings, and the need to collate information from these different services. In England, the tools and frameworks applied in community-based primary care services focus on the collating and sharing of information regarding long-term conditions, by applying the Quality and Outcomes Framework (British Medical Association 2019). This national standardised framework is embedded in community-­based general practices and is linked to financial remuneration for certain activities. For example, for patients with long-term conditions, financial remuneration is linked to annual assessments against key clinical outcomes. However, this is not the same approach applied in general practices or primary care within prisons in England, as the use of the Quality and Outcomes Framework is not mandatory, and if completed there are no links to financial remuneration. The only mandated processes for primary care in prison regarding the identification of long-term conditions is screening on reception, such screening focuses on identification and not clinical outcomes (Wright et al. 2021a, b). Therefore, there is the possibility of a missed opportunity to improve clinical outcomes associated with long-term conditions. The primary care nurse is optimally placed to address these missed opportunities and support the implementation of the Quality and Outcomes Framework.

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Primary care nurses within prisons also lead clinics to meet the needs of prisoners with and without long-term conditions. This may include clinics for prisoners over the age of 50, as service specification for primary care in prisons in England (NHS 2020) states prisoners over the age of 50 need to have access to a clinic, which provides a medication review and a complete health and social care screen. The aim of the health and social care screen is to support the identification and treatment of long-term conditions, as well as the development of a care plan that is implemented and reviewed on a regular basis. Other clinics may include a focus on diabetes, respiratory conditions, wound dressings, infectious diseases such as hepatitis C (which will be explored further in the next section), HIV/AIDs or open clinics when a prisoner has requested to see a healthcare professional.

2.3 Health Promotion The development and implementation of health promotion within primary care services in a prison is due to the need to support prisoners to adopt healthy behaviours and lifestyles. Prisoners are recognised to have led unhealthy lifestyles prior to entering prison. However, the prison environment also contributes to the maintenance of unhealthy behaviours of prisoners. The impact of continued unhealthy behaviours of prisoners is the development of lifestyle-related health issues, such as obesity (Gates and Bradford 2015). Prisoners have also identified the need for support to adopt healthy behaviours with almost a third of prisoners in the United Kingdom engaging with health or well-being services whilst in prison (Lewis 2013). Prisoners also seek support from other prisoners or referrals to exercise programmes delivered within prison gyms (South et al. 2014). The World Health Organization has created the concept of health-promoting prisons to further support prisoners to adopt healthy behaviours, which acknowledges that individual’s health is not only determined by their actions and healthy behaviours but also requires a supportive environment (Baybutt et al. 2014). The concept of health-promoting prisons involves four essential elements: first, the implementation of programmes to support prisoners to improve their skills, confidence, abilities and understanding of health to empower them to make informed decisions regarding their health. In response, HMP Brixton, in 2015, implemented a programme to support the health promotion of prisoners by appropriately trained professionals. The health promotion programme supported prisoners to attend six appointments, where they received advice to adopt healthy behaviours with a focus on diet, exercise and smoking cessation (Finnie 2018). Second, the need for prisons to improve the physical and social environments of prisons and the recognition of prison as a home for prisoners and a workplace for staff. Therefore, the implementation of programmes to support and promote the health of both prisoners and prison staff. Third, the development of the management of prison and daily prison regime to support a whole-prison approach to health promotion, including the physical,

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mental, social and spiritual health of prisoners and prison staff. Lastly, the structured collaboration with community services (Baybutt et al. 2014). In prisons in England and Wales, the Prison Service Order number 3200, Health Promotion, was implemented in 2003, which supports the approach of the World Health Organization, with a whole-prison approach to both creating and supporting a health-promoting prison. The PSO number 3200, explicitly states: The Health Promotion Section in the local plan must specifically address, as a minimum, needs in five major areas: • Mental health promotion and well-being • Smoking • Healthy eating and nutrition • Healthy lifestyles, including sex and relationships, and active living • Drug and other substance misuse

The process of supporting health promotion within each of these areas commences with the completion of a health needs assessment with consideration of the individual prisoner within a prison environment. Health promotion clinics support the further assessment of prisoners, are led by primary care nurses and include screening, assessment, advice, education, support and training. Health promotion occurs depending on the needs of each individual prisoner, although this is generally divided into three distinct categories, which included health promotion all prisoners are likely to need (Box 3), health promotion many prisoners are likely to need (Box 4) and health promotion some prisoners are likely to need (Box 5). Box 3 Health Promotion All Prisoners Are Likely to Need

–– screening for communicable diseases, such as sexually transmitted diseases, HIV, hepatitis C, followed by advice on prevention of communicable disease, whilst in prison and on release –– screening, advice and education on unhealthy behaviours and high-risk lifestyles, which may include substance misuse, such as illegal drugs, but also prescribed medications and alcohol, smoking and the impact of passive smoking –– support to adopt healthy behaviours within the prison setting, which may include increased physical activity and a balanced diet –– advice and support to promote the mental health of prisoners during their sentence, and the importance of social interaction, identification and engagement in meaningful activities and the continued contact with and maintenance of relationships with family and friends.

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Adapted from the World Health Organization, Europe (Baybutt et al. 2014) Box 4 Health Promotion Many Prisoners Are Likely to Need

–– training and support to develop interpersonal and psychological skills, including the development of their self-esteem, and address any identified needs, such as anger management –– education in health and decision-making skills to support prisoners to understand the impact of risky or unhealth behaviours and become empowered to change their behaviours –– support to develop life-skills, which may include skills to support prisoners to look for work on release, or related to parenting during and upon release –– referral to structured support to help with specific health promotion interventions, which may include peer support, peer mentoring and/or smoking cessation Adapted from the World Health Organization, Europe (Baybutt et al. 2014) Box 5 Health Promotion Some Prisoners Are Likely to Need

Some prisoners are likely to need: –– education related to specific long-term conditions or communicable diseases, which may include different options for treatment and prevention of transmission, but also realist physical outcomes during serving their prison sentence –– immunisation for specific diseases, such as TB, pneumococcus, hepatitis, flu and COVID-19 –– advice on the maintenance of specific diseases whilst serving a sentence, including diabetes, epilepsy, asthma and sickle-cell disease –– access to specialist services, normally provided within secondary healthcare services, such as screening and early detection of cancer –– access to specialist treatment programmes, for example for prisoners who may identify as transgender and require hormones or further surgical procedures Adapted from the World Health Organization, Europe (Baybutt et al. 2014)

3 Implementation of Nurse-Led Interventions Primary care within a prison is supported by Advanced Nurse Practitioners (ANP), more recently defined as Advanced Clinical Practitioners (ACP). The term ACP is to support an equitable approach of advanced clinical practice of nurses and other healthcare professionals. A definition of the roles and responsibilities of ACPs

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generally will be discussed, as well as the competencies of ACPs (primary care nurses) as identified by regulatory bodies, and how these are implemented in primary care and in prisons, followed by an example of the implementation of nurse practitioners within a primary care team to support both the physical and mental health of prisoners (Wong et al. 2018). The second example will focus on a nurseled intervention to support prisoners with chronic hepatitis C virus (HCV), which was implemented in Australia (Lloyd et al. 2013); nurses within this initiative were specifically upskilled to complete assessment, triage and management of antiviral therapy. The outcomes of prisoners who were supported by this nurse-led intervention demonstrated that this approach delivered treatment for HCV safely and efficiently (Overton et al. 2019; Papaluca et al. 2019).

3.1 Advanced Nurse Practitioners and Advance Clinical Practitioners This section will commence with an overview of the definition of advance nurse practitioners (ANPs), and how these relate to nurses working in general practices and within primary care. The Royal College of Nursing (RCN) has defined advance nurse practitioners as nurses providing an advanced level of practice, rather than a specific type of practice, and more specifically: Advanced Nurse Practitioners are educated at master’s level in clinical practice and have been assessed as competent in practice using their expert clinical knowledge and skills. They have the freedom and authority to act, making autonomous decisions in the assessment, diagnosis, and treatment of patients (RCN 2018a).

ANPs are also expected to have significant roles within the four advanced practice pillars (RCN 2018a), which include management and leadership, education, research and advanced clinical practice. Each pillar is equally important. The pillar of management and leadership includes not only leading and managing innovative change but also identifying the need for change, which includes both negotiation and influencing skills, as well as networking and team development. The pillar of education includes the provision of teaching and learning within practice and academia to support the knowledge and skills of both qualified and student nurses, the provision of appropriate information and engagement with service users and, finally, mentoring and coaching of future ANPs. The pillar of research includes the abilities to critically appraise relevant research, the involvement in research, audit and service evaluations, the ability to implement the evidence from research into practice and the dissemination of evidence in conference presentations and peer-reviewed publications. Lastly, the pillar of advanced clinical practice is prescriptive of the skills of advanced practice and includes (RCN 2018b): • • • •

Problem-solving to support clinical decisions Analytical skills to support critical reflective thinking The ability to manage complex cases A comprehensive understanding of clinical governance

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A comprehensive understanding of equality and diversity Ability to engage in ethical decision-making Ability to complete assessments, diagnosis, referrals and discharges Working at a high level of autonomy Assessment and management of risk Non-medical prescribing in accordance with legislation Ability to implement therapeutic interventions to improve service user outcome Enhanced levels of communication skills Ability to promote and influence others to adopt values-based care in practice The development of appropriate advanced psycho-motor skills.

Nurses working at an advanced level within general practices have been identified as ANPs and this role was originally supported and defined by competencies written by the RCGPs in 2015, which encompassed the RCN guide to advance nursing practice (2012, which has since been revised). The competencies identified by the RCGPs have also been revised in 2020 to include advanced clinical practice (ACP) nurses working in general practice or primary care settings. The revised framework for ACP (primary care nurse) builds upon the definitions of ACP described by Health Education England in the multi-professional framework for advanced clinical practice in England (2017). The definition of ACP is therefore the same across both frameworks: Advanced clinical practice is delivered by experienced, registered health and care practitioners. It is a level of practice characterised by a high degree of autonomy and complex decision making. This is underpinned by a master’s level award or equivalent that encompasses the four pillars of clinical practice, leadership and management, education, and research, with demonstration of core capabilities and area specific clinical competence. Advanced clinical practice embodies the ability to manage clinical care in partnership with individuals, families, and carers. It includes the analysis and synthesis of complex problems across a range of settings, enabling innovative solutions to enhance people’s experience and improve outcomes (Health Education England 2017, p. 8).

The framework for ACPs (primary care nurse) builds on the four pillars identified by Health Education England and adopted by the RCN.  The ACP (primary care nurse) framework has further developed the four pillars, with the identification of 13 core competencies, specifically for primary care nurses. The pillar of clinical practice includes the three domains such as person-centred collaborative working; assessment, investigations and diagnosis; and condition management, treatment and prevention, whereas the pillars of leadership and management, education and research are encompassed by one domain, appropriately titled leadership and management, education and research (RCGPs 2020). The core domains and relevant competencies are identified under each domain are presented in Table 1. The specifications for ACP of primary care nurses have been clearly defined, and this definition is clarified further for ACP primary care nurses working within prisoners. The NHS (2020) service specifications for medical and nursing in primary care within prisons in England identifies the need for ACPs to have completed

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Table 1  The four domains and core competencies of an ACP (primary care nurse) Domain Person-centred collaborative working

Assessment, investigation and diagnosis Condition management, treatment and prevention Leadership and management, education and research

Competency 1. Communication and consultation skills 2. Practising holistically to personalise care and promote public and personal health 3. Working with colleagues and in teams 4. Maintaining an ethical approach and fitness to practice 5. Information gathering and interpretation 6. Clinical examination and procedural skills 7. Making a diagnosis 8. Clinical management 9. Managing medical and clinical complexity 10. Independent prescribing and pharmacotherapy 11. Leadership, management and organisation 12. Education and development 13. Research and evidence-based practice

education and training in the management of drug and alcohol misuse, for example, the completion of the RCGP certificate Level 1 and working towards Level 2 of the Management of Drugs Misuse and the commencement of education and training in the Management of Alcohol Problems within 12 months of commencing as an ACP in primary care in prison. These qualifications are especially important for primary care nurses supporting the treatment of substance misuse in primary care, which is discussed in more depth in chapter “Substance Misuse in Prison”. The NHS (2020) specifications for primary care nursing in prison also explicitly states that each prison will have a clinical lead nurse, who is responsible for the management and leadership of primary care services and coordinates the care of prisoners with long-term conditions. The responsibilities of the clinical lead nurse, who is usually a Band 7, also includes the coordination of nurse-led clinics through rostering appropriately skilled staff to effectively deliver primary care services, as well as an oversight of the appropriate development, implementation and review of care plans for prisoners with healthcare needs. Further responsibilities include ensuring the safety of nursing staff, providing assurance that staff are practicing within the NMC code of conduct, leading on infection control, providing clinical supervision and providing expert nursing advice to prisoners, colleagues within nursing and other healthcare professionals regarding the provision of care within prison.

3.2 Physical and Mental Health Interventions Nurse-led interventions within primary care in prison have been developed to specifically support the needs of prisoners, therefore there are a wide range of initiatives demonstrating the wide knowledge of primary care nurses. In this section, four nurse-led interventions will be discussed to demonstrate the variety of support primary care nurses provide within prison. The four nurse-led interventions to be

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discussed in this section include a focus on the sexual health of men in prison (Kelly et al. 2020), mind–body relaxation technique to support prisoners’ stress and anxiety (Pralong et al. 2020), a healthy aging in prison clinic (Fedele 2021) and hepatitis C virus nurse-led interventions (Baines 2022; Overton et  al. 2019; Papaluca et al. 2019). A nurse-led intervention to support the sexual health of men in prison has been implemented in Northern Ireland (Kelly et al. 2020). Primary care nurses within a prison completed a competency-orientated educational programme to support them to be able to provide asymptomatic sexual transmitted infections (STIs) testing in heterosexual prisoners, including chlamydia, syphilis, gonorrhoea, hepatitis and HIV.  The training included nine core e-learning modules and engagement in a 1-day workshop, which included role play to support primary care nurses to become comfortable taking a comprehensive sexual history. The focus on heterosexual prisoners was due to the guidance of the British Association of Sexual Health and HIV (2019), as well as the need for men who have sex with men to continue to be seen within a specialist health service due to discussions regarding pre-exposure prophylaxis. The published account of this intervention does not explain how men who only have sex with other men whilst in prison were supported and screened for asymptomatic STIs. However, nurse-led clinics were implemented either once a week or once a fortnight, and during a 6-month period, 12 prisoners (7%) tested positive for chlamydia and six prisoners (50%) were treated within two days of their positive test, with a further three prisoners treated within four working days. The results demonstrate the success of the nurse-led implementation of STI screening and treatment of prisoners (Kelly et al. 2020). A nurse-led intervention of mind–body relaxation techniques to support prisoners’ stress and anxiety has been implemented in Switzerland (Pralong et al. 2020). Primary care nurses with qualifications in therapeutic patient education and group facilitation supported a weekly mind–body intervention. Each intervention comprised of five elements: 1. An informal welcome of prisoners who help to organise the room ready for the session, whilst discussing their needs they wish to address in the current session. 2. Nurses and prisoners walk around the room, whilst completing warm-up movements and deep breathing exercises. 3. Nurses and prisoners stand in a circle and complete stretching exercises, including the tensing and relaxation of muscles, deep abdominal breathing and finally yoga balancing poses. 4. The next set of exercises are completed on yoga mats and involve stretching and strengthening core muscles of the back, which is followed by lying still for exercises of mindfulness and relaxation. 5. The end of the invention includes a debriefing and the tidying of the room together.

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Prisoners reported a number of reasons for attending one or more of the mind–body interventions, which included feeling stressed, back problems, to improve physical fitness and to support relaxation and sleep, although a few prisoners also mentioned curiosity. The benefits of attending one of more mind–body interventions included improved sleep (50%), reduced physical tension (62.5%), improved back pain (62.5%) and overall reduction of stress (43.8%). An unexpected outcome reported by prisoners was the opportunity to connect with other prisoners as well as the opportunity to learn relaxation exercises that prisoners could complete by themselves as required. The results suggest the nurse-led mind–body intervention is a successful method to support prisoners with non-medical stress and anxiety whilst in prison (Pralong et al. 2020). A nurse-led healthy ageing in prison clinic for older prisoners, those aged over the age of 60 with long-term conditions, has been implemented in Australia (Fedele 2021). The aim of the clinic was to support the health of older prisoners through the creation of a nurse-led model of care, with the inclusion of both care for long-term conditions and health promotion through the development of prisoners’ health literacy. Prisoners who attended the clinic were offered a 6-week programme of care including an initial health assessment, the development of a health plan to support their needs and an assessment with a physiotherapist. On the third week of the programme, all prisoners were also assessed by GP to review their medications and their long-term conditions, as well as their capacity to manage their own medications (in-possession medications). Although the clinic was originally designed for prisoners over the age of 60 with long-term conditions, this was changed to support all prisoners with long-term conditions. An early review of the first 62 prisoners who completed the programme identified that six prisoners were diagnosed with a new condition, 57 prisoners were immunised, 30 prisoners were tested for memory problems, 53 were tested for diabetes and 29 prisoners were referred for cardiac rehabilitation. The results suggest the nurse-led healthy ageing in prison clinic has supported prisoners’ health, and more importantly, prisoners who completed the programme have begun to manage their own long-term conditions (Fedele 2021). Nurse-led hepatitis C interventions are essential in the provision of healthcare in prisons. First, the World Health Organization has identified a goal of reducing the incidence of hepatitis C by 80% and mortality due to hepatitis C by 65% by 2030 (WHO 2016). Second, the main risk factor of transmission of hepatitis C in Western countries is due to intravenous drug use, in particular the injection of narcotic substances (Shepard et al. 2005). In Australia, almost half of prisoners have reported a lifetime history of intravenous drug use, and just over half of prisoners have the hepatitis C seroprevalence (Butler and Simpson 2017). Due to prisoners’ lack of engagement and access of healthcare service, prisons are an optimal setting to support the screening and treatment of a population who have a higher prevalence of hepatitis C than the general public (Larney et al. 2013). Nurse-led models of assessment and treatment of prisoners with hepatitis C have been widely implemented in Western countries, including the Australia and the United Kingdom (Overton et  al. 2019; Papaluca et  al. 2019; Baines 2022). An

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example of a nurse-led model of care for the screening and treatment of hepatitis C in Australia includes the offer of screening for viral hepatitis during reception screening. For prisoners who received a positive antibody result are then comprehensively assessed by a nurse within the prison, including assessments for co-­ infections, as well as investigations, such as liver function tests, platelet account and INR.  These prisoners, especially those with co-infections and other abnormal results, are referred to a Hepatitis Clinical Nurse Consultant, who visits the prisoner in prison. This process supported prisoners to be provided with appropriate treatment and further follow-up. Of those prisoners who commenced treatment following a positive antibody result for hepatitis C and were tested 12 weeks after treatment completion, 92% had no detectable viral load (Overton et al. 2019), demonstrating the importance of hepatitis C screening of prisoners and how this process can be supported by a nurse-led intervention and a nurse specialist. In England, a recent nurse-led hepatitis C screening intervention occurred at HMP Lewes, a young offenders and adult male Category B prison, with a population of around 800 prisoners. The importance of the screening programme was due to the recognition of the spread of hepatitis C not only through intravenous drug use but also through non-sterile tattooing and piercing that occurs in prisons. The hepatitis C screening drive, a nurse-led test-and-treat intervention, was supported by specialist hepatology nurses from the local NHS Foundation Trust and the charity Hepatitis C Trust. The intervention occurred over 3 days with 96% of prisoners tested. Of the prisoners tested, 45 prisoners were identified to have antibodies and were further screened for active infection, of which only nine prisoners were identified to be carrying the virus and were commenced on appropriate treatment within two days (Baines 2022). Both nurse-led interventions to screen and treat hepatitis C in prisoners have proven to be successful; although both implemented very different approaches, the continuation of screening and testing for hepatitis C is essential to support the health of this population.

3.3 Experiences of a Primary Care Prison Nurse The experience of a primary care prison nurse will be explored in her own words, with the aim to bring to life the realities of her role. Nina Shamaris, a specialised in Prison Nursing, was a Senior Nurse (Band 6) involved in caring for patients within the prison environment, from their physical requirements to supporting their mental health. Nina worked in a Category B male prison, with an average of approximately 1000 prisoners. According to her, this was a very challenging role dealing with highly complex cases. Nina provides an overview of her experiences, despite the fact that her duties whilst working within prison included various tasks and duties, such as screening all prisoners as they entered the prison, completing appropriate referrals, delivering the wellness clinic for prisoners following screening, delivering medication through medication hatches, attending to emergencies, supporting prisoners in segregation, accompanying prisoners to hospital appointments outside of the prison and the delivery of routine clinics (hepatitis B, flu, detox and wellness).

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Case Study: Holistic Care

I was working in the reception clinic, when a patient came through reception, I noted the patient had a leg ulcer which had been caused due to his misuse of substances, specifically injecting drugs intravenously. This prisoner was known to the establishment, and I had treated him before whilst he was within our care, through assessment he disclosed that once he had left prison, he had encountered some personal circumstances that led him to use drugs again. The use of intravenous drugs was possibly a major cause of the further breakdown of his leg ulcer. The smell of the leg ulcer was a major concern to the prisoner, as he had already been placed in a different cell to other prisoners due to the smell. On assessment the leg ulcer was red and inflamed and needed an immediate intervention. However, due to the demands of reception, it is difficult to spend sufficient time with each prisoner, and this prisoner required a specific dressing to be obtained, and the prescription of both antibiotics and analgesia. The demands on my time were to continue to screen other prisoners so they could be transferred to the appropriate wing, however, this prisoner needed his immediate treatment for his leg ulcer, therefore, I contacted the GP on site to prescribe relevant antibiotics, dressings, and analgesia as a matter of urgency and contacted the pharmacy onsite to ensure these would be available within the same day. The prisoner remained embarrassed about the smell of his leg ulcer and the reaction of other prisoners, who had already complained. I reassured him that I would dress his wound later today when the appropriate dressings had arrived. I then informed the wing he was being transferred to that he needed to remain in a single cell due to circumstances of his health condition and I would be assessing him later that day. Both the reassurance of treating his leg ulcer and being placed in a single cell helped relieve some of the prisoner’s anxiety. I dressed the wound later that evening and talked through the plan of care whilst he was in prison. I advised him that I would ensure he would have his leg ulcer dressed daily to help heal his would and reduce the smell, and I would see him in the Wellman clinic the following day for the first dressing change. I reviewed the prisoner the next day in the Wellman clinic, and he was in pain from his leg ulcer and his mood appeared low. During the process of changing his dressing, the prisoner began to discuss that he was annoyed with himself for going back on the drugs when he left prison, as he had not taken any drugs for over a year. The process of changing his dressing allowed us to informally chat about his personal circumstances, including his mental health, and possible processes and support to help him once again to stop using intravenous drugs. Although, the prisoner discussed positive influences in his life, when he last left prison, he described he had fell in with ‘the wrong circle’. This was the first of many conversations, his leg ulcer required a compression dressing, and I was one of only a few nurses who were competent in applying this form of dressing, and therefore we had informal chats daily for

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the next few months. Within each assessment and dressing of his leg ulcer, we discussed his mental health and how he was coping. The prisoner appeared throughout this time to have become more positive and stated that our conversations when delivering care to his leg ulcer has helped him see that he had positive influences in his life and that due to the leg ulcer slowly getting better he felt that things were finally starting to look up. During this time the prisoner reached out to his family and arranged to stay with them once he was released, he also advised me that he has not taken any drugs that were not prescribed to him whilst he was serving his sentence. We discussed how he had coped not taking drugs, and the importance of continuing to abstain from drugs due to the devasting effect on his leg ulcer, which we had worked so hard together to heal. During assessment and dressing changes with this prisoner I introduced concepts of health promotion to help aid his wound healing, such as the need for a healthy balanced diet. During these discussions the prisoner informed me due to the healing of his leg ulcer he felt much better mentally, and he was positive that he would not start taking drugs again, which was important to prevent his leg ulcer returning. I spoke with him about options for when he was released to enable this to happen, and he advised me was going to stay with family and they were committed to help support him socially and mentally. Throughout this prisoner’s sentence to his release date, which was approximately 9 months later, all the interventions and collaboration between myself and the prisoner, I was pleased to see him being released with not only an improved leg ulcer, but improved mental health, and looking forward to life. This prisoner was in and out of prison when I was working there quite frequently, and I am pleased to say that he did not return with the remaining time I worked at that prison for the following 3 years.

Case Study: Autonomous Decision-Making

When I was coming into the prison on a night shift, I could see that it was extremely busy in the reception area. I made my way up to the nurse’s station which was based in the centre of the prison and could see that there had been a situation during the day that had delayed the administration of evening medication to the prisoners. I was the only senior primary care nurse allocated for the night shift. Therefore, if no incidents have occurred all daytime medication, reviews, and reception screening should be completed prior to my start time. This is essential as all nurses and staff apart from allocated staff for the night shift needed to leave the establishment no later than 9.30 pm, due to security. The handover from the primary care nurses identified there was still new prisoners to screen in reception, medication to be administered, especially to those who were detoxing and any calls that may arise throughout the evening.

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I prioritised those who needed screening in reception as they may have chronic medical conditions that needed attention or medication or some prisoners may have been at risk of self-harm or suicide, and again this needed to be assessed urgently. During this process I assessed a prisoner who was a type 1 diabetic and was on insulin, his insulin needed to be prescribed by our doctor and brought up from reception for me to be able to administer the appropriate dose. Whilst assessing this prisoner he became pale, so I checked his blood sugar and ketones, both were raised, he needed his insulin immediately. On my route to fax the prescription to the doctor for signing, I had an emergency call ‘code red’ which meant excessive blood loss on another wing. I could not ignore this call, due to being the only senior primary care nurse on duty, therefore I ran to the wing. This prisoner on the ‘code red’ call has severely self-harmed his arm, felt faint and had lost the sensation in his fingers. I had to rely on the prison staff for help with this situation, I compressed his wound and applied the appropriate dressing, checked his blood pressure and gave reassurance throughout. However, whilst I was with this prisoner, I received another call on the radio stating the prisoner with type 1 diabetes prisoner had become unwell. I had to make a decision and prioritise which prisoner need my immediate attention. Therefore, I asked the prison officers to stay with the prisoner who had self-harmed, and to radio me should any further issues arise in my absence, whist I went to the prisoner with type 1 diabetes, who was on the other wing. On arrival in reception, I noted the prisoner with diabetes was becoming unwell, thirsty and was vomiting, which are all symptoms of hyperglycaemia. I re-checked his blood sugars, and these had now rose to reading just ‘high’ I advised the prison officer in charge that this prisoner needed to go out to the hospital as he now required urgent intravenous intervention, which we were unable to deliver with within the prison. I called for an ambulance, but I was advised that the ambulance could potentially take over an hour, due to other commitments. I needed to act quickly, so I contacted the doctor again, to gain authorisation to send the prisoner to hospital via a taxi, which was agreed. I asked the prison staff to radio me when they would arrive at the hospital, so I knew he had arrived safely and within their care. The officers phoned and advised that the hospital stated that due to me acting as quickly I had prevented him from going into a diabetic coma. I needed to go back and assess my other prisoner who self-harmed as he needed some more assistance. I informed The Prison Officer in charge that he also needed to go out to the hospital due to the loss of sensation in his fingers which needed to be assessed further as soon as possible. I was advised that there was not enough prison staff to send out both prisoners, however I advised that if this prisoner does not go out to hospital and be assessed this

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could have a detrimental effect on his health and the prison could face liability should any complications arise. The prison agreed with this rationale and my sound knowledge and arranged for the prisoner to be taken to hospital. The impact of having two prisoners with escorts in hospital left the prison with very limited prison staff, which could have been difficult to manage if other emergencies arose throughout the evening prior to return of the other staff. The prisoner who self-harmed later arrived back at the prison with no severe issues or complications, however he was put on an observation book due to his self-harm.

Case Study: Patients’ Best Interest

I had several calls to one prisoner who had been self-harming on quite a few occasions and was known to both the prison staff and nursing staff due to their self-harming. I was present for one call with this prisoner, who had self-­harm and had deeply cut both wrists, which was treatable within the prison, as the doctor was able to suture both wounds. On this occasion, I was talking to the prisoner how stated he had ‘had enough’ and did not see the point of carrying on. I tried to reassure him and asked him what specifically had made him do this. He advised me that this was due to his relationships on the outside and that he was unable to see his baby or in fact his partner. I attempted to give reassuring advice and confirming that his baby would like to get to know his dad, and this was possible, but in self-harming or possibly worse, this would be hard for both his partner and his baby if something did happen. The prisoners appeared to be less anxious, and I felt like he was looking at the bigger picture, and ways of getting to know his baby even though he was in prison. The prisoner was placed on observations and was checked twice an hour to ensure he remained safe and had not self-harmed. Later in the same day, a ‘code blue’ came over the radio, I ran to the call, and found the same prisoners on the floor with a ligature around his neck, which he had made from his bed sheet. His cell mate had raised the alarm very quickly, therefore we were able to attend to him in a timely manner. He was coherent and was asking me to let him go and to leave him as he did not want to be here anymore. I advised him that it was my duty of care to protect him and to ensure he was safe. His observations were stable, and he showed no signs of immediate concerns, however the ambulance was called due to this being a ‘code blue’ call. Whilst we were waiting for the ambulance, he became very hostile and angry at me being there to help. He said that it was my fault that he could not go (in other words die). He stated that his partner on the outside had finished their relationship, which caused him to feel that he had no other alternative than to do what he did. I sat with him and explained my role as a nurse and stated again

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that it is my duty of care and no matter what the reason it’s my job to ensure the safety of prisoners within my care and that I am here to help, and of course if this situation was to arise again then I would do the same again. During this time, I revisited our previous conversation with the prisoner regarding his new-born baby and reiterated again that his baby would need a father and he could develop this relationship even from prison. The prisoner did appear to listen and calmed down throughout our conversation. The ambulance crew arrived, and the prisoner refused to go to hospital for further assessment, and the ambulance crew agreed there were no immediate concerns. The prisoner was placed on constant watch, and I placed him on nursing review for the following day. The next day I went to assess the prisoner and he advised me (with a smile) that he was in a much better place, and he had spoken to his partner and mother of his child and managed to talk things through with her. He thanked me for talking him through other options and realised that there was help available. He also apologised for his behaviour and was pleased nurses were there to help. I reiterated I do indeed have a duty of care no matter what the circumstances and that help is at hand to get him through this time. He was reviewed by the GP and the mental health team, to which he was placed on medication to help with his anxiety, and this appeared to settle his outlook through time and his stay within the establishment.

4 Conclusion This chapter has introduced the core purposes of primary care and the generalist approach of this speciality. The contemporary development of Primary Care Networks in England has further supported the provision of primary care services, including those within a prison setting. An important element of primary care services within prison settings is to engage with people who have not previously engaged with health services or fully understand the role of primary healthcare. The role of the primary care nurse within the prison setting is explored, as well as the range of support and interventions provided, including support for prisoners’ general health, long-term conditions, and infectious diseases through screening, assessment, diagnosis and treatment. The final element of this chapter is the exploration of a primary care nurse’s experiences in the form of three case studies to provide a practical understanding of the role of the primary care nurse in prison.

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Baybutt M, Acin E, Hayton P, Dooris M (2014) Promoting health in prisons: a settings approach. In: Enggist S, Moller L, Galea G, Udesen C (eds) Prisons and health. World Health Organization. https://www.euro.who.int/__data/assets/pdf_file/0005/249188/Prisons-­a nd-­H ealth.pdf. Accessed 2 Sept 2022 Bonomi AE, Wagner EH, Glasgow RE, Vonkorff M (2002) Assessment of chronic illness care (ACIC): a practical tool to measure quality improvement. Health Serv Res 37(3):791–820 British Association of Sexual Health and HIV (BASHH) (2019) Standards for the management of sexually transmitted infections (STIs). https://www.bashh.org/about-­bashh/publications/ standards-­for-­the-­management-­of-­stis/. Accessed 2 Sept 2022 British Medical Association (2019) The Quality and Outcomes Framework (QOF). BMA. https://www.bma.org.uk/advice-­and-­support/gp-­practices/funding-­and-­contracts/ quality-­and-­outcomes-­framework-­qof. Accessed 2 Sept 2022 Butler T, Simpson M (2017) Nation Prison Entrants’ Blood-borne Virus Survey Report 2004, 2007, 2010, 2013, and 2016, Kirby Institute (UNSW Sydney). https://kirby.unsw. edu.au/report/national-­p rison-­e ntrants-­b loodborne-­v irus-­a nd-­r isk-­b ehaviour-­s urvey-­ report-­2004-­2007-­2010. Accessed 2 Sept 2022 Collett S, Wong A, Taurima K, Livesay G, Dehn A, Johnson ANB (2022) Utilising a nurse navigator model of care to improve prisoner health care and reduce prisoner presentations to a tertiary emergency department. Australasian Emergency Care 25(4):341–346 Condon L, Hek G, Harris F (2007) A review of prison health and its implications for primary care nursing in England and Wales: the research evidence. J Clin Nurs 16:1201–1209 Cowman A, Walsh E (2013) Patient and public involvement in prison health care. Primary Health Care 23:26–31 Department of Health (2012) Long term conditions compendium of information, 3rd ed. https:// assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/ file/216528/dh_134486.pdf. Accessed 2 Sept 2022 Fedele R (2021) Nursing in prison: how a nurse-led clinic is making a difference in the lives of older prisoners with chronic health conditions. Australian Nursing and Midwifery Journal. https://anmj.org.au/nursing-­in-­prison-­how-­a-­nurse-­led-­clinic-­is-­making-­a-­difference-­in-­the-­ lives-­of-­older-­prisoners-­with-­chronic-­health-­conditions/. Accessed 2 Sept 2022 Finnie AJ (2018) Integrating prevention and health promotion in a London prison. BMJ Open Quality 7:e000097 Frazer A (2014) Primary health care in prisons. In: Enggist S, Moller L, Galea G, Udesen C (eds) Prisons and health. World Health Organization. https://www.euro.who.int/__data/assets/ pdf_file/0005/249188/Prisons-­and-­Health.pdf. Accessed 2 Sept 2022 Gates ML, Bradford RK (2015) The impact of incarceration on obesity: are prisoners with chronic diseases becoming overweight and obese during their confinement? J Obes 2015:1–7 Health Education England (2017) Multi-professional framework for advanced clinical practice in England. https://www.hee.nhs.uk/sites/default/files/documents/multi-­professionalframeworkf oradvancedclinicalpracticeinengland.pdf. Accessed 2 Sept 2022 Healthcare Safety Investigation Branch (2019) Management of Chronic Health Conditions in Prisons Healthcare Safety Investigation I2018/020. https://hsib-­kqcco125-­media. s3.amazonaws.com/assets/documents/hsib_report_management_chronic_conditions_prisons. pdf. Accessed 2 Sept 2022 HMPS (2006) Prison Service Order (PSO) No 3050  – Continuity of Healthcare for Prisoners. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/ file/922804/PSO_3050_continuity_of_healthcare_for_prisoners.pdf. Accessed 2 Sept 2022 Kelly C, Templeton M, Allen K, Lohan M (2020) Improving sexual healthcare delivery for men in prison: a nurse-led initiative. J Clin Nurs 29:2285–2292 King’s Fund (2001) Nurse-led primary care. Learning from PMS pilots. King’s Fund, London King’s Fund (2011) Improving the quality of care in general practice. King’s Fund, London King’s Fund (2020) Primary care networks explained. King’s Fund, London

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Larney S, Kopinski H, Beckwith CG, Zaller ND, Jarlais DD, Hagan H, Rich JD, van den Bergh BJ, Degenhardt L (2013) Incidence and prevalence of hepatitis C in prisons and other closed settings: results of a systematic review and meta-analysis. Hepatology 58:1215–1224 Lewis G (2013) The benefit of sport and physical education for young men in prison: an exploration of policy and practice in England and Wales. Prison Service J:3–11 Lloyd AR, Clegg J, Lange J, Stevenson A, Post JJ, Lloyd D, Rudge G, Boonwaat L, Forrest G, Douglas J, Monkley D (2013) Safety and effectiveness of a nurse-led outreach program for assessment and treatment of chronic hepatitis C in the custodial setting. Clin Infect Dis 56(8):1078–1084 Marshall T, Simpson S, Stevens A (2001) Use of health services by prison inmates: comparisons with the community. J Epidemiol Commun Health 55(5):364–365 NHS (2020) Service specification Primary care service  – medical and nursing for prisons in England, 2020. https://www.england.nhs.uk/wp-­content/uploads/2020/03/primary-­care-­ service-­spec-­medical-­nursing-­for-­prisons-­2020.pdf. Accessed 2 Sept 2022 NHS England (2022) Primary care networks. https://www.england.nhs.uk/primary-­care/primary-­ care-­networks/. Accessed 2 Sept 2022 NHS England and NHS Improvement (2020) Service specification. Primary care service – medical and nursing for prisons in England. https://www.england.nhs.uk/wp-­content/uploads/2020/03/ primary-­care-­service-­spec-­medical-­nursing-­for-­prisons-­2020.pdf. Accessed 2 Sept 2022 NHS England, HM Government (2018) National partnership agreement for prison healthcare in England 2018–2021. HM Government, London Overton K, Clegg J, Pekin F, Wood J, McGrath C, Lloyd A, Post JJ (2019) Outcomes of a nurse-­ led model of care for hepatitis C assessment and treatment with direct-acting antivirals in the custodial setting. Int J Drug Policy 72:123–128 Papaluca T, McDonald L, Craigie A, Gibson A, Desmond P, Wong D, Winter R, Scott N, Howell J, Doyle J, Pedrana A, Lloyd A, Stoove M, Hellard M, Iser D, Thompson A (2019) Outcomes of treatment for hepatitis C in prisoners using a nurse-led, statewide model of care. J Hepatol 70(5):839–846 Peek H (2022) Modernising medication management in a prison setting. https:// patientexperiencenetwork.org/resources/case-­studies/2217/. Accessed 2 Sept 2022 Pralong D, Renaud A, Secretan AD, Blanc M, Charmillot N, Mouton E, Wolff H, Tran NT (2020) Nurse-led mind-body relaxation intervention in prison: a multi-perspective mixed-method evaluation. Nurs Outlook 68(5):637–646 Public Health England, NHS England (2016) Make Every Contact Count (MECC): Consensus statement. https://www.england.nhs.uk/wp-­content/uploads/2016/04/making-­every-­contact-­ count.pdf. Accessed 2 Sept 2022 Royal College of General Practitioners (2015) General practice advanced nurse practitioner competencies. https://www.rcgp.org.uk/getmedia/55ebcac9-­65a0-­46ed-­bc80-­da754fd21f54/ RCGP-­g eneral-­p ractice-­a dvanced-­n urse-­p ractitioner-­c ompetencies-­m ay-­2 015-­A .pdf. Accessed 2 Sept 2022 Royal College of General Practitioners (2020) Core capabilities framework for advanced clinical practice (nurses) working in general practice/primary care. https://www.skillsforhealth.org.uk/ wp-­content/uploads/2020/11/ACP-­Primary-­Care-­Nurse-­Fwk-­2020.pdf. Accessed 2 Sept 2022 Royal College of Nursing (2018a) Royal College of nursing Standards for Advanced Level Nursing Practice. https://www.rcn.org.uk/Professional-­Development/publications/pub-­007038. Accessed 2 Sept 2022 Royal College of Nursing (2018b) Advanced level nursing practice: introduction. https://www.rcn. org.uk/Professional-­Development/publications/pub-­006894. Accessed 2 Sept 2022 Shepard CW, Finelli L, Alter MJ (2005) Global epidemiology of hepatitis C virus infection. Lancet Infection Dis 5:558–567 Shropshire Community Health NHS Trust (2022) Medicines Policy Part 7: Medication In-possession policy (prison). https://www.shropscommunityhealth.nhs.uk/content/doclib/10474.pdf. Accessed 2 Sept 2022

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South J, Bagnall A-M, Hulme C, Woodhall J, Longo R, Dixey R, Kinsella K, Raine G, Vinall-­ Collier K, Wright J (2014) A systematic review of the effectiveness and cost-effectiveness of peer-based interventions to maintain and improve offender health in prison settings. Health Serv Deliv Res 2:1–218 Wang EA, Aminawung JA, Ferguson W, Trestman R, Wagner EH, Bova C (2014) A tool for tracking and assessing chronic illness care in prison (ACIC-P). J Correct Health Care 20(4):313–333 Wong I, Wright E, Santomauro D, How R, Leary C, Harris M (2018) Implementing two nurse practitioner models of service at an Australian male prison: a quality assurance study. J Clin Nurs 27(1–2):e287–e300 World Health Organization (2016) Combating hepatitis B and C to reach elimination by 2030: advocacy brief. https://apps.who.int/iris/handle/10665/206453. Accessed 2 Sept 2022 Wright NM, Hearty P, Allgar V (2019) Prison primary care and non-communicable diseases: a data-­ linkage survey of prevalence and associated risk factors. BJGP Open 3(2):bjgpopen19X101643 Wright N, Allgar V, Hankins F, Hearty P (2021a) Long-term condition management for prisoners: exploring prevalence and compliance with national monitoring processes. https://www.qeios. com/read/PWHD35. Accessed 2 Sept 2022 Wright N, Hankins F, Hearty P (2021b) Long-term condition management for prisoners: improving the processes between community and prison. BMC Fam Pract 22:80

Mental Health Care in Prison Monika Rybacka and Joanne Brooke

This chapter contains two case studies. The first case study will explore the realistic experience of a mental health student nurse’s clinical placement in prison. The second case study will explore the learning opportunities for mental health student nurses in mental health services in a prison.

1 Reception in Prison This section will commence with a brief overview of mental health, self-harm, and suicide screening of prisoners upon entry into prison. Traditionally, this process occurred in reception by a prison healthcare officer who completed a standardised questionnaire or screening tool, and if the screen identified any self-harm or suicide ideation, prisoners were reviewed by a doctor within the next 24 h. This approach was identified as ineffective due to the little or no evidence to support the validity or reliability of the screening questionnaires/tools. However, screening tools have now begun to be developed, and the most commonly applied will be introduced (Martin et al. 2016, 2018). The reception interview has now been adapted to include mental health expertise, such as the inclusion of a community psychiatric nurse (CPN) in prisons in England and Australia (Brown et al. 2015; Schilders and Ogloff 2014). Finally, the impact of mental health screening on  treatment patterns following screening of prisoners in reception will be explored in prison services in England (Hayes et al. 2014). M. Rybacka (*) School of Nursing, Midwifery and Health, Coventry University, Coventry, UK e-mail: [email protected] J. Brooke Centre of Social Care, Health and Related Research, Birmingham City University, Birmingham, UK e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 J. Brooke (ed.), Nursing in Prison, https://doi.org/10.1007/978-3-031-30663-1_5

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1.1 Reception Screening The process of screening prisoners as they enter a prison, either direct from sentencing or from another prison, has been discussed in detail in chapter “Primary Care in Prison”. The discussion focuses on the provision of screening by primary care services and the role of the primary nurse within the screening process. Reception screening will now be explored from the perspective of mental health screening, which has been recognised to support both the detection of a mental health illness and access to treatment. Globally, the majority of prisons report mental health and suicide screening. However, the process of screening applied across prisons, countries, and continents varies significantly. In Europe, the processes of mental health and suicide screening upon entry into prison and during a prison sentence were significantly different (Dressing and Salize 2009). A major concern identified by Dressing and Salize (2009) was the lack of standardised, valid, and reliable mental health and suicide screening tools. However, since 2009, standardised screening tools have been implemented in prisons and research has occurred to identify their validity and reliability (Martin et  al. 2013, 2016). The most frequently applied screening tools will be explored, followed by an exploration of the process of screening within prisons in the United Kingdom (UK), as identified by the National Institute for Health and Care Excellence guidelines (NICE 2017). The Brief Jail Mental Health Screen (BJMHS) is a revision of the Referral Decision Scale (RDS) (Steadman et al. 2005). The RDS was developed to support the screening of prisoners at reception to identify those who demonstrated symptoms associated with schizophrenia, bipolar disorder, or major depression (Teplin and Swartz 1989). However, the reliability and validity of the RDS were challenged, and in response the BJMHS was developed. The BJMHS contains eight questions with yes or no answers and can be administered within 3 min. This screening tool has been identified to be practical, efficient, and supports prison officers to identify male prisoners, who need to be referred to mental health services due to exhibiting symptoms of schizophrenia, bipolar, or major depression. However, the BJMHS is not appropriate for female prisoners due to an unacceptably high false-negative rate. Therefore, if the BJMHS is administered to a female prisoner the outcome is likely to indicate she does not have any symptoms related to mental health issues, even when these symptoms are present (Steadman et al. 2005). More recently, the results of the BJMHS have been identified to change across multiple admissions to prison by the same prisoners, which has raised concerns, as critics of this tool have questioned whether these changes reflect the changes in the mental health of prisoners or a problem with the screening tool or how it is being applied (Zottola et al. 2019). The Correctional Mental Health Screen for Men (CMHS-M) and Women (CMHS-W) addresses the need for different screening tools for male and female prisoners. These screening tools were developed from a US Department of Justice programme to support the screening of prisoners to identify those who required referral, assessment, and treatment by mental healthcare professionals (Ford et al. 2007). The CMHS-M or CMHS-W should be administered if a person’s presentation, behaviour, or medical history suggests they may have a mental health problem,

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or if the person has a long-term physical health condition with a functional impairment, or/and if other agencies have raised concerns as the person has progressed through the criminal justice system. The administration of the CMHS-M or CMHS-W should take no longer than 5  min, and the scoring is both simple and immediate, supporting the use of the tool during reception screening. The scoring of both CMHS-M and CMHS-W is the total number of positive answers, where the person answers yes to any question. The recommendation of further assessment by a healthcare professional occurs if a man scores 6 or more on the CMHS-M or a woman scores 4 or more on the CMHS-W. When the tool is administered to a prisoner who identifies as transgender, it is important to understand the gender they identify as and apply the appropriate tool as each tool contains questions unique for each gender. The tool has not yet been developed to support prisoners who identify as non-binary. The unique element of this screening tool is the application of different questions for men and women; the CMHS-M consists of 12 yes or no questions, whereas the CMHS-W consists of 8 yes or no questions. The first six questions on both questionnaires are the same and explore both a prisoner’s history of mental illness and the symptoms they experienced. The remaining questions are unique to each gender; the six unique questions on the CMHS-M explore whether a male prisoner has worries, holds grudges, or is constantly on guard, without any real cause. Although it also includes the following: ‘Have you ever felt like you didn’t have any feelings, or felt distant or cut off from other people or from your surroundings?’ ‘Has there ever been a time when you felt so irritable that you found yourself shouting at people or starting fights or arguments?’ ‘Do you often get in trouble at work or with friends because you act excited at first but then lose interest in projects and don’t follow through?’ (Ford et al. 2007, p. 15). Whilst the two questions on the CMHS-W are ‘Has there ever been a few weeks when you felt you were useless, sinful, or guilty?’ and ‘Do you find that most people will take advantage of you if you let them know too much about you?’ (Ford et al. 2017, p. 13). A screening tool developed in the United Kingdom is the England Mental Health Screen (EMHS); although widely referenced in the literature and applied in prisons, information on the development of the EMHS is only available in a report, which has not been published or peer reviewed (Grubin 2002). The EMHS includes screening upon entry into prison for both physical and mental health problems and contains a number of generic and specific questions for different prison populations, including adult male prisoners, female prisoners, and young offenders. The section exploring the mental health of prisoners includes four questions, with yes or no answers, and if the prisoner answers yes, further follow-up questions are asked. Similar to previous screening tools discussed, the questions include ‘Have you ever seen a psychiatrist outside?’ ‘Have you ever received medication for any mental health problems?’ ‘Have you ever tried to harm yourself?’ and lastly, ‘For some people coming into prison can be difficult, and a few find it so hard that they may consider harming themselves, do you feel like that?’ The EMHS is both a physical and mental health screening tool, with a focus on identifying a previous diagnosis or possible distress upon entering prison and the possibility of future self-harm,

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rather than an exploration of symptoms that may identify a mental health diagnosis, such as the questions included within the CMHS-W and CMHS-M. The Jail Screening Assessment Tool (JSAT) (Nicholls et  al. 2005), unlike the previous screening tools discussed, goes beyond screening to include assessment of prisoners as they enter prison. The JSAT is a structured professional judgement tool, delivered by mental healthcare professionals, which contains eight sections with several questions in each section and takes around 20 minutes to complete. The JSAT, much like the previous screening tools described, commences by identifying whether a prisoner has a history of a mental health diagnosis, substance misuse, self-harm, or attempted suicide. However, the JSAT moves on to assess the mental state of the prisoner in reception, including the prisoner’s current level of functioning and predicts how they will both socially and psychologically adapt to prison, with the inclusion of their criminal history and socio-economic demographics. The aim of the JSAT is also to identify appropriate services the prisoner may require, including mental health services. Unlike the previous screening tools, there are no scores and no-score-based decision algorithms, although guidelines support mental healthcare professionals to make decisions to support individual prisoners. Therefore, the JSAT relies on structured clinical judgement, this prevents an understanding of the validity of this tool, which some would argue is not a screening tool as goes beyond screening and includes assessing prisoners (Grisson 2006). The mental health screening tools described above, BJMHS, CHMS-M, and the EMHS, have been compared and measured against the General Health Questionnaire (GHQ 12), however, the JSAT was excluded due to the structured interview format (Dietzel et al. 2017). The GHQ is a preliminary mental health assessment widely used in the community, and identified 79.7% of 74 prisoners in an Irish prison with a possible mental health problem. When the outcomes of the GHQ were  compared to the other screening tools, the BJMHS, identified 100% of this population, the CMHS-M identified 60.8% and the EMHS 47.3% with a possible mental health problem (Dietzel et al. 2017). This very small study in one specific prison in Ireland demonstrates the variability of identifying prisoners with mental health problems across screening tools. Therefore, more prisoners than necessary may be referred for further assessment by mental health services, whilst prisoners who require referral to mental health services may not be recognised and referred. Previous studies have also identified variability in screening tools, but in contrast to the results of Dietzel et  al. (2017). For example, in a sample of 530 prisoners the EMHS was identified to be 10% more accurate than the BJMHS (Evans et al. 2010). A comparison of the validity and reliability of screening tools through a systematic review of the literature identified both the CHMHS-M and CHMS-W, and BJMHS and EMHS to be the ‘most promising screening tools’, although further understanding of the contextual factors of screening in reception to prison is required (Martin et al. 2013). These studies demonstrate the need to understand the validity and reliability of each screening tool and the information required to inform the implementation of a tool in reception screening in different prisons. In the United Kingdom, the National Institute for Health and Care Excellence (NICE 2017) guidelines 66 identify-specific screening questions regarding mental health (three questions) and self-harm and suicide risk (two questions), which are

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completed by the primary care nurse during reception screening. However, if the nurse is concerned regarding the mental health of a prisoner, NICE guidance suggests the application of the CMHS-W or CMHS-M.  If no immediate concerns, the  first    questions regarding mental health explore whether a person has ever accessed mental health services or seen a mental health professional, which encompasses a wide range of professionals from their GP to a psychiatrist, including counsellors for alcohol or substance misuse. If a prisoner responds yes, then they should be referred for a mental health assessment. The following two questions explore the immediate support a person entering a prison may require and includes information regarding past admissions to a psychiatric hospital, and the prescription of medication for mental health problems. Any information from both questions also identifies the need for a full mental health assessment by a mental health professional (NICE 2017). The two questions regarding self-harm and suicide risk explore whether the person entering a prison is feeling hopeless or thinking about or planning to harm themselves or have a history of self-harm or attempted suicide. If the answer is yes to any elements of these questions, the person requires an urgent mental health assessment, and if thought appropriate by a mental healthcare professional then the completion of the Assessment, Care in Custody and Teamwork (ACCT) Plan (which is discussed in depth towards the end of this chapter). In the United Kingdom, it is important to note  both the CMHS-W and CMHS-M and the BJMHS are applied within prisons. However, the need for immediate health screening when a prisoner enters prison in England and Wales continues to be  inconsistent as the House of Commons Justice Committee (2021, p. 15) identified: It is unacceptable that one in 12 prisoners do not have a health screening appointment within 24 hours of arrival and that Black, Asian, and other Minority Ethnic prisoners who have a mental health condition are less likely to have that identified than their white counterparts.

1.2 Mental Health Screening Mental health screening has become an important and essential element of the reception interview, although as discussed above current screening tools may not be fit for purpose. An initiative to address the validity and reliability of screening tools has been the implementation of a psychiatric nurse within reception screening. This section will explore the development of mental health screening and assessment of prisoners as they enter prison by psychiatric nurses in England and Australia (Brown et al. 2015; Schilders and Ogloff 2014). This is followed by an exploration of treatment patterns in prisons in England, after a prisoner receives a positive screen in reception for a mental health illness, self-harm, or suicide (Hayes et al. 2014). The implementation of a community psychiatric nurse (CPN) within reception screening in prisons in England was to support the development of appropriate referrals to mental health services and reduce the number of inappropriate referrals (Brown et al. 2015). The role of the CPN within reception included the triage of prisoners who have been referred to the mental health services following the completion of a screening tool by the primary care nurse. The triage completed by the

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CPN includes specialist screening through the application of a semi-structured clinical interview, which includes an assessment of past mental health diagnoses, substance misuse, as well as an examination of a prisoner’s current mental state, a possible diagnosis, evaluation of medication and risk to self and others, and whenever possible a review of their medical records. On completion of the triage, the CPN discusses each case with the multidisciplinary mental health in-reach team (which will be discussed later in this chapter), and the decision is made to either accept the prisoner into mental health services or to signpost the prisoner to other more appropriate services. A six-month evaluation of the implementation of a CPN in a London prison identified the success of the intervention (Brown et al. 2015). Three months prior to the implementation of a CPN in reception, only 31.4% of prisoners referred to mental health services were appropriate, whereas 3 months following the implementation of a CPN 93.8% of referrals were appropriate. A similar process has been documented in a prison in Melbourne, Australia, as a psychiatric nurse assesses each prisoner on reception by applying a structure interview based on a modified version of the JSAT (Schilders and Ogloff 2014). The modifications included the application of local language for income and substances, as well as gaining information from multiple sources, such as medical and criminal records. On completion of the assessment, the role of the psychiatric nurse is to use the information to allocate the prisoner a ‘rating’ from the framework developed in the prison. The ratings include P for mental health illness and SASH for suicide/ self-harm, both of which contain four categories: P1 is the classification of a prisoner who has a diagnosis of a serious psychiatric disorder or is currently acutely unwell; P2 is the diagnosis or possible diagnosis of a stable psychiatric disorder; P3 is a history of a psychiatric disorder but is currently stable; and P4 is a history of psychiatric disorder that requires ongoing treatment and support. The SASH ratings are as follows: S1 is the classification of prisoners who are at an immediate risk of suicide or self-harm; S2 is the significant risk; S3 is the potential risk; and S4 is the previous history of suicide or self-harm. The psychiatric nurse then recommends further assessment or referral to appropriate mental health support services, and all prisoners identified with a serious psychiatric disorder are followed up within 7 days. The process of applying a modified version of the JSAT by a psychiatric nurse in a prison in Melbourne, Australia, has been evaluated and identified that 81% of prisoners referred for further assessment with a psychiatric nurse, psychologist, or psychiatrist were appropriate. Of those seen by a psychiatric nurse, 42% had a severe mental illness, 65% a suspected mental illness, and 35% a history of mental illness, who were over six times more likely to be assigned to be at a high risk of suicide or self-harm compared to those without a mental health illness (Schilders and Ogloff 2014). The recommendations following screening for mental health illness, suicide, and self-harm by psychiatric nurses are influenced by the availability of mental health resources within the prison, which may be less than ideal. However, psychiatric nurses also need to consider the length of a prisoner’s sentence and whether a therapeutic programme is achievable and transferable to a community provider, demonstrating the complex case load and role of psychiatric nurses in prison.

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An important element of screening prisoners for mental health issues, self-harm, and suicide is the understanding of available care pathways and services to support prisoners following a positive screen. The outcome of the mental health screening of prisoners in reception using the EMHS (Grubin 2002) has been explored across five prisons in England (Hayes et  al. 2014), which identified 67% of prisoners screened positive for at least one element of the EMHS, 3% screened positive for ideas of self-harm, 17% a history of self-harm, 18% for a history of psychiatric treatment, and 21% for prescription of psychiatric medication. The initiation of care and support for these prisoners was measured by the implementation of an Assessment, Care in Custody and Teamwork (ACCT) and further clinical support. An ACCT is the process of developing and documenting a care plan for prisoners who have been identified as being at risk of suicide or self-harm, and ensures certain actions are taken to ensure the risk is reduced (Ministry of Justice 2019). Of those prisoners who identified current ideas of self-harm, an ACCT was opened for 71%, whilst 21% were also moved to a safer cell, which has no ligature points, although 25% of these prisoners had neither an ACCT implemented nor referral to primary or secondary mental health services (Hayes et al. 2014). Although it is not clear why these prisoners did not have an ACCT implemented due to the high risk of self-harm and suicide upon entering a prison, this would have been advisable. A further element of screening prisoners for mental health issues, self-harm, and suicide is the engagement of prisoners with treatment following a positive screen and whether treatment meets their needs. The exploration of the mental health needs of both male and female prisoners in two prisons in London applied the MRC Needs for Care Assessment to identify whether mental health services were meeting the treatment needs of prisoners with a mental health illness (Jakobowitz et al. 2017). The MRC Needs for Care Assessment (Brewin et  al. 1987) collates information over two stages. Firstly, from those who know the person and the person themselves, on the presence of problems in clinical and social functioning. Secondly, a mental healthcare professional is asked whether the person has received care relevant to each problem identified from a standardised list of items of care. Each item of care that has been provided is evaluated for its appropriateness and effectiveness, which leads to a judgement of the person’s primary need status, including met need (appropriate care is being provided), unmet need (care is required to be provided), no need (no clinical problem and therefore no need for care), or no meetable need (there is a disablement but no appropriate care available). An evaluation of 360 male and female prisoners identified that 70% of male prisoners and 80% of female prisoners had at least one unmet need for treatment, and 51% of female and male prisoners had an unmet psychological treatment need. However, nearly 54% of female prisoners and only 37% of male prisoners had all their needs met (Jakobowitz et al. 2017). Therefore, further understanding of mental health in-reach services is required  to explore the development of services to meet all the prisoners mental health needs.

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2 Mental Health In-Reach Services This section will provide an overview of mental health in-reach services within the prison services of England and Wales, the United States, and New Zealand, and discuss in depth the services provided (Forrester et al. 2013, 2018). Over the last decade, mental health services in England and Wales have received increased resources and improved organisational models of delivery, which will be discussed (Brooker and Webster 2017). Non-pharmacological interventions delivered by mental health in-reach teams will be explored, including cognitive behavioural therapy, dialectical behaviour therapy, acceptance and commitment therapy, and mentalisation-­based therapy. An element of mental health in-reach services is the need to support prisoners’ mental health due to being in prison as the prison environment and imported factors (pre-prison) negatively impact a prisoner’s mental health (Bowler et al. 2018), which will be discussed. Lastly, this section will include an exploration of the guidance and standards for implementing non-pharmacology interventions in prison, which encompass both the Stepped Care Model for People with Common Mental Health Disorders (NICE guidelines 41, 2011) and the Standards for Prison Mental Health Services—fifth edition (Townsend et al. 2021).

2.1 Overview of Mental Health In-Reach Services The implementation of mental health in-reach teams in prisons in England and Wales occurred in 2002 due to the change in commissioning and funding of mental health services in prisons, which became the responsibility of local healthcare commissioners (Department of Health 2001). This was followed by the publication of a best practice framework and guideline, the Offender Mental Health Pathway (Department of Health 2005), which provided guidance on how to manage prisoners’ mental health problems pre-prison, first night in prison, transfer to a different prison, and on release from prison. The work of prison mental health in-reach teams was then evaluated through national surveys. The first two national surveys, 2006 and 2008, focused on the challenges of recruitment and retention of staff, and in 2012 the survey identified in-reach teams had become smaller rather than growing to meet the needs of prisoners (Brooker and Gojkovic 2009; Forrester et al. 2013). However, in 2016, the national survey identified resources to support mental health in-reach teams had increased, including the number of mental health professionals and the number of prisons where a whole-system approach to mental health care had been adopted (Brooker and Webster 2017). A report by the Prisons and Probation Ombudsman (2016) identified good examples of in-reach teams in prisons and staff who went above and beyond to support prisoners with mental health problems to receive excellent care. However, there were still cases where care could have been improved through information sharing and appropriate referrals between prison

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staff and mental health in-reach staff, and improved coordinated care between primary health care, mental health in-reach, and substance misuse services. In prisons in England, mental health in-reach teams have traditionally worked within the framework of the Care Programme Approach (CPA) (Georgiou et  al. 2020). CPA was the provision of a framework to support assessing mental health needs and coordinating care within the community, including the sharing of information. The ethos of CPA is person-centred care, and the patient is involved in every process of their care, with the aim of empowering each patient to take ownership of their recovery. An element of the CPA was the inclusion of an annual health check for each patient. CPA has supported the improvement of care for people with severe mental illness in the community through the development of coordinated community-­ based care, care planning, and case management. The implementation of CPA in England occurred with limited resources and understanding, and some of the principles of CPA were lost (Georgiou et  al. 2020). However, CPA has now been replaced by Personalised Care and Support Planning, which is part of the wider implementation of the Community Mental Health Framework for Adults and Older Adults (NHS England and National Collaborating Centre for Mental Health 2019). The new approach plans to supersede CPA, whilst maintaining the principles of CPA, including a focus on care coordination and care planning. The new approach will support all those with mental health diagnosis and other complex comorbidities, rather than a focus on those with a severe mental illness, including patients with addiction problems and those within the criminal justice system. The implementation of this approach within prisons has commenced, but whilst writing this chapter the CPA remains the dominant approach. Models for in-reach mental health services in prisons have been developed. One example is informed by the assertive community treatment model, which has been modified and implemented in prisons in the United States and New Zealand (Kelly et al. 2017; McKenna et al. 2021). Assertive community treatment (ACT) was first developed and implemented by psychiatrists in the United States with the aim of supporting and treating people with mental health illness in the community and supporting the avoidance of acute hospital admissions (see Kent and Burns 2005, for an overview). In the United Kingdom, ACT was implemented in 2004 when the National Health Service Plan identified assertive outreach as an essential element of community mental health services (Department of Health 2000). The model was originally developed to support patients living in the community with a psychotic illness, fluctuating mental and social functioning, poor adherence and engagement with treatment and medication regimes, and for those where a relapse would have a serve consequence. The purpose of ACT is to maintain both regular and frequent contact with patients with mental health illness by healthcare professionals to both monitor their clinical conditions and actively provide treatment and rehabilitation as patients’ needs change (Kent and Burns 2005). The essential components of ACT are described in Box 1.

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Box 1 Essential Components of Assertive Community Treatment (ACT)

• The mental health community team provides a range of core services, including clinical care, which address the needs of each individual patient. • The primary goal of ACT is improvement in patient functioning, which will support an improvement in patient’s activities of daily living, social relationships, and possible employment. • Individual patient’s are supported and assisted to engage in their own symptom management. • The successful implementation of ACT requires the ratio of healthcare professionals to patients to be no more than one member of staff to 15 patients, which is a smaller than usual caseload. • A named mental health professional is assigned to each patient to support and complete comprehensive assessments and care reviews, these may be completed by the named mental health professional alone or by the wider team. • A treatment plan is developed and implemented for and with each patient, which changes and develops further over time as the needs of the patient change. • ACT includes the engagement and follow-up of each patient in an assertive manner. • The ethos of ACT is that skills learnt within treatment in the community are more readily applied in the community following the completion of treatment. Therefore, wherever possible patients receive treatment in the community they live rather than in hospitals or clinics. • Finally, the care provided by the multidisciplinary mental health community team is continuous and 24 h a day 7 days a week.

Adapted from Kent and Burns (2005). Assertive community treatment has been modified, for example, the forensic assertive community treatment (FACT) (Kelly et al. 2017), which was developed in the United States. FACT is specifically for people who have a serious mental health illness and are within the criminal justice system. The difference between FACT and ACT is the focus on preventing both recidivism (tendency of an offender to reoffend) and incarceration, which involves the provision of different treatments and services, and the inclusion of a probation officer as a member of the multidisciplinary team. The importance of the inclusion of probation officers has been identified, which include the development of collaborative working with mental health professionals and access to further services, although the different approaches to safety and health need to be identified and managed (Lamberti et al. 2011). A contemporary systematic review and meta-analysis of studies exploring the effectiveness of FACT on health and forensic outcomes identified little impact on health-related outcomes, but a greater impact on forensic-related outcomes (Goulet et al. 2022). The only positive health-related outcome following the implementation

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of FACT was an increase in the use of outpatient services, although individual studies identified an improvement in the global functioning of patients, which may not have been captured within the health-related outcomes measured in other studies. Positive forensic-related outcomes included lower arrests and incarceration rates, with a higher chance of avoiding further incarceration or shorter incarcerated sentences (Goulet et al. 2022). Assertive community treatment has been modified and delivered within the STAIR model (McKenna et al. 2021), which has been developed through an understanding of the literature, and includes screening, triage, assessment, interventions, and reintegration (Forrester et al. 2018). STAIR contains the necessary elements of mental health in-reach services within prisons and supports prisoners on their return to the community. STAIR is simple to follow, and the first three elements can be identified within mental health screening, triage, and assessment described in the previous sections of this chapter; interventions will be described in the next section. Finally, reintegration involves the planning of community support prior to release to enable continuous delivery of appropriate mental health services (Forrester et  al. 2018). In Aotearoa, New Zealand, 19 prisons mental health in-reach teams who adopted STAIR were compared with teams who did not adopt STAIR (McKenna et al. 2021). Mental health in-reach teams who adopted STAIR demonstrated multidisciplinary team service delivery and the use of technologies to support discharge planning but lacked a comprehensive approach to psychosocial interventions (McKenna et al. 2021). The following section will introduce interventions to support prisoners’ mental health.

2.2 Non-pharmacological Interventions The mental health in-reach teams within prisons deliver a wide range of non-­ pharmacological interventions to meet the needs of the prisoners. In England, the types of interventions delivered in prisons vary considerably due to the needs of the prisoners and the availability of skilled staff (Durcan 2021). Many of the interventions discussed are implemented to support prisoners’ mental health and well-being, as well as substance misuse disorders, and can be delivered by either mental health in-reach teams, including mental health or psychiatric nurses, or psychological services. Four interventions, which are typically implemented, include cognitive behavioural therapy (CBT), dialectical behaviour therapy (DBT), acceptance and commitment therapy (ACT), and mentalisation-based therapy (MBT). These interventions will now be explored in more depth and how they are implemented within a prison setting. Cognitive behavioural therapy (CBT) is a psychological intervention to support an understanding of an incident/experience through the identification and understanding of the relationships between feelings, thoughts, and behaviours, which was originally developed by Beck (1964). Cognition in CBT is conceptualised as core beliefs (strongly held beliefs developed in childhood), dysfunctional assumptions (rules for living, which may be maladaptive), and negative automatic thoughts

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(involuntary negative thoughts triggered by a situation) (Beck 1976). The three elements of cognition form a cognitive model, which is applied as a framework to understand a person’s anxiety/depression or presenting problem. The ethos of CBT is to support an individual to understand their own thinking, beliefs, and behaviours and enable them to develop tools and strategies to change their negative cognitive and behavioural patterns (Fenn and Byrne 2013). Therefore, CBT is a problem-­ focused structured intervention through a goal-oriented therapeutic approach. Due to the problem-focused approach of CBT, the approach is suitable for a wide range of problems, including physical and mental health and well-being. The structured approach of CBT involves both the duration of a session with aims and objectives and the number of therapy sessions with overarching aims and objectives. Many empirical studies have been undertaken and have begun to demonstrate the positive impact of CBT for prisoners on a wide range of health and well-being outcomes. The implementation of CBT within prisons varies considerably, for example, the length of a CBT intervention may vary from 14 weeks to 6 weeks, or just one CBT session. Due to the COVID-19 pandemic, the inclusion of online CBT has also begun to be implemented in prisons in the United States (Elison-Davies et al. 2022). However, the positive impact of CBT on prisoners includes an increased resilience prior to release (Budiyono et al. 2020), reduction in psychological distress and enhancement in psychological well-being of prisoners (Mak and Chan 2018), reduction in anger and aggression in male prisoners (Ayub et  al. 2016), reduction in the severity of insomnia of male prisoners (Randall et al. 2019), and the reduction in recidivism of high-risk reoffenders on probation (Barnes et al. 2017). Dialectical behaviour therapy (DBT) derives from cognitive behavioural therapy, which was originally developed to support people living in the community with a borderline personality disorder (BPD). However, DBT has been developed to be delivered in a prison setting. A main component of DBT, which is traditionally delivered over four modules, is the implementation of workshops to support the development of skills to address the ineffective behavioural patterns that are common in people diagnosed with a BPD. These modules include a focus on mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance, alongside an individual weekly therapy session (Linehan 1993). During these modules, other aspects relevant to an individual may also be addressed, such as behaviours that disrupt the progress of the therapy and more intense support should a crisis occur. DBT supports the development of primarily acceptance skills and coping skills. DBT has been identified as effective in prison settings, including an improvement in impulsivity of prisoners with a BPD (van den Bosch et al. 2005) and emotional regulation (Axelrod et al. 2011). Although DBT has also been identified as beneficial for prisoners without a BPD, including improvement in emotion regulation (Neacsiu et al. 2014) and interpersonal skills (Stepp et al. 2008). Similar to dialectical behaviour therapy, acceptance and commitment therapy (ACT) also derives from cognitive behavioural therapy (Hayes et al. 2006). ACT is also an action-oriented approach to therapy and focuses on supporting a person to begin to understand their inner emotions rather than avoiding or denying them, which involves goal setting and skill development through exposure to negative

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thoughts or experiences. ACT contains six core principles which support psychological flexibility, including acceptance, cognitive defusion, being present, self as context, values, and committed action (Hayes et al. 2006). The approach of ACT is suitable for many mental and physical health conditions, such as anxiety disorders, depression, psychosis, substance disorders, as well as chronic pain. ACT has been adapted for use in prison, one example is the implementation of a brief ACT by a novice therapist with prisoners convicted of a violent crime, which was effective in increasing the prisoner’s values behaviour. The implementation of ACT has also been identified to increase the hope of male prisoners and reduce their irrational beliefs (Eisenbeck et al. 2016). An ACT-based programme has been implemented within the correctional system in Iowa, USA, and has been identified to support the risk assessment, responsivity to the needs of prisoners, and general correctional practices, although challenges were identified (Zarling and Scheffert 2021). Mentalisation-based therapy (MBT) is a psychoanalytic therapy, which is a complex long intervention to support individuals’ ability to reflect and increase their mentalising capabilities (Bateman and Fonagy 2006). The aim of MBT is to increase an individual’s understanding of how their thoughts and beliefs link to their actions and the feelings these behaviours evoke in others (mentalisation). MBT involves both group and individual therapy. MBT was originally developed to support people with borderline personality disorder but has since been applied more widely, including antisocial personality disorder. However, within a prison setting it may not be appropriate to commence a long intervention such as MBT due to the high turnover of prisoners in most prisons either due to their release into the community or transfer to another prison. Although the possibility of shortening the duration of MBT has begun to be explored, the outcomes of a 14-month and a 20-week MBT programme have been compared (Juul et al. 2021). The shortened MBT programme consisted of 20 weeks of group therapy., the first five sessions included psychoeducation and an introduction to MBT. However, the outcomes of this study have yet to be published. MBT has been implemented with offenders in England, whilst on probation, although some confusion around the concepts within MBT was identified (Warner and Keenan 2022). A contemporary study has explored the clinical outcomes for patients with BPD at 12 months following DBT or MBT (Barnicot and Crawford 2019). The outcomes of this study suggest greater reductions in self-harm and improvement in emotional regulation in patients who received DBT compared to those who received MBT, although those who received MBT were more likely to complete their 12 months of therapy. However, on completion of 12 months of either DBT or MBT, there were no differences in patient outcomes such as incidents of self-harm, severity of BPD, and emotional dysregulation (Barnicot and Crawford 2019). Each of the therapies discussed, CBT, DBT, ACT, and MBT, all have different philosophical and methodological approaches, and address slightly different psychological concepts. Therefore, the understanding of which therapy is most effective in addressing different mental health and well-being issues of prisoners is complex and is only just beginning to be explored and understood. An important element for consideration in any therapy is the pre-prison factors that impact a prisoner’s mental health and well-­being, which have been identified to include childhood abuse, substance misuse, and unemployment (Bowler et al. 2018).

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2.3 Implementation of Interventions The implementation of therapy to support prisoner’s mental health and well-being in prisons in England is required to be delivered within the stepped care model for people with common mental health disorders (NICE 2011, updated by NHS Evidence 2013) and within the Standards for Prison Mental Health Services—Fifth Edition (Townsend et al. 2021). The stepped care model is an approach to support healthcare professionals and people with common mental health disorders and their families to engage in effective interventions, which meet their needs. The stepped care model has been developed for community mental health services, although it has been adopted within the Standards for Prison Mental Health Services (Townsend et al. 2021). Step 1 involves assessment and referral, which has been discussed earlier in this chapter. Steps 2 and 3 refer to treatment and referral for treatment, however, step 2 commences with the need to identify the correct treatment option; refer to Box 2 for guidance on information required to identify the most appropriate treatment option. The implementation of appropriate interventions to meet the needs of the patient is identified in Box 3, which provides an overview of the stepwise approach to ensure the level and intensity of interventions meet the needs of the patient. Box 2 Identifying the Most Appropriate Treatment Option

Firstly, the mental health professional, patient, and family (in the community) need to discuss the mental health disorder the patient is experiencing and consider: –– –– –– –– ––

The patient and family’s past experience of the mental health disorder The patient’s past experience of and response to previous treatment A discussion on the possible trajectory of symptoms A discussion of the diagnosis, including the severity and duration A discussion of possible associated functional impairment arising from the disorder or treatment –– A discussion of both social and personal factors that may impact the disorder or treatment –– An understanding of the presence of any comorbid disorders Secondly, when a mental health professional is discussing possible treatment options with a patient and their family, it is essential the conversation includes –– An overview of the proposed intervention, including the nature, content, and duration –– The possible tolerability or tolerability of the proposed intervention

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–– The possible interactions with any current medications or ongoing interventions –– If currently receiving an intervention or medication, the implications for continuing current treatments Thirdly, when a mental health professional makes a referral for treatment, the preference of the patient and their family needs to be considered when choosing one of a number of evidence-based treatments.

Adapted from: Common mental health problems: identification and pathways to care. Clinical guideline 123 (NICE 2011). Box 3 Stepped-Care Model: Common Mental Health Conditions and Recommendations

Step 3 –– Mild to moderate depression which has not responded to a low-intensity intervention, or moderate to severe depression on initial presentation— recommendations—amongst other therapies, CBT, antidepressant medication, self-help groups –– General anxiety disorders with functional impairment, which has not responded to a low-intensity intervention—recommendations—CBT, applied relaxation, drug treatment, self-help groups –– Obsessive-compulsive disorder with moderate to severe functional impairment—recommendations—CBT including exposure to response prevention therapy, antidepressants, self-help groups –– Post-traumatic stress disorder—recommendations—CBT, eye movement desensitisation and reprocessing, and drug treatment Recommendations for all conditions—support groups, befriending, rehabilitation programmes, educational and referral for further assessment and interventions Step 2 –– Mild to moderate depressive symptoms—recommendations—self-help both individual and group-based, online CBT, structured physical activity, antidepressants –– Generalise anxiety disorders—recommendations—self-help both individual and group based

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–– Obsessive-compulsory disorder with mild to moderate functional impairment—recommendations—individual or group CBT, including exposure to response prevention therapy, self-help groups –– Post-traumatic stress disorder with mild to moderate presentation— recommendations—CBT or eye movement desensitisation and reprocessing Recommendations for all conditions—support groups, befriending, rehabilitation programmes, educational and referral for further assessment and interventions Step 1 –– All conditions—both known and suspected presentation of common mental health disorders—recommendations—the commencement of identification, assessment, education, monitoring and referral for further assessment and interventions

Adapted from Common mental health problems: identification and pathways to care. Clinical guideline 123 (NICE 2011). The Standards for Prison Mental Health Services (Townsend et al. 2021) provide specific guidance on reception and assessment, treatment and recovery, discharge and transfers, and medicine management for patients within prison. The Standards were developed through a process of extensive consultation with stakeholders, such as prison staff, mental health professionals who provided care within prison, patients/prisoners, and commissioners, and the first edition was published in 2015. The Standards are a framework to support the assessment of the quality of mental health services within prison; this process includes the classification of essential, expected, and desirable standards. Failure to meet essential standards would ‘result in a significant threat to patient safety, rights, or dignity and/or would breach the law’ (Townsend et al. 2021, p. 6). The Standards regarding treatment and recovery are summarised below, and whether these processes have been classified as essential, expected, or desirable: • Mental health professionals work with each patient/prisoner to develop a written care plan, which reflects their individual needs. On completion of the care plan, a written copy is provided to the patient (essential standard). • When a patient is diagnosed with a mental health condition, mental health professionals offer information about their condition, in a way they can understand and retain; this may be verbal, written, or digital (essential standard). • Prior to the commencement of an intervention, the mental health professional must provide clear information regarding the intervention to the patient, including information on both the risks and benefits, allowing the patient time to ask questions. All of which is recorded in the patient’s medical records (essential standard).

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• Prior to the commencement of a psychological intervention, an assessment of the patient’s physical health is completed (essential standard). • The stepped care model for people with common mental health disorders (NICE 2011) is the model applied to manage patients to support appropriate assessments and treatment interventions (desirable standard). • Low-level interventions (according to the stepped care model) are accessible for all patients, which are adapted to their needs, and are delivered by a mental health professional or an adequately trained individual who is supported by a mental health professional (expected standard). • Evidence-based interventions appropriate for patient’s bio-psychosocial need are commenced within a time frame, which is agreed (essential standard). • The multidisciplinary mental health team (MDT) discusses all referrals, current assessments, and reviews once a week unless an urgent referral is required, which does not need to be discussed at an MDT meeting (essential standard). • The MDT has a responsibility to follow up patients who have not attended an appointment, and gain an understanding of whether patients are unable to engage in the intervention, the risk of not engaging, and how long to continue to follow up the patient (essential standard). • In female prisoners, there is a care pathway for the perinatal period, from pregnancy to 12  months post-partum, which includes assessment, care and treatment, and referral to a specialist perinatal team (essential standard). The stepped care model for people with common mental health disorders and the Standards for Prison Mental Health services identify specific structures and recommendations for mental health professionals when supporting prisoners with their mental health. The model and framework support the necessary processes and provide guidance on assessment, referral, and the level of intensity of interventions to be provided by mental health professionals. However, it must be recognised that both the model and the framework are congruent with the guidance and structures of clinical interviews and therapeutic interventions discussed within this chapter, and the professional standards of mental health professionals.

3 Role of the Mental Health Nurse The role of the mental health nurse or community psychiatry nurse in prison includes the involvement in assessment and provision of interventions for prisoners with identified mental health disorders, which have been discussed earlier in this chapter. The focus of the role of the mental health nurse in this section is on supporting prisoners who are at risk of self-harm and suicide, which within a prison setting includes the Assessment, Care in Custody and Teamwork (ACCT) assessment, which is predominantly applied for prisoners who are identified as being at risk of self-harm or suicide. The stages, implementation, and the responsibilities of different members of the multidisciplinary team within the prison setting will be explained and discussed (Pike and George 2019). The final element of this section will include case

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studies by mental health student nurses, which demonstrate the learning opportunities within mental health services within prison, and the role of qualified mental health nurses supporting students.

3.1 Assessment, Care in Custody and Teamwork (ACCT) Self-harm is the leading cause of morbidity in prisons around the world; this has been discussed in depth in earlier chapters and informs the role of the mental health nurse within prison. The mental health nurse is involved in identifying prisoners who may be at risk of self-harm and suicide and implementing appropriate interventions to reduce the risks identified. This process is supported by the Assessment, Care in Custody and Teamwork (ACCT). ACCT was developed and implemented in prisons in England and Wales by the HMPPS in 2005. Information regarding this process has been updated in 2011 and 2021 within the prison service instruction (PSI 642011) management of prisoners at risk of harm to self, to others, and from others (Safer Custody) (HMPPS 2011, 2021). ACCT is a framework, which requires interventions to occur within certain time frames to reduce the risk of self-harm or suicide by a prisoner. ACCT can be implemented for any prisoner if a member of staff receives information that a prisoner may be at risk of self-harm or suicide, this information may come from members or staff or prisoners, but also from family members or external agencies. The first process of opening an ACCT is the completion of a Concern and Keep Safe form, which involves asking the prisoner open questions to determine or clarify their risk. These questions must cover the following topics: • • • • • •

Suicide attempt or statement of intent to kill self Self-injury or statement of intent to self-harm Unusual behaviour or talk Very low mood, withdrawn, slowed down Problems related to drug or alcohol withdrawal Other concerns, including vulnerability due to age or immaturity

Following this discussion, the mental health professional documents their concerns and the concerns raised by the prisoner. Then if a risk of self-harm or suicide is identified, an ACCT is opened. An ACCT is an official registered document and requires the generation of a  log number, which is usually obtained from the safer custody team (but this may vary across prisons). However, once an ACCT has been opened, an Immediate Action Plan (IAP) must be implemented within the hour to maintain the safety of the prisoner. The IAP may be completed with the wing/unit manager and a member of the mental health team, primarily a mental health nurse. The IAP includes a number of elements to consider, which include • Location—identification of where the prisoner feels safe, which may include the completion of the Cell Sharing Risk Assessment (HMPPS, 2015: PSI 20/2015), commonly referred to as the CSRA assessment, which assesses the risk a prisoner will be violent towards their cell mate, and supports the safer cell referral to healthcare

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• Frequency of staff support—including conversations with the prisoner and observations of the prisoner, both during the day and night • Mental health interventions—referral to mental health services, identify whether in-person medications are in progress (see chapter “Primary Care in Prison”) or medications the prisoner may have access to • Phone access—which may include arranging an external call with family or Samaritans arranged by the wing/unit • Listener access—support from other prisoners who have taken on the role of listener or peer support • Other immediate interventions—this may include anything appropriate for the individual prisoner, such as removing razors or medication, providing distraction activities The next process occurs ideally within the following 24 hours and involves the first case multidisciplinary case review meeting, and agreement of the ongoing frequency of conversations and observations during the day and night, all of which is documented within the ACCT. The multidisciplinary care review meetings continue to monitor the progress of the prisoner at a frequency that reflects the risk of self-­ harm and suicide by the prisoner. If the prisoner does self-harm, the F213SH—Self-­ harm form must be completed.; of the two copies, one is filed in the ACCT and one is sent to healthcare for further assessment and recording. The closure of an ACCT occurs when the multidisciplinary team case management has assessed the prisoner and no longer considers they are at risk of self-harm or suicide. However, the ACCT is held for 7 days, during which it can be reopened if the need arises. Finally, a post-­ closure interview with the prisoner occurs and is documented within their ACCT.

3.2 Case Studies Two case studies of the experiences of mental health student nurses undertaking a placement within mental health services in a prison are presented.  The first case study will explore the realistic experience of a clinical placement in prison. The second case study will explore the learning opportunities for mental health student nurses in mental health services in a prison. Realistic Expectations of a Clinical Placement in Prison

I have felt quite safe, although I do think you need to mentally prepare yourself to go into a prison and what is going to happen. My fellow students were curious when I told them I had a placement in prison and asked if it was extremely dangers. I told them it wasn’t dangerous, and it was possibly safer than being on an inpatient ward, where people are unpredictable, overall, both prisoners and prison officers were respectful to each other. It was nerve-­ racking every time I went in the prison, I must admit I was nervous, but as a third-year student, I am used to going into new placements and meeting new

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people but going into a prison it was a very daunting experience. After the first week is was OK as all the staff, prison officers and healthcare know who I am, but at the beginning it was quite scary to be honest. I don’t think a placement in prison is for everyone, I think you need to be aware that even though the prisoners are your patients, they have committed crimes and some of them are horrific crimes, but you need to be able to set that aside and see them as patients. There were prisoners who would talk quite openly and in graphic detail about their crime, during their sessions. I found that difficult, especially when it was related to children, particularly when they showed no remorse. I found that really difficult, although I didn’t treat them any differently, but I did find that very difficult. However, my mentor provided me with support prior to going into any session with anyone who had committed an offence against children, especially the very awful crimes. I would always be told beforehand, and asked if I wanted to go in, and that was really helpful as I could prepare myself for that session. Personally, for me, I think prisoners with a mental health diagnosis are stigmatised more than the general population, because once you have got a label of being a criminal that sticks with you for the rest of your life, and no one really asks you about the situation that led you to be labelled as a criminal. For example, a lot of patients I supported in prison, were there because they had reacted to their abusers, and I don’t know if I was in that situation, would I have reacted any differently. In acute community mental health services, patients can be acutely unwell, and they could have a criminal record, and you don’t stigmatise them with that label, and I think that is really important, that if you are going to work in a prison, you need to be aware of that, and not everybody can work in that environment for that reason.

Learning Opportunities for Mental Health Student Nurses

My placement in the prison was with the mental health in-reach team, and my assessor/mentor was a CPN (Community Psychiatric Nurse), who had her own caseload within the prison. So, each day we see allocated patients on the wings, whilst going round the prison, a bit like a ward round. The CPN discusses what has been happening for her patients with prison staff and checks in with their well-being, but also assesses prisoners not on her caseload, which includes prisoners who have requested to see a CPN, or prisoners have been flagged by prison officers. I have had a couple of opportunities to complete an assessment, under my assessor’s supervision, so I know how to do the assessment and how to get all the information from the prisoner and what we can do to support them, because there is a lot of services within the prison that we can offer them such as psychological services, or a referral to a GP if they cannot sleep, and things like that.

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An important element of my learning included working closely with prison officers, as they are essential to maintain the security of the prison, but also support the provision of healthcare. Most of the officers, all though not all, were keen to learn how to support prisoners with their mental health, but they haven’t had in-depth training or education. So, we as mental health nurses, or nursing students may recognise the behaviour of some prisoners and know the questions to ask to understand the behaviours. Whilst prison officers might not know the questions to ask to understand a prisoner’s behaviour, or have the time to ask questions, and a prisoner’s behaviour is attributed to attention seeking, which I hate. During my placement in prison, prison officers did state prisoners were just behaving in a certain way as they were attention seeking, but it was our (nurses) responsibility to say no it is not attention seeking, it is someone calling for help, and you might need to give them the attention to address their needs. A role I supported my CPN with was supporting prison officers understanding of mental health and how to identify relevant behaviours. During my placement in healthcare in the prison I have been engaged with assessing risk and understanding risk management, from both working with my assessor and understanding the assessment of risk completed by prison officers. I have learnt the importance of reading a patient’s notes, both health and criminal as this supports an understanding of their background and the development of gold-standard care to address all their needs. I have also learnt how to and the need to involve different teams to support prisoners, writing assessments and completing documentation. Both the CPNs and the mental health nurses at the prison have a lot of responsibility, although they do delegate, which supported my learning through the opportunity to complete different tasks, I now feel more confident in my knowledge, skills, and abilities.

4 Conclusion This chapter has explored the importance and necessity of assessing the mental health of prisoners in reception to prison, and the need for expert mental health professionals, such as mental health nurses, to complete these assessments, referrals, and deliver appropriate interventions. The frameworks and models, which influence both the implementation of mental health services and the day-to-day work of mental health professionals, have been introduced. The most common interventions implemented in prison have been discussed, which included cognitive behavioural therapy, dialectical behaviour therapy, acceptance and commitment therapy, and mentalisation-based therapy. The important role of the mental health team in assessing and supporting prisoners who may engage in self-harm and suicide has been introduced, which is predominantly through the implementation of an ACCT.  Lastly, the

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experience of mental health nursing students has been included in this chapter to support an understanding of the mental health nurse, which also includes supporting the next generation of nurses.

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Prisoners with Intellectual Disabilities Vicky Sandy-Davis

This chapter contains a case study exploring a learning disability nursing student’s experience of a clinical placement in prison.

1 Prisoners with Intellectual Disabilities Historically, the definition of prisoners with intellectual disabilities (ID) has focused purely on the basis of the intelligence quotient (IQ) with four categories of ID ranging from mild, with an IQ score of 50–70, to people with a profound ID who have an IQ score of less than 20. However, IQ testing has been subject to extensive criticism over the years as test results can vary according to factors such as mood and motivation (Greg 2001). A degree of literacy is also required to complete an IQ test, so it has been argued the test is largely suited to cultural elements within Western society. More recently, whilst cognitive ability is still considered a factor in determining whether an individual falls into the category of ID, assessment of adaptive behaviour across conceptual, social, and practical skills is integral to a diagnosis (World Health Organization 2019a, b; Schalock et al. 2021). The definition of ID applied by different services, which provide support for people with ID, varies significantly, creating difficulties with discourse and subsequently continuity in service provision. Health and social care provision in the United Kingdom provides support for people who meet the criteria for ID as outlined in the White Paper ‘Valuing People’, in which the following definition is put forward: Learning disability is a reduced ability to understand new or complex information coupled with a reduced ability to cope independently and which started before adulthood with a lasting effect on development. (Department of Health 2001, p. 14) V. Sandy-Davis (*) West Midlands Region, Royal College of Nursing, Birmingham, UK e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 J. Brooke (ed.), Nursing in Prison, https://doi.org/10.1007/978-3-031-30663-1_6

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This definition excludes the use of IQ as a specific measure whilst accounting for intellectual ability on a more generic basis and includes both pathological and social functioning. However, it should be noted that IQ is still widely used as an indicator for ID both for the purposes of initial screening and identification, and as part of wider holistic assessment. The term ‘intellectual disabilities’ (ID) will be applied throughout this chapter.

1.1 UK Health and Criminal Justice Provision A broader criterion is applied in the Criminal Justice System (CJS) when referring to offenders who fall into the category of ID, which incorporates both learning or intellectual disabilities and learning difficulties, referred to informally as ‘LDD’. Lord Bradley, in his review of people with learning disabilities and mental ill health in the CJS, states: Even when talking to professionals in this field, I found that there was a lack of consensus in defining the boundaries between learning disability, borderline learning disability and learning difficulty. The problems with definition are due in part to the lack of agreement on the most effective methods of identification and assessment. (Department of Health 2009a, b, p. 19)

The reason for the blurring of definitions is explored in ‘No-one Knows’, report, which examined the treatment of people with ID in the CJS (Talbot 2008). The report identified precise definitions of intellectual disabilities and difficulties that would either ‘include or exclude people by a very fine margin’ (Talbot 2008, p. 2). The blurring of definitions identifies the potential for inconsistencies in the provision of appropriate support for this population. An extensive review of people with mental health problems and/or intellectual disabilities in the CJS led by Lord Bradley (Department of Health 2009a, b) explored existing policy and appropriate alternatives to prison for offenders who fall into these categories. The findings demonstrated a tendency to confuse ID and mental illness despite the recognition that mental illness was separate from ID. This has been further exacerbated by the identification of the term ‘neurodivergence’ within the CJS, which refers to any condition that falls into the category of neurodevelopmental disorders, including LDD, acquired brain injury, tic disorders, and other cognitive impairments (Criminal Justice Joint Inspection [CJJI] 2021). The CJS also recommends a common screening tool for any individual falling into this category as they progress through the CJS (CJJI 2021), which may not be appropriate or sensitive to all of these conditions. New guidelines for sentencing offenders with mental disorders identified three categories: a mental disorder, defined as conditions like schizophrenia, depression, or post-traumatic stress disorder; developmental disorders, defined as autism or learning disability; and neurological impairments, including acquired brain injury or dementia (Sentencing Council 2020). Whilst recognition and support of this population can only be of enormous benefit, the ongoing inconsistencies with definition and subsequently identification are evident.

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1.2 International Perspectives Learning disability is a term still commonly applied in the United Kingdom. However, the term intellectual disability is now being introduced; this term is widely applied in Australia, Canada, Ireland, New Zealand, and the United States (Reichow et al. 2014). In the United States, the term was introduced in 2010 by the American Association for Intellectual and Developmental Disability (AAIDD), replacing mental retardation. In the United States, the term learning disability refers to specific learning disorders such as dyslexia, dyspraxia, and dyscalculia (Reichow et al. 2014). In England, the term learning difficulties is more commonly used in regard to these specific educational needs as this population is more likely to have normal or above-average intelligence and therefore does not meet the UK criteria for ID (Kane et al. 2011). Whilst some of the terms mentioned are interchangeable, the use of different terms both internationally and professionally can make a common understanding difficult and increases the risk of misinterpretation, diagnosis, and support between countries, which is further enhanced when custodial institutions have their own definitions with reference to both sentences and support of offenders whilst in custodial services.

1.3 Historical Developments Historically, definitions of ID have changed in line with developments in knowledge and understanding, and a reflection of both social and cultural attitudes and beliefs, which have influenced changes in legislation, policy, and service provision. The first classification of ID was in the late nineteenth century, with three main groups based on the aetiology of their disability, namely, idiots (congenital causes), idiots and feeble-minded (accidental), and feeble-minded (developmental) (Mutua et  al. 2011). This was indicative of an increasing recognition that people with ID were able to learn and develop cognitively, which had not been acknowledged previously. The Idiot’s Act of 1896 was subsequently established, in which it was prescribed that local authorities had a duty of care to provide education, care, and training in local asylums for people who fell into these categories (Race 2005). The Eugenics movement in the early twentieth century linked ‘feeble-­ mindedness’ to socially undesirable traits, including criminality and immoral behaviour. The ideology of the Eugenics movement focused on improving the human gene pool by promoting segregation based on gender, and institutionalisation to prevent procreation (Mutua et al. 2011; Reinders et al. 2019; McConnell and Phelan 2022). At this time, the ‘feeble-minded’ and ‘mental deficient’ were considered to cause the problems in society; to address this, the Mental Deficiency Act of 1913 was introduced, which further segregated ‘mental defectives’ from the community (Hall 2008). The act introduced five classifications of ID, including idiots, imbeciles, feeble-minded persons, mentally infirm persons, and moral imbeciles. In 1919, the Ministry of Health became responsible for the care of people with ID, and many were cared for in asylums under the Mental Deficiency Act 1913.

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The Mental Deficiency Act 1913 was replaced by the Mental Health Act 1959, which placed responsibility for the care and support of those with ID who presented a risk to themselves or the wider community under the remit of the National Health Service (NHS). The terms ‘sub-normality’ and ‘severe sub-normality’ were introduced by the act to replace mental deficiency and moral imbecile, both of which were abolished (Gates and Mafuba 2016). The Mental Health Act was renewed in 1983 and amended in 2007, with the legal definition of learning disability referred to as a state of arrested or incomplete development of mind which includes significant impairment of intelligence and social functioning. (Mental Health Act 1983, amended 2007)

However, the Mental Health Act provides care and treatment for people with ID under the criteria of Mental Disorder. The criterion for detention of an individual with ID under the Mental Health Act is ‘an individual who is abnormally aggressive or demonstrates seriously irresponsible behaviour’ (part 1:2a), which includes offenders with ID.  An important element to consider is the pathway through the CJS for individuals with ID, which commences with their journey to detention, the necessity for treatment through appropriate health service provision within the CJS, and how individuals with ID are diverted from the CJS to external health service provision. However, at the time of writing, amendments to the Mental Health Act are in progress, with a view to further embedding the principles of choice and autonomy, least restriction, therapeutic benefit, and individualised care for those with a mental disorder who meet the criteria for detention and compulsory treatment.

1.4 Prevalence Attempts to estimate the prevalence of ID in the CJS have been problematic due to the previously mentioned differences in definition and terminology. Despite the extensive review of neurodiversity undertaken by the CJJI in 2021, the offender equalities’ annual report for 2020–2021, whilst stating that disability is a protected characteristic under the Equality Act (2010), does not include data about offenders with disabilities as ‘data continues to be limited’ (Ministry of Justice (MOJ) 2021, p. 4). Despite the inconsistencies presented through terminology and identification, studies have highlighted the disproportionately high number of people with ID in the United Kingdom who come into contact with the CJS and are subsequently incarcerated. Of offenders with an ID, 20–30% are unable to cope with aspects of the CJS (Loucks 2007). In a UK prison, the prevalence of prisoners with ID who demonstrated significant deficits in their intellectual abilities, was estimated to be 31% (Hayes 2007). The prevalence may be higher due to the application of a range of standardised tests of intelligence and adaptive behaviour; using the wider definition of social competency combined with intelligence ratings to increase accuracy in the identification of prisoners with ID is essential. This is consistent with findings from the CJJI, which

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identified that 29% of the offender population had a learning disability or challenge, of which 36% were male and 39% female (CJJI 2021). Of this population, 7% of prisoners had an IQ of less than 70 and a further 25% had an IQ of less than 80, highlighting the borderline definition of an ID, which constitutes a group of individuals who also have additional support needs. Overrepresentation of people with ID in prison is clear as it is estimated that just over 2% of the general population have ID (Department of Work and Pensions 2021). It is clear therefore, that a significantly high prevalence of people with ID come into contact with the CJS and are subsequently detained. Inconsistencies with identification and overrepresentation of people with ID in prison are also reflected in other Western countries, such as the United States, Australia, New Zealand, and European countries (Sǿndenaa et  al. 2008; Gulati et  al. 2018; Trofimovs et al. 2021; Hellenbach et al. 2017). These inconsistencies are demonstrated in the prevalence of people with ID in prison, with a range of estimates between 2 and 40% (Garcĺa-Largo et al. 2020). The worldwide prevalence of people with ID, with data gathered from Australia, New Zealand, Dubai, the United States, and the United Kingdom, identified that a prevalence of up to one and a half percent of all prisoners had a clinical diagnosis of ID (Fazel et al. 2008). Whilst this is significantly lower than the estimations in other studies, the diagnostic and survey methodologies were inconsistent; however, the prevalence of people with ID in prisons worldwide remains high. Two further issues need consideration; firstly, the prevalence statistics presented are only a reflection of the individuals with ID who are already in contact with the CJS, including those in prison, and this could potentially be a significant underestimation of the actual population with ID who present with behaviours that could be considered to constitute offending. Secondly, the difficulty in identifying the relationship between ID and offending behaviour needs to be accounted for, as a significant amount of offending behaviour in the intellectually disabled population goes unreported or undetected (Holland et al. 2002). Different attitudes towards reporting offending behaviour of individuals with ID have been identified; police are more likely to report an individual with ID involved in a serious crime compared to their carers (McBrien and Murphy 2006). Therefore, it is impossible to identify the number of people with ID who have avoided contact with the CJS, because of the potential number of individuals who present with behaviours which may constitute offending, but go unreported.

2 Health Inequalities in Prisoners with Intellectual Disabilities People with intellectual disabilities experience poorer health outcomes than the rest of the population (Heslop et al. 2013; NHS 2019; Perera et al. 2019; NIHR 2020; Whittingham et al. 2020; Heslop et al. 2021; Mencap 2022a, b). People with ID are five times more likely to be admitted to hospital than the general population for various health conditions (NIHR 2020). Examples include urinary and respiratory infections, diabetes, heart disease, hearing and vision impairment, thyroid, and gastrointestinal disorders. All of these conditions can be avoided or treated through

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access to primary health care, which is often hindered by a lack of reasonable adjustments and understanding of the needs of people with ID. A review of NHS England data found a higher incidence of both physical and mental health issues in people with ID compared to the wider population, and these are likely to be complex, with many individuals with ID presenting with two or more conditions (Perera et al. 2019). The vulnerability of the population of people with ID was particularly highlighted during the recent COVID-19 pandemic. In 2020, COVID-19 was the leading cause of death in males aged 35 and above, and females aged 20 years and above (Heslop et al. 2021). People with ID were over six times more likely to die from COVID-19 compared to people of the same age and gender in the general population (Mencap 2020). The high prevalence of co-existing health conditions increases the vulnerability of individuals with ID with an increased risk of dying prematurely (Tromans et al. 2020). Prisoners with ID and additional comorbidities were particularly vulnerable and at a higher risk of severe symptoms and death from COVID-19 (Wilburn et al. 2021). In addition, prisoners with ID were profoundly disadvantaged by the quarantine regime as information was inaccessible and led to misunderstandings regarding changes in their daily routine (Prison Reform Trust 2021). The global prevalence of physical health outcomes in prisoners with ID is scarce. However, in seven prisons in Queensland, Australia, a higher incidence of health conditions, including heart disease and hearing problems, as well as less chance of receiving preventative health care, was present in prisoners with ID than prisoners without ID (Dias et al. 2013). Research into the health status of people with developmental disabilities in prisons in Canada also found a high incidence of disease, with an increased likelihood of hospitalisation, and a higher prevalence of self-­ harm, substance misuse, and psychotic episodes (Whittingham et  al. 2020). Therefore, people with ID in prison require greater support, care, and resources (Hellenbach et al. 2017). Furthermore, whilst prison settings can be difficult to cope with for people with ID, these difficulties can be exacerbated for individuals with additional health needs (Hellenbach et al. 2017). The incidence of mental ill health has also been found to be significantly higher in people with ID compared to the rest of the population. Mental health problems include eating disorders, obsessive-compulsive disorder, drug and alcohol dependency, personality disorder, bipolar disorder, and schizophrenia, as well as self-­ harming behaviours and suicidal ideation (Bhandari et al. 2015; Hellenbach et al. 2017; Perera et al. 2019). The Adult Psychiatric Morbidity Survey estimated that 25% (1 in 4) of people with lower intellectual functioning presented with symptoms of mental health issues compared to 1  in 6 of the general population (McManus et al. 2016). The number of people with ID and mental ill health decreased with an increase in intellectual functioning. Therefore, potentially, mental ill health issues increase with the vulnerability of a person with ID. The incidence of mental ill health, as with physical conditions, is significantly higher in prisoners with ID than those in the prison without an ID. For example, prisoners with ADHD, ID, or autism had an increase in self-harm and suicide-­ related behaviours compared to prisoners without these conditions (McCarthy et al. 2019). In addition, 52.2% of men in a UK prison with neurodevelopmental disorders

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had at least two additional mental health disorders (McCarthy et  al. 2019). In Australia, a higher prevalence of substance misuse was found in prisoners with ID compared to those without (Bhandari et al. 2015). A significantly higher level of psychosis, attempted suicide, and self-reported lack of social support has been identified in those with an ID (Hassiotis et  al. 2011), although  people with an ID or autism have simultaneously been identified as being prescribed anti-­psychotics and/ or anti-depressants without any appropriate clinical indications (NHS England 2017). It is further highlighted that there is an increased likelihood of a person with an ID within the criminal justice system being prescribed antipsychotic medication in the 5 years prior to their death. The negative experiences of being detained in prison can contribute to the mental ill health of prisoners with ID. Reports of the treatment of prisoners with ID has been collated by the Prison Reform Trust (2014), and issues identified included bullying, sexual harassment, loneliness, confusion, and a lack of understanding of prison rules and regulations. Over half of the prisoners with an ID reported that they had been ‘scared’ whilst in prison and had been bullied or people had been ‘nasty’ to them. Prisoners with an ID were five times more likely to have been subject to control and restraint, and over three times more likely to report having spent time in segregation (Prison Reform Trust 2014; Murphy et al. 2015). More recently, prisoners with an ID have been identified at a greater risk of being bullied and exploited whilst in prison (Durcan 2021). However, not all the experiences were negative. The Prison Reform Trust (2014) identified prisoners with an ID who reported positive experiences including access to education, and an improved social environment compared to their living arrangements at home. In addition to the population of people with an ID, a significant number of prisoners with autism have been identified, with estimates ranging from 1 to 4% of the prison population (Fazio et al. 2012; Ashworth 2016; Chaplin et al. 2021). The CJJI (2021) identified the presence of autistic traits or indicators in the prison population, as three times higher than the general population, ranging from 16 to 19%, which is considerably higher than previously estimated. Whilst not all autistic individuals have an ID, autism has been found to be more common in people with an ID than the general population (National Institute for Health and Care Excellence (NICE) 2016). Autistic people present with specific behavioural and social issues and require additional understanding and support. Autistic prisoners are significantly more likely to attempt suicide than those without autism, and present with  an increased incidence of self-harm and additional mental disorders (Chaplin et  al. 2021). When a prisoner has both autism and an ID, there is a crucial need for specialist support.

3 Screening and Identification Whilst there have been and still are inconsistencies in screening in the prison service for intellectual disability and the additional health needs of prisoners with an ID, this has been recognised and there are developments being undertaken to make

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improvements in service provision. An action plan to improve the experience of those with neurodiversity has been developed by the Ministry of Justice (MOJ 2021) and guidance by the NHS (2020) to include the effective identification and support of prisoners with an ID, and reasonable adjustments to be implemented as appropriate in the prison setting. The early identification of an ID is vital in obtaining an appropriate outcome for offenders with an ID and should enable diversion into health services where appropriate (Talbot 2008; Department of Health 2009a, b; Durcan 2021; CJJI 2021; NHS 2021). This is essential as people with an ID often have their convictions overturned on appeal. People with an ID are overrepresented in miscarriages of justice as a result of unreliable or false confessions (Gudjonsson and Joyce 2011). The unreliable confessions may be due to the comprehension and communication difficulties of offenders with an ID, but also a lack of training and knowledge of CJS employees regarding ID. In addition, there is a risk of suggestibility as someone with an ID may not understand the questions being asked (Standen et al. 2017), and early identification of individuals with an ID may prevent wrongful convictions. These issues have been addressed with the development of a Liaison and Diversion service, which supports early assessment and identification of individuals with an ID by healthcare professionals, including learning disability nurses. An important role of Liaison and Diversion is to divert those with an ID to appropriate services outside of the CJS to ensure appropriate support is provided (NHS England and NHS Improvement 2019; CJJI 2021). Historically, few prisons used routine screening for intellectual disabilities (Murphy et  al. 2015). Whilst information pertaining to individual health needs should be identified at an earlier point in the journey through the CJS, and should be available on reception into prison, this is not always the case. The CJJI (2021) review of neurodiversity in the CJS identified that initial screening should be carried out at the earliest possible stage of contact. However, the CJJI (2021) review found that this was not consistent and a wide range of screening tools are used across the CJS, some of which were not implemented effectively and, in many cases, ‘no screening at all was taking place’ (p.  24). The CJJI (2021) further noted that if screening is successfully carried out at an early stage, reasonable adjustments under the Equality Act (2010) could be effectively provided, such as fair access and treatment for those with ID, or diversion out of the CJS into a more appropriate setting. Therefore, to mitigate against the disadvantages imposed on prisoners with ID, identification of both the presence of an ID and any accompanying physical and mental health needs is vital. On reception into the prison, it is advised in the primary care service specification for prisons in England that All patients much undergo an initial health screen on receipt into the establishment by an appropriately qualified, competent registered nurse to identify any immediate health needs or risk-particularly in relation to issues such as suicide or self-harm, mental health, learning disability ….

An initial screening for physical and mental health issues should be undertaken and completed as part of the ‘First Stage Assessment at Reception to Prison’ (NICE

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2017) in which a series of questions are posed, both to identify any existing conditions and ongoing treatment interventions, but also to gather information about the history and everyday living skills of the individual. The initial screening tools include the Basic Custody Screening Tool (NHS 2021). Screening should be a brief exercise and is completed to identify any initial indicators that may constitute an ID, as well as any additional mental or physical health needs. The healthcare practitioner who completes the screening requires relevant knowledge and experience to recognise signs of a potential ID (NICE 2017; Durcan 2021); therefore, a learning disability nurse may be best placed to complete reception screening. Effective information sharing with primary and secondary health service provision is essential in gaining an individual’s relevant clinical and social history. Historically inter-agency communication is inconsistent (CJJI 2021). Therefore, it is important that initial screening and further assessment are completed in a sensitive and robust manner to avoid missing any health issues or an ID. The initial screening process will trigger the necessity for any further and more robust assessment and diagnostic testing, and this is necessary for both education and healthcare interventions whilst in prison. Ideally, this should be carried out at an early stage; however, assessment can occur at any stage during a prisoner’s detention. There is a range of screening tools available to identify an ID as well as any additional needs, such as the Learning Disability Screening Questionnaire (LDSQ), the Hayes Ability Screening Index (HASI), and the Do-IT Profiler (NHS 2021). The LDSQ has been tested on a sample of 3000 prisoners in three prisons in England and was acknowledged to identify a prisoner with an ID more frequently than other screening tools (Murphy et al. 2015). The LDSQ is brief and valid, and requires minimal training and is an appropriate choice as a standard tool for screening in prisons. In order to effectively assess for an ID and its presentation, a full diagnostic assessment of both IQ and adaptive behaviour is necessary. This can, however, be both costly and time consuming, and requires an element of training and professional experience that may not be available in a prison setting (Murphy et al. 2015). If this is not possible, a specialist practitioner would need to be commissioned from external primary healthcare services to carry out the assessment (NHS 2021). Waiting lists can be long, and this can lead to a delay in the provision of necessary interventions for the prisoner with an ID and associated needs (CJJI 2021). If appropriately trained healthcare professionals are available, IQ testing and adaptive behaviour assessment include an exploration of both social and emotional behaviours. There is a wide and varied range of assessment and diagnostic tools in use, and it is important that the most appropriate tools are utilised to assess individuals in the prison setting. The Wechsler Adult Intelligence Scale (WAIS), to measure IQ for people with ID, is an example of a commonly used assessment tool. However, for initial screening of an ID, the use of WAIS has demonstrated to result in comparatively low prevalence rates of ID in prisoners, suggesting that this may not be the most effective assessment tool for individuals in prison, and the LDSQ may be more effective in identifying the presence of an ID in prisoners (Murphy et al. 2015).

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Screening for autism or autistic traits should also occur with all offenders at an early stage of contact with the CJS.  Whilst there are many screening tools for autism, these have limitations, which can result in over- or under-screening with inconsistent outcomes (Durcan 2021). Despite this, it is important that the indicators for autism or autistic traits are identified upon reception into the prison, and the Diagnostic Interview for Social and Communication Disorders (DISCO) is a recommended assessment tool. DISCO is a diagnostic assessment which explores current behaviour, skills, any difficulties experienced by the individual, and has a focus on offending behaviour. The Do-It profiler includes indicators of autism and ADHD, and this is also recommended as an initial screening tool. Screening for autism is a specialist skill, and if no one in the prison mental health service has the necessary skills, this would need to be completed by an external professional with training and knowledge in the presentation of autism (NHS 2021). Screening may again trigger the necessity for further diagnostic tests and assessment for the presentation of autism, either with or without an accompanying ID. Whilst consistency in screening for an ID is important, self-reporting is often a more accurate indicator than evaluation by custody officers. Self-reporting can provide clarity in identifying an ID and the impact on the quality of life of the individual compared to objective observation and responses to structured assessment (Shogren et al. 2021). However, evaluations based on self-reporting are largely disregarded, resulting in a lack of appropriate support (Young et al. 2013). Despite this, there is recognition that the ability to self-report is an important element of the screening process and is recommended within the CJS (CJJI 2021).

3.1 Screening and Assessment for Mental Ill Health Initial screening may identify indicators of mental ill health or whether an individual has a history of mental ill health, in which case a second-stage mental health assessment is required to be completed (NICE 2017; Durcan 2021). Screening for mental ill health in individuals with an ID requires historical records and information from previous carers and service provision, which can provide important information that can otherwise be difficult to ascertain. However, it has been identified that information sharing between external primary and secondary health services is inconsistent. This can result in a lack of information regarding mental and physical health conditions, and the delay in continuation of medication and treatment (Durcan 2021; CJJI 2021). The initial screening process has been identified to miss 75% of mental health needs (Durcan 2021), which could potentially be exacerbated for individuals with ID due to problems with insight, communication, and comprehension. Therefore, without consistency in the identification of mental health issues and appropriate treatment interventions, there is a risk of the exacerbation of preexisting mental health issues. Whilst it is recommended that second-stage screening for mental health issues is completed by a registered nurse, an understanding of ID is important; therefore, a professional with experience of mental health issues in ID would be best placed to

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carry out an assessment of this nature, such as a learning disabilities nurse. A lack of insight, comprehension, and verbal communication skills in a person with ID can often result in limited ability both to recognise a deterioration in their mental health and to communicate this effectively. Observational skills are therefore an important aspect of screening and assessment to identify any issues that can easily be overlooked or wrongly attributed to ID. This is a far-too-common issue and is known as ‘diagnostic overshadowing’ and can ultimately lead to a significant deterioration of the mental or physical health of an individual with ID, leading to the need for further therapeutic or clinical treatment interventions which could have been avoided. Therefore, knowledge, training, and experience of working with people with ID are prerequisites to effectively completing a mental health assessment, and again learning disability nurses have the necessary training and knowledge to effectively undertake this role. There is a wide range of screening and assessment tools available to identify mental health needs, and these include adapted tools for people with an ID.  The Correctional Mental Health Screen for Men (CMHS-M) or Women (CMHS-W) is the assessment recommended by NICE (2017). This may be appropriate for people with an ID who demonstrate insight and understanding and are able to respond appropriately. A qualified professional and ideally a learning disability nurse should be aware of issues with communication and comprehension and therefore can ensure that questions are worded appropriately to ensure understanding. For some people with an ID, a standard mental health assessment tool may not be appropriate and specialised knowledge and experience may be required to interpret the results (NICE 2016). Adapted assessment tools may be more appropriate, such as the Psychiatric Assessment Schedules for Adults with Developmental Disabilities (PAS-ADD). The PAS-ADD is a commonly used mental health assessment tool, and can be facilitated by a specialist health professional. The PAS-ADD scores more highly than other assessments on the sub-scales of depression and psychosis and is therefore advisable in assessing prisoners with ID in these areas. The Mini-PAS-ADD is a shorter version of the PAS-ADD and is designed to be utilised by non-specialists to identify potential mental health issues, with a view to referring for further assessment (Devine et al. 2009). The Mini-Pass-Add would potentially be a useful assessment tool to use at any stage to identify signs and symptoms of deteriorating mental health of prisoners with an ID. Other examples of adapted assessment tools include the Glasgow Anxiety Scale for People with an Intellectual Disability (GAS-ID) and the Glasgow Depression Scale for People with a Learning Disability (GDS-LD). These tools include self-rating to identify indicators of depression or anxiety. For prisoners with an ID who are diagnosed with a mental disorder which requires treatment in hospital, transfer to a secure psychiatric facility which specialises in the treatment of individuals with ID should be facilitated under the remit of the Mental Health Act (MHA) (1983). Part III of the MHA provides guidance for patients within the CJS, and section 47 should be implemented for the transfer to hospital of a person serving a prison sentence, and this may include restrictions put in place by the Ministry of Justice under section 49. Detention under the MHA should follow assessment and diagnosis by an appropriately trained Psychiatrist,

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and under the 2007 amendment of the MHA, a patient can only be detained in a setting which provides appropriate treatment. On recovery, a patient should either be transferred back to the prison setting to serve the remainder of their sentence or discharged in the event that their sentence has been served. Previously, delays have been identified for prison transfers due to both communication and administrative issues (Department of Health 2009a, b; Durcan 2021). Transfer guidance has recently been published by NHS England and NHS Improvement (2021) to overcome these issues, and a timescale of no longer than 28  days from referral for assessment to transfer hospital has now been established to prevent further delays. It is important to remember that an ID does not equate to a lack of capacity. As is the case with the rest of the population, under the Mental Capacity Act (2005) a lack of capacity cannot be assumed without a capacity assessment, and this is important, especially in the case of an individual with an ID, whose communication skills may be limited as well as there being potential issues with comprehension. If a lack of capacity is suspected, an assessment must be undertaken by an appropriately qualified professional. Otherwise, there is no significant reason that an individual with an ID should not be offered the opportunity to fully participate in screening and assessment.

3.2 Screening for Cognitive Decline The life expectancy of people with an ID is increasing, with longer sentences becoming increasingly common (Durcan 2021) it can be asserted that a growing number of people with dementia are inevitable in this population. The risk of early-­ onset dementia is widely known in people with an ID, especially in those with Down’s syndrome. However, signs of cognitive decline can be difficult to identify as a result of pre-existing cognitive impairment as well as comparatively low cut-off scores in cognitive screening tests, and this can result in under-identification and a lack of treatment (Holst et al. 2018; Takenoshita et al. 2019; Arvio and Bjelogrlic-­ Laakso 2020; Holingue et al. 2022). All types of dementia have been found to be more common at earlier ages in people with an ID, with an estimated 13% of people with ID in the 60- to 65-year age group diagnosed with dementia compared with 1% of the general population. In the ID population, a screening of 230 individuals, using the British Present Psychiatric State-Learning Disabilities assessment, identified 42% showed two or more signs of dementia, and symptoms were almost as common in under 40 year olds as they were in those aged 70 and older (Arvio and Bjelogrlic-Laakso 2020). Therefore, dementia in prisoners with an ID is potentially significant within prisons. Therefore, there is a need for baseline screening in people with Down’s syndrome, and the implementation of a baseline screening assessment for cognitive decline in people with an ID as part of a dementia pathway (Herts Valley Clinical Commissioning Group 2018). Baseline screening is particularly important for individuals with an ID detained in prison. Initial screening is recommended when a person with an ID is healthy, to establish a baseline level of functioning and

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cognitive ability. Due to the difficulties in identifying the signs of cognitive decline, this would enable more accurate assessment at an earlier stage, enabling effective monitoring, treatment, and support as necessary. Whilst there are standardised assessment and screening tools to identify early signs of dementia, these may not be appropriate to screen people with an ID due to differences in presentation. However, there are screening tools which are effective in identifying dementia in individuals with ID. The Dementia Questionnaire for People with Learning Disabilities (DLD) is a screening tool for early detection of dementia that can be completed by carers, with 50 items to identify orientation, speech, practical skills, mood, activity, interests, and behavioural disturbances (Herts Valley Clinical Commissioning Group 2018). Further examples include the Early Detection Screen for Dementia (EDSD) which is a screening questionnaire, again specifically designed for people with ID. The tool identifies changes in behaviour, thinking, and adaptive skills (Deb et al. 2007; Holingue et al. 2022) and is described as a useful tool to detect changes in baseline functioning and collect relevant information for further monitoring and therapeutic intervention as necessary (Holingue et al. 2022). There is a consensus that older prisoners with moderate or severe symptoms of dementia should be transferred to a more appropriate care environment in order that they can be appropriately supported with the implementation of any necessary reasonable adjustments (Durcan 2021). There is also an urgent need for early and ongoing specialist support and education for staff who support individuals with an ID (Holst et al. 2018). Due to the differences in the presentation of early signs of cognitive decline in people with ID, appropriate training, knowledge, and experience are essential. The implementation of a dementia pathway across the prison estate is essential, with the inclusion of mandatory baseline screening. This is also needed to support the identification of early signs of dementia and ensure appropriate multidisciplinary support or diversion to a specialist health setting. Appropriate  screening tools are pre-requisite for prisoners with an ID to ensure baseline screening, assessment, and treatment are completed within the prison setting.

4 Support for Prisoners with Intellectual Disabilities The Equality Act (2010) identifies ID as a protected characteristic, and individuals with ID are therefore legally protected from discrimination. Therefore, the implementation of reasonable adjustments should be considered for every aspect of the prison environment; for prisoners with ID, the importance cannot be overstated. Public Health England in their guidance state that Under the Equality Act 2010 public sector organisations have to make changes in their approach or provision to ensure that services are accessible to disabled people as well as everybody else. (Public Health England 2020: 1)

Prison surroundings need to be accessible and easy to navigate for prisoners with either ID and/or autism (NHS 2021), and this should be considered in the development of policy and procedure.  Writtenforms and documentation are not

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presented in an accessible format, and this can disadvantage prisoners with ID. The use of alternative formats such as signs, symbols, and simple and concrete language in larger fonts should be utilised where possible. Prisoners with ID and/or autism may require information to be individualised to ensure accessibility and understanding, and this can be developed with assessment and guidance from a Speech and Language Therapist. Prisoners with autism may have difficulties with sensory integration and processing, and this can result in the presentation of reactive behaviours which can be difficult to manage. Current guidance suggests that it is therefore important that a quiet environment is provided with minimal sensory stimulation. It  is recognised that the structured routine provided as part of the prison regime can be of benefit to autistic people, and many respond well to the prison environment (NHS 2021). Reasonable adjustments are also required to support prisoners with ID and/or autism within both education and treatment programmes. Prisoners with ID, whilst being disproportionately represented across the prison estate internationally, are significantly less able to participate in a meaningful way in prison education and treatment programmes without adaptations, and this can result in higher rates of recidivism, and a higher likelihood of return to prison (Rowe et al. 2020; Ramsay et al. 2020). Both educational and treatment programmes need to be adapted appropriately, and this can be achieved through effective screening and responsivity to the needs of the individual with ID and/or autism (Ramsay et al. 2020). In addition to the necessity for reasonable adjustments to be made to educational programmes, offender treatment programmes also need to be accessible to those with ID and/or autism. Examples include adapted sex offender and fire setter treatment programmes (Alexander et al. 2015; Cohen and Harvey 2016), as well as adaptations to alcohol and drug treatment interventions (McGillivray et al. 2016). There are some individual examples of the success of adapted educational and treatment provision, and a person-centred and individualised approach, which significantly improves educational outcomes for prisoners with ID. In Australian prisons, additional support units (ASUs) have been established to accommodate a small number of the most vulnerable prisoners with ID or cognitive impairment. ASUs have supported a person-centred approach for a small number of prisoners and achieved a significantly higher level of success for prisoners with ID than mainstream interventions provided for the general population (Rowe et  al. 2020). Importantly, the opportunity to build relationships is highlighted as a central tenet of good practice in education, training, and employment programmes for prisoners with ID, as is a collaborative, multidisciplinary approach. Parc Prison in Wales is another example of specialised provision for prisoners with ID, with the establishment of a dedicated wing to address both health and sensory needs, and is staffed by learning disability nurses (Cole 2020). The provision of specialist provision has resulted in significantly reduced rates of exploitation of prisoners with ID by other inmates, the use of force, violent incidents, and self-harm. In addition, there have been ‘massively positive outcomes’ (p. 15) in health, including mental health status. The CJJI (2021) also highlighted positive examples of such adaptations and recommend the introduction of neurodiversity support managers in prisons.

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However, the introduction of reasonable adjustments in some environments within the CJS remains challenging. Another example of the use of reasonable adjustments is the introduction of therapeutic communities. These provide an alternative therapeutic model used in some prisons and high secure services to provide for vulnerable prison groups, including, for example, people with ID, personality disorder, or complex needs. Therapeutic communities are described as ‘psychologically informed planned environments’; environments where the social relationships, the structure of the day and different activities are all deliberately designed to help people’s health and wellbeing. (Taylor et al. 2015, p. 124)

Therapeutic communities provide a structured routine in which psychotherapeutic activity, education, and occupational interventions are provided to a small group. The aim of the therapeutic community is to provide a communal environment in which prisoners share responsibility and decision-making in addition to taking responsibility for running and maintaining the community (Taylor et  al. 2012). HMP Dovegate is an example of a therapeutic prison, and a recent inspection report identified prisoners received good support, including those who felt vulnerable (HMIP 2018). The report also identified good relationships between staff and prisoners, and as a direct result less violence was reported, despite a history of violent offending by many prisoners (HMIP 2018).

4.1 Training and Knowledge Prison staff are required to support the specific needs of prisoners with ID, which include screening, identification, complex physical and mental health issues, cognitive decline, and the reasonable adjustments, alongside the need for adapted educational and offender treatment programmes. The concept of training in the CJS as a way to improve awareness of knowledge and attitudes towards offenders with ID provides a potentially simplistic answer to a very complex problem (Talbot 2008; Department of Health 2009a, b; Hellenbach et al. 2017; Durcan 2021; NHS 2021). Lord Bradley’s recommendations led to the development of practice guidelines for professionals working within the CJS, as well as accessible guidance for supporting offenders with ID.  For example, training was developed and implemented for entrance-level prison officers in learning disability awareness (MOJ 2010). Several publications have also been produced by third-sector organisations such as Change Organisation, which produces accessible guidance for people with ID who are in contact with the CJS. Other publications include guidance from several widely recognised organisations such as the British Institute for Learning Disability (BILD), the National Autistic Society, and Dyslexia Action. Training initiatives for prison staff to support prisoners with ID have been commissioned and implemented. For example, Keyring Organisation developed training in partnership with people with ID who had experience of the CJS, including time spent in prison, and the training was implemented and facilitated in partnership with people with ID (Keyring 2014). However, although the Support for Justice

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group, which is a sub-group within Keyring,  continues to actively provide this training, this is not on the same scale. Other isolated examples of training have been implemented, but limited resources have impacted the wide delivery of such training. More recently with the introduction of the term neurodiversity, CJS staff, including those working in the prison estate, identified that they had little or no training, and their awareness to offer support was ‘practically non-existent’ (CJJI 2021, p. 35, 6.14). Prison healthcare staff were more likely to have some knowledge about neurodiversity as this was provided as part of their professional training rather than through the prison setting. Minimal training in neurodiversity has been delivered in-house by healthcare or education specialists to peers. The MOJ (2022) action plan is to roll out a programme of awareness raising, and this has already commenced in partnership with HMPPS.  An initial mapping exercise is planned to identify current training offered locally as well as any local plans to deliver further training. A core competencies framework is also being developed to describe core knowledge, skills, and behaviours required to work with people with ID and other neurodivergent needs, and a ‘National Neurodiversity Training Toolkit’ is also planned for rollout at the end of 2022. With the current focus on neurodiversity in England and Wales, including the need for support for prisoners with ID, it is possible that the national training initiatives described will provide a better experience for vulnerable prisoners.

5 The Role of the Learning Disability Nurse The importance of specialist knowledge and training in the needs of prisoners with ID in all areas of service provision is clear. Learning disability nursing is the only profession in the United Kingdom, and perhaps internationally, that offers 3 years of training with a focus purely on the holistic health and social care needs of people with ID, resulting in professional registration with and governance by the Nursing and Midwifery Council (NMC). Countries such as America, Canada, and Australia, amongst others, deliver more generic nursing programmes, with opportunities to specialise following qualification (Green 2018). Despite this, there are only 16,953 learning disability nurses registered with the NMC in August 2022; therefore, this is the smallest nursing cohort compared with 92,780 registered mental health nurses and 567,291 adult nurses (NMC 2022). Learning disability (LD) nurses are sought both in the prison estate and in Liaison and Diversion services to support people with ID (Durcan 2021). However, it has been stated that prisons have only recently begun to understand the importance of this role (Trueland 2020). Learning disability nurses are trained in all areas of the needs of individuals with ID and have additional skills and knowledge in • Behaviour management and positive behaviour support including de-escalation • Skills and knowledge in adapted communication, mental health and physical health issues, including the assessment and management of self-harm and suicidal ideation

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Knowledge of autism and sensory needs Clinical skills Medication and administration Leading and coordinating person-centred packages of care, as well as in-depth knowledge of relevant legislation The list is not exhaustive. Trueland (2020, p. 8) goes on to state that A lot of the learning disabilities nurses who have been working in prisons for some time have just been getting on with it, developing and adapting tools, providing support and training to officers who don’t really know what they’re dealing with, so they are adding value there as well.

Whilst this is typical of learning disability nurses, it also highlights the additional and important role in education and awareness raising, and making reasonable adjustments to effectively support prisoners with ID. As with all of the branches of nursing, learning disability nurses are trained to work autonomously applying an evidence-based approach. Their role in the prisons begins with initial screening at reception into the prison as they are able to adapt screening and assessment tools and facilitate assessments to meet individual needs and provide improvement in the identification of individuals requiring specialist support and adaptations. Learning disability nurses are also skilled in the assessment and identification of mental and physical health issues in people with ID, which can be difficult to identify. Importantly, learning disability nurses have an in-depth understanding of the social needs of people with ID, and this includes the impact of social inequality as a factor in offending behaviour (Fyson and Yates 2011; Chaplin et al. 2013; Emerson and Halpin 2013). One of the most important skills of the learning disability nurse is to work collaboratively using a person-centred, individualised approach. Following assessment, a person-centred plan of care will be developed in partnership with the individual where possible, and this includes crisis management and the assessment of potential risk. Learning disability nurses follow a strengths-based approach and work with the individual to move forward through therapeutic relationship building. As a result of their training and understanding of the needs of people with ID, learning disability nurses are able to advocate on behalf of people with ID in the prison setting and reduce inequalities in their treatment and support, thereby improving the experiences of prisoners with ID. An important element to support learning disability nurses in their role within a prison setting as described above is an inclusive and comprehensive undergraduate programme to support both their registration and expertise in supporting people with ID who are in contact with the CJS.  This is achieved through appropriate clinical placements during undergraduate learning disability nurse programmes, such as a clinical placement in health care in a prison. These placements are beginning to be implemented and have been identified as beneficial when appropriate support prior to, during, and post the clinical placement is provided by both the education institution and the prison. The following case study will explore the experiences of a learning disability student nurse who completed a clinical placement in prison health care.

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Case Study: Learning Disability Student Nurse’s Experience of a Clinical Placement in Prison

I became interested in nursing in prison during the University’s open day, and I was speaking to somebody to about the learning disability nurse career path, and prison was something I had definitely not considered! When the opportunity came up, I thought this would be a challenge, and I would either love it or hate it, plus as a student you have the opportunity to ask questions and it would not be the end of the world if I didn’t enjoy it. When I got a placement in prison I contacted the prison practice support lead. I asked her what information she could give me, I wanted to know everything, about shift patterns, everything she could tell about the placement itself, and what I would be expected to do. I was sent a student pack, which explained the different teams I could work with, what was expected of me, and obviously the basics of what you can and cannot take into a prison, as you don’t know that unless you work there, and also the manager of the prison organised a day for me to visit prior to starting, and it just broke the ice and on my first day I wasn’t as half as nervous as if I would have been if it had been my first experience. I had some challenging experiences, one time, I accompanied a clinical psychologist for a session with a prisoner on one of the wings, during the session his behaviour was up and down, and then he briefly mentioned about having a weapon on him. The psychologist had started the session with stating if he said anything that raised concerns, she would have to tell the prison officers, so we had to stop the session and tell the prison guards and complete an intelligence report. I was surprisingly OK, but I recognised I needed to get out of this situation, that was the scariest experience I had, and you do think, what could have happened if circumstances were different, but that could have happened in a mental health ward, not just in prison. I worked with the only learning disability nurse within the prison, although her job title was a community psychiatric nurse, so she was dual trained as a mental health nurse and a learning disability nurse, so I spent most of my time with this nurse. I was surprised, her work was more mental health than learning disability. Although, she had a caseload of prisoners with learning disabilities, and completed assessments on new prisoners, but her mental health knowledge was amazing, she worked with a lot of people with personality disorders, along with autism and ADHD. So, that surprised me that she did so much mental health work, but there is such a link, because you can’t just treat someone’s mental health problem and ignore their learning disability and vice versa. So, it was interesting to see her role. Some of the really good experiences I had was working with a person on my assessor’s caseload, who she had been working with weekly, and by the end I felt I had a really good rapport with him, a professional relationship, by the end he had broken down a lot of barriers, and it was nice to see that some

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of the work that I had done was working, using a lot of positive reinforcement with him, as he had autism and ADHD, and that would be part of my job. I felt I learnt so much, and developed my communication skills and relationships with patients, as well as my personal confidence, as it pushed me as it was a different way of nursing, but it was a great experience, and things I would use in other areas that I didn’t think I would. I am really really interested in a job in prison, and it is purely because I have been on a prison placement, if I hadn’t done this, it wouldn’t have crossed my mind to look for jobs in a prison!

6 Conclusion The first part of this chapter has put forward definitions and terminology used in reference to learning or intellectual disability, with an explanation of how these differ in other countries and the issues that may arise as a result of these differences. The historical and social context of intellectual disability has then been explored, and the development of terminology in line with attitudes, legislation, and policy. The prevalence of intellectual disability in the prison service has been discussed both in the United Kingdom and internationally, and consideration of physical and mental health conditions in prisoners with intellectual disability has been put forward. The second part of the chapter considers screening and identification of prisoners with ID, and screening for mental health needs and cognitive decline. Support for prisoners with ID has been explored with consideration of reasonable adjustments and adapted educational and treatment programmes. Finally, the role of the learning disability nurse has been discussed, and the importance of the specialist skills and knowledge of the learning disability nurse in supporting prisoners with intellectual disabilities.

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Herts Valley Clinical Commissioning Group (2018) Dementia diagnosis and healthcare pathway for people with a learning disability. https://www.enhertsccg.nhs.uk/sites/default/files/ pathways/Dementia%20LD%20Pathway%20Toolkit%202018.pdf. Accessed 26 May 2022 Heslop P, Blair P, Fleming P, Hoghton M, Marriot A, Russ L (2013) Confidential inquiry into premature deaths of people with learning disabilities (CIPOLD). Norah Fry Research Centre, Bristol. https://www.bristol.ac.uk/media-­library/sites/cipold/migrated/documents/ fullfinalreport.pdf. Accessed 26 May 2022 Heslop P, Byrne V, Calkin R, Pollard J, Sullivan B (2021) The learning disabilities mortality review – annual report, 2020. Norah Fry Research Centre, Bristol. http://www.bristol.ac.uk/ sps/leder/uob-­2015-­21/annual-­reports/. Accessed 26 May 2022 HM Inspectorate of Prisons (2018) HMP Dovegate therapeutic prison-impressive institution working with high-risk, violent men. Crown Copyright, London Holingue C, Wise E, Caoili A, Klein A, Kald LG, Beasley J (2022) Screening for dementia among adults with intellectual disability: outcomes from a pilot study. J Mental Health Res 15(1):20–36 Holland T, Clare ICH, Mukhopadhyay T (2002) Prevalence of ‘criminal offending’ by men and women with intellectual disability and the characteristics of ‘offenders’: implications for research and service development. J Intellect Disabil Res 46(1):6–20 Holst G, Johansson M, Ahlstrӧm G (2018) Signs in people with intellectual disabilities: interviews with managers and staff on the identification process of dementia. Healthcare 6(3):103 Kane ST, Walker JH, Schmidt GR (2011) Assessing college-level learning difficulties and “at riskness” for learning disabilities and ADHD development and validation of the learning difficulties assessment. J Learn Disabil 44:533 Keyring (2014) Working for justice group. http://www.keyring.org/wfj. Accessed 2 Aug 2022 Loucks N (2007) The prevalence and associated needs of offenders with learning difficulties and learning disabilities. Prison Reform Trust, London McBrien J, Murphy G (2006) Police and carers’ views on reporting alleged offences by people with intellectual disabilities. Psychol Crime Law 12(2):127–144 McCarthy J, Chaplin E, Forrester A, Underwood L, Hayward H, Sabet J, Young S, Mills R, Asherson P, Murphy D (2019) Prisoners with neurodevelopmental difficulties: vulnerabilities for mental illness and self-harm. Crim Behav Ment Health 29:308–320 McConnell D, Phelan S (2022) The devolution of eugenic practices: sexual and reproductive health and the oppression of people with intellectual disability. Soc Sci Med 298:114877 McGillivray JA, Gaskin CJ, Newton DC, Richardson BA (2016) Substance use, offending and participation in alcohol and drug treatment programmes: a comparison of prisoners with and without intellectual disabilities. J Appl Res Intellect Disabil 29:289–294 McManus S, Bebbington P, Jenkins R, Brugha T (2016) Mental health and wellbeing in England: adult psychiatric morbidity survey 2014. NHS Digital, Leeds Mencap (2020) My health, my life: barriers to healthcare for people with a learning disability during the pandemic. https://www.mencap.org.uk/sites/default/files/2020-­12/MyHealthMyLife_ COVID%20report.pdf. Accessed 27 May 2022 Mencap (2022a) What is a learning disability? https://www.mencap.org.uk/learning-­disability-­ explained/what-­learning-­disability. Accessed 27 May 2022 Mencap (2022b) Health inequalities. https://www.mencap.org.uk/learning-­disability-­explained/ research-­and-­statistics/health/health-­inequalities. Accessed 27 May 2022 Mental Capacity Act (2005). https://www.legislation.gov.uk/ukpga/2005/9/contents. Accessed 27 May 2022 Mental Deficiencies Act (1913). https://www.legislation.gov.uk/ukpga/Geo6/11-­12/40/schedule/ FIRST/part/II/crossheading/the-­m ental-­d eficiency-­a ct-­1 913-­3 -­4 -­g eo-­5 -­c -­2 8/enacted. Accessed 27 May 2022 Mental Health Act (1983). https://www.legislation.gov.uk/ukpga/1983/20/contents. Accessed 27 May 2022 Mental Health Act 1983 (amended 2007). Legislation.gov.uk. 2015. [online]. Accessed 22 May 2022

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Reinders J, Stainton T, Parmenter TR (2019) The quiet progress of the new eugenics, ending the lives of persons with intellectual and developmental disabilities for reasons of presumed poor quality of life. J Policy Pract Intellect Disabil 16(2):99–112 Rowe S, Dowse L, Newton D, McCillivray J, Baldry E (2020) Addressing education, training and employment supports for prisoners with cognitive disability: insights from an Australian programme. J Policy Pract Intellect Disabil 17(1):43–50 Schalock RL, Luckasson R, Tassé MJ (2021) An overview of intellectual disability: definition, diagnosis, classification and systems of support. Am J Intellect Dev Disabil 126(6):439–442 Sentencing Council (2020) Sentencing offenders with mental disorders, developmental disorders, or neurological impairments. https://www.sentencingcouncil.org.uk/overarching-­guides/ magistrates-­court/item/sentencing-­offenders-­with-­mental-­disorders-­developmental-­disorders-­ or-­neurological-­impairments/. Accessed 15 June 2022 Shogren KA, Bonardi A, Cobranchi C, Krahn G, Murray A, Robinson A, Havercamp SM (2021) State of the field: the need for self-report measures of health and quality of life for people with intellectual and developmental disabilities. J Policy Pract Intellect Disabil 18(4):286–295 Sǿndenaa E, Rasmussen K, Palmistierna T, Nǿttestad J (2008) The prevalence and nature of intellectual disability in Norwegian prisons. J Intellect Disabil Res 52(12):1129–1137 Standen PJ, Clifford A, Jeenkeri K (2017) People with intellectual disabilities accessing mainstream mental health services: some facts, features and professional considerations. J Mental Health Training, Educ Pract 12(4):215–223 Takenoshita S, Terada S, Kuwano R, Inoue T, Cyoju A, Suemitsu S, Yamada N (2019) Prevalence of dementia in people with intellectual disabilities: cross sectional study. Int J Geriatr Psychiatry 35:414–422 Talbot J (2008) No-one knows: prisoners voices: experiences of the criminal justice system by prisoners with learning disabilities and difficulties, final report and recommendations. http:// www.prisonreformtrust.org.uk/wp-­content/uploads/old_files/Documents/No%20One%20 Knows%20report-­2.pdf. Accessed 15 June 2022 Taylor J, Trout S, Christopher J, Bland A (2012) A therapeutic community for personality disorder in a high secure intellectual disability service: inception and early experiences. Adv Ment Health Intellect Disabil 6(4):165–170 Taylor J, Crowther S, Bryant C (2015) Therapeutic communities for people with intellectual disability and complex needs. Adv Ment Health Intellect Disabil 9(3):124–131 Trofimovs J, Dowse L, Srasuebkul P, Trollor JN (2021) Using linked administrative data to determine the prevalence of intellectual disability in adult prison in New South Wales. Austr J Intellect Disabil Res 65(6):589–600 Tromans S, Kinney M, Chester V, Alexander R, Roy A, Sander JW, Dudson H, Shankar R (2020) Priority concerns for people with intellectual and developmental disabilities during the Covid-19 pandemic. Br J Psychol 6(128):1–6 Trueland J (2020) Making reasonable adjustments in prisons: the role of the learning disability nurse. Learn Disabil Pract 23(5):7–10 Whittingham L, Durbin A, Lin E, Matheson FI, Volpe T, Dastoori P, Calzavara A, Lunsky Y, Kouyoumdjian F (2020) The prevalence and health status of people with developmental disabilities in provincial prisons in Ontario, Canada: A retrospective cohort study. J Appl Res Intellect Disabil 33(6):1368–1379 Wilburn J, Blakey E, Trindall A, Burr H, Tanti V, Doolan S, Palmer I, Jewell T, Balakrishnan R (2021) COVID-19 within a large UK prison with a high number of vulnerable adults, March to June 2020: an outbreak investigation and screening event. Int J Infect Dis 104:349–353 World Health Organization (2019a) Mental disorders. https://www.who.int/news-­room/fact-­ sheets/detail/mental-­disorders. Accessed 15 June 2022 World Health Organization (2019b) ICD-11; International statistical classification of diseases and related health problems, 11th ed. https://www.who.int/standards/classifications/classification-­ of-­diseases. Accessed 15 June 2022 Young S, Goodwin EJ, Sedgwick O, Gudjonsson GH (2013) The effectiveness of police custody assessments in identifying suspects with intellectual disabilities and attention deficit hyperactivity disorder. BMC Med 11:248

Substance Misuse in Prison Joanne Brooke

This chapter contains two case studies of a substance misuse nurse’s reflection on a positive experience of working with a prisoner and a negative experience, which involved supporting a prisoner who was unwilling to detox.

1 Substance Misuse of Prisoners Substance misuse, such as drug and alcohol use in society, has multiple detrimental effects, including offending, and there is a high proportion of the prison population who have substance misuse histories. This section will commence with a definition of substance misuse, substance use disorder, and a brief discussion of the common substances misused. The prevalence of past and present substance misuse of prisoners will be explored, including the different substances misused, and substance misuse amongst specific prison populations, such as those with mental health illness, ADHD, and women. Prevalence and examples will be drawn from prison populations within England and Wales, the United States (US), and Australia. This will lead to the discussion that it is not unusual for prisoners to seek, be offered or ordered to address their substance misuse during a prison sentence.

1.1 Definition of Substance Misuse The term substance misuse rather than drug misuse has been developed to incorporate substances that may not be officially recognised as drugs, although both terms are still applied. An overview of substance misuse was introduced in chapter “Prison J. Brooke (*) Centre of Social Care, Health and Related Research, Birmingham City University, Birmingham, UK e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 J. Brooke (ed.), Nursing in Prison, https://doi.org/10.1007/978-3-031-30663-1_7

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Populations, Culture, Violence, and Drug Misuse” and involves the use of chemical substances that are either legal or illegal, which can change a person’s emotions and behaviour at a rate that can be harmful or problematic to themselves or others (Bennett and Holloway 2005). In the United Kingdom (UK), the National Institute for Health and Care Excellence (NICE 2017) has defined drug misuse as: dependence on, or regular excessive consumption of, psychoactive substances, leading to physical, mental, or social problems. This term does not include occasional or experimental drug use in adults. (NICE 2017, p. 12)

The World Health Organization (WHO 2022) has defined psychoactive substances and drugs. Psychoactive drugs are defined by their impact on the individual including the effects on an individual’s mental processes, perception, cognition, and consciousness, as well as their mood and emotions. Psychoactive drugs are part of the classification of psychoactive substances, which also contains alcohol and nicotine, although not all psychoactive substances are addictive. These definitions are further expanded by the UK Advisory Council on the Misuse of Drugs (ACMD) by the inclusion of any substance … which is being or appears to be misused and which is having or appears to be capable of having harmful effects sufficient to cause a social problem. (ACMD 2022a, b)

The Advisory Council on the Misuse of Drugs was established in 1971 following recommendations within the newly implemented Misuse of Drugs Act. The ACMD is an independent expert body, which provides recommendations to the government following in-depth inquiries into all aspects of drug use, including the classification and scheduling of new drugs under the Misuse of Drugs Act 1971.

1.2 Diagnosis of Substance Misuse The diagnosis of substance misuse is both complex and challenging and incorporates a multitude of substances and stages of substance use. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) details and supports the diagnosis of mental health disorders, prominently applied in the US (American Psychiatric Association 2013). In the latest addition, the DSM-5 has amalgamated the terms ‘substance abuse’ and ‘substance dependence’ and identified the overarching term of substance use disorder. A person is diagnosed with a substance use disorder if they demonstrate two or more of a possible 11 criteria. If a person demonstrates one of the criteria, they are identified as being at risk of developing a substance use disorder, and if they demonstrate two to three criteria, they may be diagnosed with a mild substance use disorder, four of five criteria a moderate substance use disorder, and more than six criteria a severe substance use disorder. The possible 11 criteria include 1. Taking a substance for longer than intended or taking a substance in larger amounts than intended

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2. Trying to or wanting to either cut down or stop taking a substance but not being able to do so 3. Using a lot of time in acquiring, using, or recovering from the use of a substance 4. Experiencing either cravings and/or urges to use a substance 5. Using a substance prevents the completion of usual home, work, or school activities 6. Continuing using a substance even when it has caused problems within relationships 7. Giving up important and desirable social, recreational, or occupational activities due to the use of a substance 8. Using a substance again and again, even when this puts the person in danger 9. Continuing use of a substance, even when a person is experiencing physical and/or psychological problems that are potentially made worse by the substance 10. Increasing the amount of the substance to gain the same effect, the development of tolerance to the substance 11. Developing withdrawal symptoms that occur if the substance has not been taken but can be relieved by taking the substance (APA 2013) Internationally, including the UK and now in the US, the International Classification of Diseases (ICD) is applied systematically to document a diagnosis. Clinical terms, conditions, and diseases are coded within the ICD to support the recording of health conditions within primary, secondary, and tertiary care, often supporting both the payment and commissioning of services. The approach of ICD also supports the standardisation of health data across countries and supports comparable data on the causes of mortality and morbidity between counties, countries, and continents. The ICD was commenced in the nineteenth century, and the latest version ICD-11 was adopted by the World Health Assembly in 2019 and published at the beginning of 2022 (WHO 2022). ICD-11 classifies disorders due to substance use or addictive behaviours as … disorders that result from a single occasion or repeated use of substances that have psychoactive properties, including certain medications. Typically, initial use of these substances produces pleasant or appealing psychoactive effects that are rewarding and reinforcing with repeated use. With continued use, many of the included substances have the capacity to produce dependence. They also have the potential to cause numerous forms of harm, both to mental and physical health. (ICD-11 2022)

The above definition of substance use disorder within ICD-11 includes substances that are non-medical and non-psychoactive. Substance use disorders are classified under the heading of substance used, and the classes include the use of alcohol; cannabis; synthetic cannabinoids; opioids; sedatives, hypnotics or anxiolytics; cocaine; stimulants, including amphetamines, methamphetamine, or methcathinone; synthetic cathinones; caffeine; hallucinogens; nicotine; volatile inhalants; MDMA (ecstasy) or related drugs, including MDA; and dissociative drugs, including ketamine and phencyclidine. The final four classes include the use of other specified psychoactive substances; the use of multiple specified psychoactive

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substances; the use of unknown or unspecified psychoactive substances; and finally, the use of non-­psychoactive substances (ICD-11 2022). The classification of the substance used is the first process, followed by a specific diagnosis, which may include an episode of harmful psychoactive substance use; harmful pattern of psychoactive substance use; or substance dependence, intoxication, or withdrawal; or substance-induced delirium, psychotic disorder, mood disorder, anxiety disorder, obsessive-compulsive disorder, or impulse control disorder. The final two categories are other specified disorder due to substance use or disorder due to substance use, unspecified (ICD-11 2022). Although it is not the role of the nurse in substance misuse to diagnose patients, it is important that they are aware of ICD-11 classifications and the implications for both funding and commissioning of substance misuse services. The most common substances misused or reported to be misused by prisoners at the commencement of a sentence are opiates, alcohol, cannabis, and cocaine, or a combination of these substances; more information is provided below. Spice is also included as it is recognised as a substance that is used within prison; refer to chapter “Prison Populations, Culture, Violence, and Drug Misuse” for an overview of spice in prison. An overview of the short-and long-term impact and withdrawal symptoms of each of these substances is provided in Table 1.

Table 1  Overview of the main substances reported by prisoners Drug Alcohol

Cannabis

Overview of the impact, short-term and long-term, and withdrawal symptoms Impact of substance – Increased confidence especially in social settings Short-term impact on health – Drowsiness, slurred speech and vision, nausea and vomiting, poor coordination, slow reaction times, impaired short-term memory – High blood pressure Long-term impact on health – Irregular heartbeat, stroke, cardiomyopathy – Fatty liver, alcohol hepatitis, liver cirrhosis – Reduced immune system, increased infections – Wernicke–Korsakoff syndrome Withdrawal symptoms – Sweating, tremors, insomnia, restlessness, increased heart rate, nausea and vomiting, anxiety, hallucinations, and seizures Impact of substance – Increased sense of euphoria, relaxation, and sensory perception Short-term impact on health – Drowsiness and slowed reaction time – Balance and coordination problems and slowed reaction time – Increased heart rate, appetite, heightened awareness increasing anxiety Long-term impact on health – Increased risk of mental health problems, including paranoia – Chronic cough and repeated respiratory infections Withdrawal symptoms – Irritability, increased anxiety, negative impact on sleeping, decreased appetite

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Table 1 (continued) Drug Cocaine

Opiates, example of heroin

Spice

Overview of the impact, short-term and long-term, and withdrawal symptoms Impact of substance – Increased energy, euphoria, and confidence – Restlessness, anxiety, paranoia, panic attacks Short-term impact on health – Enlarged pupils, narrowed blood vessels, increased heart rate, blood pressure and temperature, which may lead to irregular heart rhythms, heart attack, stroke – headache, nausea, abdominal pain, insomnia, psychosis, seizure, coma Long-term impact on health – Loss of sense of smell, nasal damage, and nosebleeds if snorting – Lung damage if smoking – Poor nutrition, weight loss, and infection and death of bowel tissue Withdrawal symptoms – Restlessness, insomnia and unpleasant dreams, tiredness, depression, increased appetite, slowed thinking and movements Impact of substance – Euphoria Short-term impact on health – Dry mouth, nausea and vomiting, itching, reduction in respirations and heart rate, increased rate of infections Long-term impact on health – Collapsed veins and abscesses due to injection of drugs, constipation and stomach cramps, infection of the values in the heart, both liver and kidney disease, pneumonia, risk of HIV/AIDS and hepatitis, overdose, and death Withdrawal symptoms – Muscle and bone pain, restlessness and insomnia, diarrhoea and vomiting, cold flushes with goosebumps, known as cold turkey Impact of substance – Designed to mimic the effects of cannabis, but the impact of spice is unpredictable, unpleasant and more harmful Short-term impact on health – Inability to move, dizziness, breathing difficulties, vomiting or diarrhoea, acute kidney injury, chest pain, heart palpitations, seizures – Extreme anxiety, paranoia, suicidal thoughts, psychosis Long-term impact on health – Unknown Withdrawal symptoms – Headaches, difficulty concentrating, low mood, restlessness, and irritability, anxiety and possible cravings

Adapted from the NIH National Institute on Alcohol and Abuse and Alcoholism (2022); NIH National Institute on Drug Abuse (2022); NHS Inform (2022)

1.3 Prevalence of Substance Misuse In 2019, it was estimated by the World Health Organization there were over 180,000 deaths globally, which were directly related to drug use disorders (WHO 2022). In England and Wales, in 2021, 4859 deaths were registered as drug poisoning, of which 3060 were classified as being due to drug misuse. A further 1219 deaths had no information available to classify. Therefore, if these deaths were reclassified as

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related to drug use, 84% of all drug poisoning deaths were due to drug misuse (ONS 2022a). The highest rate of drug misuse deaths has occurred in the North East of England for the last nine years, which remains significantly higher than in the rest of England (ONS 2022a). The use of drugs in England and Wales continues to rise and the Office of National Statistics (ONS) report for the year ending June 2022, identified 3% of those aged 16–59 reported the frequent use of drugs (ONS 2022b). Those in prison in England and Wales have been identified as a high-priority group most at risk of harm from using drugs (ACMD 2018). This has been supported by the prevalence of adults in secure settings in alcohol and drug treatment programmes between 1 April 2018 and 31 March 2019, which was estimated to be 53,193 prisoners. Of these prisoners, 53% identified problems or dependency on opiates (identified as mainly heroin), 18% on non-opiates (identified as mainly cannabis, crack, and ecstasy), 18% non-opiates and alcohol, and the remaining 11% alcohol (Public Health England 2020). When exploring the prison population as a whole and not just those in an alcohol and drug treatment programme, 58% reported a problem with an opiate, 44% a problem with alcohol, 33% a problem with cannabis, and 24% a problem with cocaine (Office for Health Improvement and Disparities 2022a). However, when exploring substance use by sex, female prisoners (75%) are more likely to report opiate use than male prisoners (50%), male prisoners (20%) are more likely to report non-opiate use than female prisoners (8%), male prisoners (20%) are more likely to report non-opiate and alcohol use than female prisoners (8%), and male prisoners (11%) are more likely to report alcohol use than female prisoners (9%) (Public Health England 2020). In Australia, the prevalence of prisoners who identified using drugs in the past year prior to entering prison was 65% of this population (Australian Institute of Health and Welfare 2019). When compared to the general population during the same time frame, there was a  significant different as only 16% of the Australian general population reported using drugs (Australian Institute of Health and Welfare 2016), alluding to the clear link between substance use and criminal activity (Winter et al. 2016). Prisoners reported using methamphetamine, commonly known as crystal meth, cannabis, analgesia, and sleeping medications (Australian Institute of Health and Welfare 2019). Deaths due to alcohol and/or drugs in Australian prisons have ranged between 2 to 6 prisoners each year, from 2015 to 2021 (Australian Institute of Criminology 2021). However, when exploring the number of deaths of prisoners in Australia, it must be recognised that the prison population in Australia is significantly less than the prison populations in England and Wales and the US. In the US, the prison population is substantial, and the majority of prisoners are convicted of a drug-related crime. The National Institute on Drug Abuse has estimated the prevalence of prisoners with an active substance use disorder as 65% of the prison population, and a further 20% of prisoners did not meet the criteria for a substance use disorder, however, they tested positive for drugs or alcohol when they were arrested (National Institute on Drug Abuse 2020). The US Department of Justice has identified the prevalence of prisoners dying from drug and/or alcohol intoxication in both state and federal prisons  has increased significantly (Carson 2021). In 2001, 35 prisoners died from drug and/or alcohol intoxication, however, in

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2018, 249 prisoners died from drug and/or alcohol intoxication, which is an increase of 611% (Carson 2021). Although there has been an increase in prisoners in both state and federal prisons, this does not account for over a 600% rise in deaths due to drug and/or alcohol intoxication.

1.4 Substance Misuse in Specific Prison Populations An understanding of substance misuse in specific prison populations is required to ensure prisoners are provided with appropriate programmes to support a holistic approach to support their individual needs. A number of specific prison populations will be explored, including prisoners with a substance use disorder and one or more mental health disorders (Mundt and Barany 2020; Butler et al. 2011), aolder prisoners (Haesen et al. 2019). Followed by prisoners with a substance use disorder and a diagnosis of attention-deficit hyperactivity disorder (ADHD) (Young et al. 2015) or post-traumatic stress disorder (PTSD) (Facer-Irwin et  al. 2021). Within each of these specific populations, differences between male and female prisoners will also be introduced. The comorbidity of substance misuse and mental health disorders has been recognised  in the general population, in the prison population  the co-occurrence of severe mental illness, personality disorders, and substance use disorders has been acknowledged. In a male prison and a female prison in Chile, the co-occurrence of these three disorders was present in 46% of male prisoners and 17% of women prisoners, highlighting men of a younger age and lower educational attainments were the most at risk (Mundt and Barany 2020). The prevalence of a mental health disorder and a substance disorder was present in 29% of prisoners in New South Wales Australia, although a higher prevalence was identified in female prisoners, 46% compared to 25% of male prisoners (Butler et  al. 2011). Different mental health disorders and substances used were identified between men and women, for example, cannabis use disorder and psychosis were more prominent in men, and affective disorder and alcohol use disorder was more prominent in women (Butler et al. 2011). Younger prisoners have been recognised to be more at risk of a mental health disorder and a substance use disorder (Mundt and Barany 2020). However, a review by Haesen et al. (2019) identified older prisoners (those over the age of 50) have a higher prevalence of a mental health disorder than younger prisoners, but a similar prevalence of a substance use disorder (Moschetti et al. 2015; Sodhi-Berry et al. 2015). Older prisoners were more likely to be diagnosed with an alcohol use disorder, whilst younger prisoners were more likely to use illicit drugs (Davoren et al. 2015; Moschetti et al. 2015). The classification of an older prisoner needs further clarification as those aged 50–54 have been identified to have a higher prevalence of a substance use disorder than those aged 65–69 (Hayes et al. 2012). Finally, Haesen et al. (2019) identified the prevalence of alcohol use disorder in older prisoners is similar to that of older people living in the community.

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The comorbidity of substance misuse and ADHD in prisoners has been recognised (Young et  al. 2015). ADHD is syndrome, which impacts an individual’s behaviour through hyperactivity, impulsivity, and inattention, which  commences in childhood, and significantly impacts individual’s psychological, social, and educational functioning (NICE 2022). The prevalence of substance misuse in those with a diagnosis of ADHD in prison has been identified to be as high as 74% (Young et al. 2015), a personality disorder 60%, and a mental health disorder 96% (Young and Cocallis 2021). Prisoners with ADHD are more likely to be prescribed methadone, use amphetamines, and experience increased levels of alcohol use disorders (Young et  al. 2020). However, the association between ADHD and offending is complex; this association is influenced by substance use disorders, although offending at a young age and violent crimes appear to be related directly to ADHD (Román-Ithier et  al. 2017). Therefore, it is imperative prisoners with ADHD are supported with programmes to reduce their substance use and programmes to support their ADHD. The comorbidity of substance misuse and PTSD in prisoners has been recognised (Facer-Irwin et al. 2021). The prevalence of PTSD in prisons within the UK has been estimated to range from 5 to 14% in male prisoners and from 12 to 23% in female prisoners (Bebbington et al. 2017; Tyler et al. 2019). ICD-11 defines two conditions, which are related to the impact of traumatic events, PTSD, and complex PTSD (CPTSD) (Cloitre 2020). PTSD is diagnosed following exposure to a traumatic event, which is an event or a series of events that are defined as extremely horrific or threatening. The impact of the event or events on an individual includes the re-experiencing of the traumatic event, avoidance of reminders of the traumatic event, and a current sense of threat. A diagnosis of CPTSD includes the symptoms of PTSD, but additional symptoms of difficulties in regulating emotion, a negative self-concept, and difficulties with relationships (Cloitre 2020). An exploration of PTSD and CPTSD in a prison in London identified 8% of the male prisoners met the criteria for PTSD and 17% for CPTSD (Facer-Irwin et  al. 2021). Variables associated with a diagnosis of PTSD included alcohol dependence, and variables associated with CPTSD include substance misuse (Facer-Irwin et al. 2021). The higher estimated prevalence of PTSD in female prisoners than male prisoners may be due to the different types of traumatic events experienced by males and females. In one study, 31% of female prisoners experienced interpersonal sexual trauma in childhood, 35% in adolescence, and 28% in adulthood, which was a significant predictor of PTSD symptoms (Komarovskaya et al. 2011). In female prisoners, these higher levels of childhood and adulthood trauma have been identified to correlate with more severe symptoms of PTSD, which have been identified to mediate substance misuse and violent offending (Howard et al. 2017). One of the symptoms of CPTSD is difficulties with relationships, and dysfunctional relationships have been identified as a mediator between female prisoners’ substance use and offending (Kreis et al. 2016). Therefore, the relationships between the type of traumatic events, severity and symptoms of post-traumatic disorders, substance use, and offending are complex.

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The above overview of substance use in specific prison populations identifies the complexity of substance use disorders and the potential occurrence of comorbidities. Treatment programmes and substance misuse interventions need to identify and recognise comorbidities as substance use cannot be treated successfully in isolation. Holistic substance misuse interventions require a collaborative multidisciplinary approach to address comorbidities and more widely social and environmental factors, which impact on an individual. When all factors are addressed, it is possible to break a prisoner’s cycle of repeat offending and time spent in prison and psychiatric institutions.

2 Substance Misuse Interventions This section will commence with an overview of the new guidance on commissioning and quality standards for alcohol and drug treatment, including recovery in England (Office for Health Improvement and Disparities 2022b), the Drug misuse and dependence: UK guidelines on clinical management (Department of Health 2017) and the Prison Drug Strategy (2019). A comparison of substance misuse treatment services within the US and Australian prisons will be explored. There are numerous substance misuse interventions. However, in this section, the Breaking Free Online Health and Justice, which is a computer-assisted therapy programme in the UK, will be discussed (Elison-Davies et al. 2018). This will be followed by an overall discussion of effective alcohol and drug interventions in prisons, with a focus on both the prison needle and syringe programme and exit preparation programme for both male and female prisoners (Bartle et al. 2021).

2.1 Guidance, Strategies, and Policies for Substance Use in England Guidance and white papers have been recently developed and published regarding alcohol and drug treatment in England, following two reports published by Dame Carol Black. The first commissioned report was an assessment of the illegal drug supply in the UK (Black 2020), and the second commissioned report included specific recommendations to improve both prevention and the treatment and recovery from substance use (Black 2021). Following these reports, the Office for Health Improvement and Disparities (2022b) provided new guidance on the commission and quality standards for alcohol and drug treatment, including recovery. The guidance includes elements of partnership and governance, commissioning cycle, whole and integrated system approaches, and high-quality treatment systems. The importance of this guidance is the inclusion and partnership working of all relevant local organisations that represent the needs of people affected by alcohol and drug use, which includes local organisations which support those who are or who have served a prison sentence. These partnerships support a whole and integrated systems approach to ensure integrated pathways and packages of care are developed  to

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enable those who are or who have served a prison sentence to access the right support at the right time. The above guidance on the commission and quality standards for alcohol and drug treatment supports the current Drug misuse and dependence: UK guidelines on clinical management (Department of Health 2017). The clinical guidelines are to support healthcare professionals who provide substance use interventions, including psychiatrists, other doctors, pharmacists, other health and social care professionals, such as nurses. The clinical guidelines include the essential psychological components of treatment, pharmacological interventions, and includes a chapter on the criminal justice system, which contains a specific section on prison and other secure environments. The section on prisons, identifies a prison as a positive environment to initiate or maintain treatment and enables the development of a pathway for engagement with community services upon a prisoner’s release. The clinical guidelines identify elements specific to prison environment that need to be understood by suitably skilled staff to provide safe and effective care, including the • Understanding of the nature of drug dependence • Understanding of the key risks involved for an individual prisoner during their sentence and after their release • Engaging in and supporting integrated working • Focusing on the continuity of care on reception to the prison, during a prisoner’s sentence and transfers to other prisons, and upon release (Department of Health 2017) The Drug misuse and dependence: UK guidelines on clinical management also identifies specific scenarios relevant to the prison environment, which health and social care professionals need to be prepared to manage to ensure care is equivalent to that provided in the community, whilst prioritising the safety of prisoners, staff, and the prison environment (Department of Health 2017). These scenarios include • Assessment in reception, the first night in prison, including the identification of any risk factors, such as withdrawal from any substances, self-harm or suicide, and the implementation of a plan to reduce associated risks • The need to assess each prisoner safely and rapidly in reception due to the high number of prisoners arriving each day • Recognition of the multiple physical and mental health comorbidities, including multiple substance use disorders, including multiple drugs, alcohol, and tobacco • Recognition of the over-representation amongst prisoners of those with unstable and possibly untreated long-term conditions • Difficulty in planning immediate care due to a lack of clinical data that is verifiable during the reception assessment • The need to address self-reported levels of community-prescribed polypharmacy, which may be overestimated, and adjusting prescriptions accordingly

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• Following reception and during the first few days of prison the need for careful medication administration due to the risks of abuse of prescribed medications • Difficult decisions regarding the management of confirmed polypharmacy for multiple long-term conditions due to both known risks and the possibility of closer clinical monitoring in the prison environment • Difficulty in accessing or communicating with community services during reception assessments, which frequently occur in the evening, including drug treatment services • A lack of clarity regarding which local service providers to approach • Concern regarding the risk of self-harm and suicide on a prisoner’s entry into prison • Responding clinically to the impact of current trends in substance use, such as new psychoactive substances, including synthetic cannabinoid receptor agonists • The need to adapt community formularies to ensure safety within the prison environment, for example, the first-line use of methadone rather than buprenorphine (Department of Health 2017) Finally, the Drug misuse and dependence: UK guidelines on clinical management (Department of Health 2017) identifies several periods of transition for those entering and leaving prison that require intense and planned clinical management. As well as the need for the health and social care professionals to acquire and maintain relevant skills to support prisoners in the unique prison environment, whilst addressing the multiple clinical and therapeutic priorities of each prisoner. The clinical guidelines provide clear guidance on all aspects of substance use interventions within the prison environment, ensuring comparative, but safe care. The Prisons Drug Strategy (HMPPS 2019) enables the provision and delivery of UK guidelines on clinical management of drug misuse (Department of Health 2017) in prisons in England and Wales through a focus on restricting supply, reducing demand, and building recovery. The overall aim of the Prison Drug Strategy is to reduce substance use within prisons in England and Wales, enabling prisons to be a safe place for both staff and prisoners. But, also to develop prisons into a place of opportunity for prisoners to engage in activities, which will support them ‘to live law-abiding lives, and support them to overcome addiction’ (HMPPS 2019, p. 5). Building recovery, within the Prison Drug Strategy, focuses on peer support, accessible support services, a range of integrated services, prisoner awareness, through the development and implementation of key workers, staff awareness, and staff training. The procedures necessary to enable building recovery in prisons include the collaborative commissioning of healthcare services and medicine management, and partnerships with friends and families of prisoners, and those providing care in the community to support continuity of care, which requires a whole system approach (HMPPS 2019). The Prison Drug Strategy (HMPPS 2019) is further supported by a contemporary policy document first published in 2021 and updated in 2022, From harm to hope: A 10-year drugs plan to cut crime and save lives (HM Government 2021). The policy, which was informed by the two reports by Dame Carol Black (2020, 2021),

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focuses on breaking the drug supply chain, delivering a world-class treatment and recovery system, and changing the demand for recreational drugs. The policy identifies a number of initiatives which are planned to be implemented in 2023 such as the testing of prisoners for different types of drugs, including new and emerging psychoactive substances, as well as prescribed medication, and the implementation of Drug Strategy Leads in prisons to maintain the focus on recovery across each prison estate (HM Government 2021).

2.2 Breaking Free Online Health Justice Programme Breaking Free Online Health and Justice is a computer-assisted therapy programme which has been identified to be successful when delivered in community settings (Elison et  al. 2017) and has been developed to be delivered within a prison environment (Elison-Davies et al. 2018). The programme has been developed to address both substance misuse and offending for those serving a prison sentence. The content of the programme related to substance misuse was developed from the National Treatment Agency for Substance Misuse guidance and relevant NICE guidelines. The underlying principles of the programme include cognitive-behavioural approaches/therapies and mindfulness-based relapse prevention. The programme contains eight sessions, with two sessions a week for 4 weeks, and can be accessed as a standalone intervention or alongside other formal or obligatory interventions as part of a prisoner’s sentence. The programme has been developed with HMPPS in England and Wales to ensure all interventions are appropriate for the prison environment and comply with security processes. The first step of the Breaking Free Online Health and Justice programme is the completion of a psychometric assessment, which measures the same six domains of the Lifestyle Balance Model (Davies et al. 2015), including negative thoughts, emotional impact, unhelpful behaviours, difficult situations, physical sensations, and lifestyle (Elison et al. 2016). The information from the assessment is mapped to the six domains of the model, and a visual map created, each domain is represented by a colour, green, amber, or red, which identify the domains that are implicated or impaired and impact substance misuse and/or offending. The next stage of the programme is the provision of tailored advice, which includes the completion of intervention strategies aligned to each domain represented by the colours amber and red. Resilience is also supported within the programme by the encouragement of the completion of interventions within domains represented as the colour green, which do not impact on substance misuse or offending. The clinical content within the interventions focuses on understanding and addressing difficult situations, risky situations, negative thoughts, emotions, physical sensations, unhelpful behaviours, and lifestyle, with the inclusion of psychoeducation on the effects of alcohol and drug misuse (Elison-Davies et al. 2018). However, the impact of the programme on subsequent substance misuse and offending when delivered to prisoners during a sentence is currently unknown.

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2.3 Effective Alcohol and Drug Interventions in Prisons Harm reduction programmes, which include prison needle and syringe programmes, are essential within prisons due to the disproportionate prevalence of blood-borne viruses, such as hepatitis C and HIV, which have been related to substance misuse (WHO, Europe 2014). Therefore, it is essential within alcohol and drug treatment programmes in prison to address the wider issues of health, with the aim to prevent as well as treat serious infectious long-term conditions (National Institute on Drug Abuse 2014). The introduction of prison needle and syringe programmes is not new and was first introduced towards the end of the twentieth century and has been successful in reducing the spread of blood-borne viruses and supporting prisoners to enter substance misuse interventions (Dolan et al. 2003; Stöver and Nelles 2003). Prison needle and syringe programmes include the anonymous deposit of used syringes and the distribution of sterile needles and syringes by prison-appointed individuals. However, prison needle and syringe programmes remain highly controversial and rarely introduced. In 2016, it was identified only 60 of 10,000 prisons globally had introduced a prison needle and syringe programme even though the evidence identifies the positive impact of such programmes and has not identified any negative impacts (Stöver and Hariga 2016). Exit preparation programmes are also essential for prisoners with a history of alcohol or drug misuse to support re-integration into the community, enable engagement with community-based treatment programmes, and reduce the risk of a relapse of substance misuse and offending. Exit preparation programmes differ considerably. Two will briefly be introduced one in a male prison (Bahr et al. 2013) and one in a female prison (Begun et al. 2011). Firstly, a short-term drug treatment for male prisoners prior to release, which was implemented in the US, is an intense 30-day cognitive behavioural therapy programme for prisoners with either alcohol or drug misuse (Bahr et al. 2013). The treatment programme is delivered for 5 hours a day 5 days a week over four consecutive weeks. Completion of the treatment programme was associated with a reduction in prisoners’ return to prison as only 27% of those who had completed the treatment programme were returned to prison for more than 30 days in the 14 months following release, whereas 46% of prisoners who did not complete the treatment programme were returned to prison for more than 30 days (Bahr et al. 2013). Screening of prisoners for their risk of alcohol dependence or misuse is essential to support prisoners throughout their sentence and re-integration into the community. A brief screening tool for alcohol consumption is the Alcohol Use Disorder Identification Test (AUDIT) (Babor et al. 2001), which is considered to be a ‘gold standard’ screening tool, is widely used across criminal justice settings in the UK (Coulton et al. 2012). The World Health Organization developed AUDIT and the 10 questions within the brief screening tool, which includes three questions on hazardous alcohol use, such as an individual’s frequency of drinking, typical quantity of alcohol consumed, and frequency of heavy alcohol consumption. The following three questions screen for an individual’s dependency on alcohol, including impaired control over drinking, increased quantity of drinking, and drinking in the morning.

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The last four questions explore harmful use of alcohol through the screening for guilt after drinking, not remembering events when drinking, alcohol-related injuries, and concern regarding their alcohol consumption (Babor et al. 2001). A brief intervention for women prisoners with alcohol and drug misuse, implemented in the US, included a brief screening and feedback intervention (Begun et al. 2011). The brief screening included the Alcohol Use Disorder Identification Test-Including Drugs (AUDIT 12), which was based on the AUDIT.  However, AUDIT-12 contained two supplementary questions, how often do you use other substances, and how often do you use two or more substances, and in the last seven questions of the AUDIT, which explore the consequences of alcohol consumption, these questions were amended to include both alcohol and drug consumption (Campbell et al. 2001). Once the AUDIT-12 was completed, a brief intervention was delivered, which consisted of a 60-to-90-minute motivational interview. The aim of the motivational interview was to enable women prisoners to understand their own motivation and commitment to change their behaviours related to alcohol consumption. The interview then supported women prisoners to begin to address their decisions by exploring options through support systems and challenging perceived barriers. Two months following release from prison, women who had completed the brief intervention self-reported a significant reduction in both their alcohol and drug use (Begun et al. 2011).

3 The Role of the Nurse in Substance Misuse This section will commence with a general discussion on the role of the nurse in substance misuse and the recommendations developed by Public Health England and the Royal College of Nursing (2017), including elements of public health and physical health initiatives, psychosocial interventions, medicine management, and non-medical prescribing. This is followed by an introduction of the role of the nurse in substance use in prison, and lastly two case studies of the experience of a substance misuse nurse working in prison.

3.1 The Role of the Nurse in Substance Misuse The role of the nurse in alcohol and drug treatment in England has been described by the Royal College of Nursing (RCN), Association of Nurses in Substance Abuse (ANSA), National Substance Misuse non-Medical Prescribing Forum, and Public Health England (PHE) in the Role of Nurses in Alcohol and Drug Treatment Services. This is a resource for commissioners, providers, and clinicians (PHE and RCN 2017). The role of the nurse in alcohol and drug treatment will be further explored, however, it is essential to acknowledge the successful provision of alcohol and drug rehabilitation involves a multidisciplinary team. Each member of the multidisciplinary team should be aware of the responsibilities of all members, including specialist doctors (PHE 2014a, b), clinical psychologists (British Psychologist

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Society 2012), and social workers (Galvani 2015), and of course both adult and mental health nurses. A collection of resources and guidance for alcohol and drug treatment, which are applicable to England, have been developed, such as Mutual aid toolkit for alcohol and drug misuse treatment (PHE 2018), Drug misuse and dependence: UK guidelines on clinical management (Department of Health 2017), Service user involvement in alcohol and drug misuse treatment (PHE 2015), and Treating drug dependence recovery with medication (PHE 2013). Although nurses may not lead the implementation of treatment for alcohol and drug misuse treatment, it is important that nurses understand the wider guidance of supporting the commission, development, and implementation of alcohol and drug misuse services. PHE and RCN (2017) have identified the role of the nurse in alcohol and drug treatment as complex as the role involves the development and delivery of interventions across various treatment settings and for complex populations. The development of interventions incorporates public health, physical health, psychosocial interventions, medicine management, and non-medical prescribing, whilst treatment settings include primary care, criminal justice system, acute hospitals, and finally complex populations are identified as older and/or homeless people, and those with a hepatic disorder, co-occurring mental health conditions, pregnant, or postnatal. The following sections will explore each of these categories relevant in more depth, with an emphasis on the interventions and the criminal justice system.

3.2 Nurse-Led Public Health Initiatives The PHE and RCN (2017) guidance of the role of the nurse in alcohol and drug treatment focuses on the added value nurses bring in these services. Nurses have been identified to add value to public health initiatives that address the priorities related to their patients, their patient’s family, and the wider community. Primary care nurses and nurses working in the community or a community such as a prison have an in-depth knowledge of the population they support. This knowledge provides an accurate insight into the needs of this population, which is essential when designing and implementing public health interventions. An overview of the public health initiatives/interventions led by nurses is described in Box 1.

Box 1 Nurse-led Public Health Interventions

Public health interventions in alcohol and drug treatment services include the provision of: • Support and supervision of pharmacological interventions, such as the commencement of detoxification and relapse prevention programmes • Non-medical prescribing

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• Advice regarding blood-borne viruses (BBV), including testing and vaccination • Brief advice on alcohol use following the alcohol Identification and Brief Advice recommendations, which provides simple structured advice to reduce an individual’s risk • Support, advice, and interventions to stop smoking Wider public health interventions include the provision of • Monitoring of diseases on local systems and responding to the needs of the local population during outbreaks, including changes in disease profiles, such as COVID-19 • Expert clinical nursing care, including physical assessments and interventions, such as blood pressure monitoring and wound care • Advice and, if appropriate, referral on diet and nutrition, to support an appropriate BMI • Advice and, if appropriate, referral to sexual health services • Advice and, if appropriate, referral to support dental and oral health • Advice and support to promote mental health and well-being, early identification of mental health concerns, and responding to any mental health crises • Holistic health assessments for older service users Adapted from The Role of Nurses in Alcohol and Drug Treatment Services (PHE and RCN 2017).

3.3 Nurse-Led Physical Health Initiatives Nurses support and lead physical health initiatives within alcohol and drug misuse interventions due to the impact of both alcohol and drug misuse on an individual’s physical health. Therefore, assessment of physical health is essential and can support referral and treatment prior to a health crisis and reduce the severity of a physical illness. The health assessments led by nurses are described in Box 2. Box 2 Nurse-led Physical Health Interventions

Physical health assessments and interventions in alcohol and drug treatment services include the provision of: • Medication management and an assessment of possible side effects, interactions between prescribed medications, and concordance, which is the involvement of the person in the decision-making progress regarding the prescription of medication to support adherence

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• Management of long-term conditions, such as liver disease, epilepsy, diabetes, asthma, respiratory diseases, and chronic pain • Health assessment to identify and manage acute health problems, including cellulitis, infections, deep vein thrombosis, abscesses, hypertension, and cardiovascular events • Acute response to symptoms from adverse reactions to a new prescribed medication or the misuse of a substance • Assessments to identify the use of harmful but non-dependent alcohol use by individuals who are being treated for other substance misuse, as alcohol use may exacerbate their physical conditions, such as hypertension, or their mental health, or interact with prescribed medications • Assessment for and prescription of vitamin supplements to support the prevention or early detection of Wernicke’s encephalopathy • Referrals to appropriate primary and secondary care specialists, which may involve cardiology, hepatology, haematology, dentistry, and optometry • Dietary assessments, with the inclusion of BMI and advice on nutrition and weight • Administration of the very brief advice to people who are willing to engage in a stop-smoking intervention, which is similar to the brief advice on alcohol as described above, but may also include advice and support to access nicotine replacement therapies and behavioural support Adapted from The Role of Nurses in Alcohol and Drug Treatment Services (PHE and RCN 2017).

3.4 Nurse-Led Psychosocial Interventions Nurses are skilled communicators, which support them to develop therapeutic relationships with their patients/clients through non-discriminatory and active listening. These skills are essential for psychosocial interventions, and therefore nurses are suitable to lead these interventions within alcohol and drug misuse interventions. Mental health nurses, due to their specific education and role, will have completed advanced training to further develop their skills and knowledge to deliver psychosocial interventions for common mental health conditions, which are transferable within alcohol and drug misuse interventions. An important element of psychosocial interventions is the use of motivational interviewing techniques, which involve an outcome-orientated assessment, and the development of coping strategies, self-­ monitoring approaches, and support to develop problem-solving skills. Guidelines for psychosocial interventions in alcohol and drug misuse have been developed by NICE in Drug misuse over 16s: psychosocial interventions (2007), which includes brief interventions, self-help, and contingency management.

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3.5 Nurse-Led Medicine Management and Non-medical Prescribing Nurse-led medicine management in alcohol and drug misuse interventions is essential as individuals seeking support may use more than one substance, which may include either prescribed medications or those purchasable over the counter. The nurse’s role in medicine management is to identify risks due to polypharmacy through the review of medication regimes, including the use of non-prescribed substances. Due to the ageing prison population, there is an increased need for nurses to understand the implications and risk of polypharmacy for older prisoners. The specific role of nurse-led medicine management within alcohol and drug misuse interventions occurs during the acute phase of detoxification and the need to monitor an individual’s physical and mental health. Nurses are involved in monitoring the progress of detoxification and support changes or alterations to doses of prescribed medications and administer prescribed prophylactic vitamin injections as required. Standards for pharmacological management for nurses have changed and  developed over the last decade, with the withdrawal of the  Standards for Medicine Management (NMC 2007), and the responsibility of medicine management is now with practice areas and employers. The Standards of Proficiency for Nurse and Midwife Prescribers (2006) have also been replaced by the Royal Pharmaceutical Society Competency Framework for all Prescribers (2019, updated 2021). The Royal College of Nursing has produced a comprehensive overview of Medicine Management to support guidance for nurses (RCN 2020). A nurse’s role may include the administration of a named medicine to a patient/ client who meets a set criterion, if a Service user Patient Group Direction (PGD) has been completed, without the need for a specific prescription for each patient/ client. PGDs, which are typically implemented in alcohol and drug interventions, include smoking cessation products, hepatitis vaccination, naltrexone for relapse prevention, and parenteral vitamins. Finally, nurses may have completed further education to become a non-medical prescriber. Public Health England (2014a, b) has developed clear guidance for nurses who are non-medical prescribers, including non-medical prescribing in the management of substance misuse. Public Health England (2014a, b) identified independent and supplementary prescribing, an independent prescriber is a practitioner who is both responsible and accountable for assessing, diagnosing, and the clinical management of patients. Whereas a supplementary prescriber works in partnership with a doctor and within agreed patient-specific clinical management plans, with the patient’s agreement. The supplementary prescriber can prescribe within the parameters identified in the clinical management plans, although remain both responsible and accountable for their own prescribing and prescribing decisions. Supplementary prescribers are also able to prescribe controlled drugs, within the limitations described. Nurses can become either independent or supplementary prescribers when they have completed appropriate and recognised further education. Most Higher Education Institutes provide education for both independent and

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supplementary prescribing as a combined programme. Once a nurse completes a recognised prescribing programme, this qualification is added to their entry on the Nursing and Midwifery Council register.

3.6 The Role of the Nurse in Substance Misuse in Prison The role of the nurse in substance misuse in prison encompasses all the elements described in the previous section as the provision of substance misuse support in prison should be equitable to that delivered in the community. Therefore, the only difference in the role of the nurse in substance misuse in prison than in the community is the consideration of security, the loss of freedom of those accessing services, and possibly their mandatory attendance as a requirement of their sentence.  The expectations of a substance misuse nurse working in prison  are listed below, the nurse may be a registered general nurse, with specific training, or a registered mental health nurse working in prisons in England and Wales: • The triage of prisoners, either new arrivals or those transferred from other prisons, or prisoners already custody, to identify their drug treatment needs • To provide holistic care for all prisoners who access substance misuse services, which may include physical interventions, such as wound care, but also the administration of both general and controlled medications, in nurse-led clinics • To provide advice to prisoners to support their general health and reduce the risk of harm due to issues relating to drug misuse • To promote the health needs of prisoners within the prison environment, but also to refer prisoners to healthcare services as appropriate • To provide a comprehensive, full, and accurate clinical substance misuse assessment of a prisoner’s drug misuse treatment needs, in collaboration with the lead substance misuse (usually a GP) • To ensure the safety of prisoners accessing substance misuse services and identify any mental health problems, which may include the completion of the prison ACCT risk assessment, and the implementation of appropriate interventions by both prison and healthcare staff • To provide recommendations and work collaboratively with healthcare professionals to identify and share a prisoner’s drug treatment needs and support the development of their integrated treatment plan • To administer controlled drug medications as prescribed and supervise the consumption of medication within the protocols of both the substance misuse service and prison • To monitor prisoners twice a day during their first week of drug treatment and complete assessments to identify when the prisoner is stable and the frequency of monitoring can be reduced, within the protocols of the substance misuse service, until monitoring is no longer required • To manage all care treatment plans for prisoners accessing substance misuse services

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• To work within prison policies and regulations, whilst promoting clinical governance and maintenance of their own clinical competencies relevant to the role of the substance misuse nurse • Finally, to support the development and implementations of relevant guidelines and protocols with other members of the substance misuse services, including the GP and pharmacist, which support the continuation of treatment for prisoners on release. The following two case studies explore both positive and negative experiences of a substance misuse nurse working in a male prison, some of the information has been amended to ensure the anonymity of both the prisoners involved and the prison where these events occurred.

Case Study: A Positive Experience of a Substance Misuse Nurse

A positive experience of a substance misuse nurse I work within the substance misuse team within a prison, and we treat people (prisoners) who have acknowledged a problem with drug addiction, which we treat with either methadone, or buprenorphine, although methadone is cheaper, and less easy to conceal, so is the preferred drug for opiate substitution therapy (OST). The guys who are on OST are some of the most vulnerable prisoners in the prisons, I very much doubt anyone wakes up one day thinking about their future and decides to become addicted to illicit drugs and spend years in prison. These prisoners have experienced societal inequality, abuse, bullying, involved in gang related activity, or developed drug using habits as way of escaping from their unhappy lives. As a substance misuse nurse in the prison environment, I think it is important to try to build a therapeutic relationship with your patients. I refer to the prisoners as patients rather than service users even though this is a medicalised term because I feel this is a more powerful description to give the prison officers and I hope this approach serves to reinforce that these prisoners need care. The patients are seen on entry to the prison, a reception assessment is completed, and an appropriate prescription organised. The role of the nurse is to administer methadone daily and review the patients on regularly to ensure they are concordant with medication and that they are not experiencing any side effects or withdrawals from opiates. Safeguarding of these vulnerable prisoners needs to be considered whilst they are in prison and following their release. Ideally patients should be released from prison and integrated successfully back into society, however this is often not the case. Young offenders who have served long sentences or remain on IP sentences can be coerced into using drugs in prison or be used to test drugs that have been smuggled into prison prior to them being sold to other prisoners. On release, it must be recognised patients who have been

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‘banged up’ for many years leads to isolation from family and friends, which may put them at risk of a relapse. Also, those who have not used illicit drugs whilst in prison will have lost their tolerance to drugs and are at a high risk of an overdose, which is one of the reasons naloxone is now given to patients who are at risk of using drugs on discharge from prison. One of my patients, who was transferred from another prison following recategorization from a category B to category C in preparation for his release, was on a relatively high dose of methadone. This patient had served a long sentence for armed robbery and had been involved in gang related activities. His drug habit had started in prison at a stage when he was depressed, in physical pain following an injury and had been vulnerable to exploitation. He had brought illicit drugs and then when in debt and unable to pay for them had been used to test various ‘spice’ concoctions to repay his debt. He had eventually asked for help, commenced OST programme, and been moved from the prison where he was in debt. On planning for this patient’s discharge, he discussed he wanted to reduce his methadone dose and leave prison not requiring any script (prescription). We talked about support he would access on the outside and his social circumstances that may influence his ability to abstain from illicit drugs. The patient decided that he would start to reach out to old friends and family who he had not been in contact with during his time in jail. Over the course of a few weeks, he wrote to his brother and was pleased to know his parents would like to come and visit him, this visit was arranged and changed his life. Following the visit of his family, my patient requested an immediate appointment for review as he wanted to reduce his methadone instantly. We discussed safe detox and agreed a 5 mg a week, that would lead to him being off OST in approximately two months. I have to say, this is the only person I have encountered who detoxed from such an amount so quickly. Overnight he decided no more drugs and began to stop taking 35  mg of methadone. He accepted some symptomatic medications to treat his muscle cramps, abdominal discomfort, and insomnia. The patient joined a remedial gym class, enrolled in education to master basic reading and writing skills, and put forward an application to gain his forklift license so he could work following release. This prisoner left prison a few months later with a basic literacy certificate, a forklift licence and offer of a job. Not many prisoners leave prison with such a good ending to their sentence, as not many patients have family, friends or even a place to call home on the outside. Homelessness is very real, and a lot of ex-offenders leave in the knowledge they will be lodged in hostels, or temporary accommodation. Some go straight to the streets because the hostels are not where they want to be, and the cycle of drug misuse and crime continues.

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Case Study: Supporting a Prisoner Who Was Unwilling to Detox

Supporting a prisoner who was unwilling to detox Working within the substance misuse team in prison healthcare can be challenging. Patients who come to prison with addiction to illicit substances are referred to the team, and we work with them to support them to detox from drugs, which is only really possible if they have a long sentence. There will be occasions when patients do not want to engage with the team as they may not want to detox and feel forced to reduce their methadone medication. However, is it right to maintain someone on opiate substitution therapy for years just because they are in prison? This is a complex ethical debate, and why treating each case individually and in collaboration with them is so important. Some patients will detox in prison and then recommence on OST prior to release for their safety and to minimise risk of returning to a lifestyle which includes the use of illegal drugs. The negative episode of care I am going to recount, occurred to me one weekend, so we had minimal staff and no management. One of our patients was in the segregation unit (CSU), and therefore to dispense his methadone we had to go to his cell accompanied by prison officers to administer his dose. This patient had refused to discuss detoxing and engage with the SM team, as he wanted to remain on methadone for his whole sentence. He had a long sentence, over five years, so this was not ideal, or in line with prison regulations and policies (at this time). As the prisoner had missed three appointments, the healthcare professional prescribing his methadone commenced a detox regime of 1 ml a week. When I arrived to administer his methadone, in line with CD regulations, I checked his ID, checked the prescription, and confirmed this with another nurse. The patient heard his dose was reduced and despite my attempt to explain that this had been done because of his lack of engagement with the service, and that if he wanted a review this could be arranged, he became very angry and continued to shout. The patient was threatening to sue the healthcare department and accusing me of breaching his human rights. I did not take this personally, I just happened to be on duty, this could have happened to anyone. However, I was not prepared for such an encounter, although it does happen at times. I attempted to calm the situation but was unsuccessful, there are times when despite your best intent and through no fault of your own you are going to be the one who receives the abuse, maybe this was because I was an ‘easy’ target as a female nurse, I don’t know. The incident did not end well for the patient, his shouting got louder and more abusive. The prison officers intervened and questioned if he was going to have his medication or not, to which he turned his anger upon them and began to argue about having his discussion with healthcare interrupted. The patient displayed increasing aggression, trying to leave his cell, and appeared to be ‘squaring up’ for a physical altercation. The prison officers requested he

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return to behind his cell door, and when he refused to do this, he was physically pushed back into the cell. An order was issued, and the patient had to remain in his cell and not to be unlocked without the presence of three prison officers. The patient refused his methadone dose and was subsequently transferred to another prison due to increased violent behaviour that warranted a higher category of prison detention.

4 Conclusion This chapter explored the definition and diagnosis of substance misuse and identified the prevalence of substance misuse amongst prisoners as 53% of all prisoners in England and Wales and 65% of all prisoners in Australia and the US. Substance misuse was acknowledged to be higher in prisoners with ADHD, PTSD, and other mental health disorders. The implementation of substance misuse interventions in prison is therefore essential, and a few of the many interventions were introduced, which included the Online Health and Justice programme, harm reduction programmes, such as the prison needle and syringe programme and the exit preparation programme. Finally, the role of the nurse in substance misuse was discussed, and more specifically the role of the nurse in substance misuse services in prison, including standards, guidelines, and protocols to support the development of this role.

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Palliative and End-of-Life Care in Prison Lydia Aston

This chapter contains two case studies, one exploring the time-consuming process to approve a compassionate release application, and one exploring the application of the risk assessment within a compassionate release application.

1 Palliative and End-of-Life Care This section introduces and defines palliative care and end-of-life care, and clear and precise definitions are provided, although it will acknowledge both concepts are sometimes ill-defined and used interchangeably, which may be due to the provision of palliative and end-of-life care on a continuum rather than in isolation. The importance of advance care planning (ACP) will then be discussed, which in prison is essential due to the lack of knowledge of a prisoner’s end-of-life wishes by prison staff and those supporting a prisoner. ACP is especially important for prisoners with long-term conditions or life-limiting conditions, and nurses are optimally placed to support these decisions (Ekaireb et al. 2018). Contemporary barriers to supporting and implementing ACP in prison settings will be explored (Macleod et al. 2020). This will be followed by a discussion of advance directives, which are legal documents that state the treatment an individual would and would not like to receive towards the end of their life, when an individual may no longer have the capacity or communication skills to convey these decisions (Pérez et  al. 2013). The ethical dilemmas of both supporting and protecting prisoners’ autonomy with advance directives will also be discussed (Andorno et al. 2015).

L. Aston (*) Centre of Social Care, Health and Related Research, Birmingham City University, Birmingham, UK e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 J. Brooke (ed.), Nursing in Prison, https://doi.org/10.1007/978-3-031-30663-1_8

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1.1 Palliative Care When an individual is diagnosed with a life-limiting condition, they should be offered palliative care from diagnosis (Sepúlveda et al. 2002). A life-limiting condition will shorten an individual’s life, although they may continue to live an active life for many years (Hain et al. 2012). The provision of palliative care from diagnosis is supported by the World Health Organization (WHO), which amended its definition of palliative care in 2002. The latest WHO definition of palliative care includes a focus on the implementation of palliative care in the earlier stages of diagnosis and across the trajectory of a life-limiting condition. The early implementation of palliative care for an individual with life-limiting conditions should include a multidisciplinary approach across appropriate disciplines, including renal, neurology, and cardiology, as opposed to a focus on oncology (Clark 2019). According to the World Health Organization (2002), palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. (WHO 2002)

Palliative care should be implemented and provided in conjunction with other treatments that may be given to prolong life, such as chemotherapy or radiotherapy (Marie Curie 2022). Palliative care is not end-of-life care and does not replace active treatment but provides a holistic approach to the care and treatment of an individual with a life-limiting condition, whilst providing support to their family. The WHO (2002) guidelines emphasise the importance of understanding dying as a normal process, and palliative care should neither hasten nor postpone death. Instead, palliative care is a support system to help patients live as well as possible until their death, supporting their family during the life-limiting condition and in bereavement. Palliative care is a specialist care service, with the inclusion of healthcare professionals who have completed training in palliative medicine, including consultants, specialist palliative care nurses, and specialist occupational therapists or physiotherapists (NHS 2022). The role of a specialist palliative care nurse is to coordinate support and care for an individual and their family, including clinical advice, guidance, planning discharges from hospital and ongoing care, whilst considering the physical, mental, and spiritual needs of the individual and their family (Connolly et al. 2021).

1.2 End-of-Life Care End-of-life care commences when an individual with a life-limiting condition approaches their last months or year of their life. The focus of end-of-life care is to support an individual to live as well as possible and to die with dignity. The time frame for the provision of end-of-life care varies across different institutions,

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guidelines, and policies. In the United Kingdom (UK), the time to implement end-­ of-­life care has been defined by both the General Medical Council (2022) and the Royal College of Nursing (RCN 2022) as: when an individual with a life-limiting condition is likely to die within the next 12 months. The time frame for the provision of end-of-life care varies due to the difficultly in recognising when an individual is likely to die, for example, certain cancers have a clear trajectory when types of dementia are dependent on the individual and almost impossible to predict when end-of-life care may be required. However, an individual who is approaching end of life has been defined as someone with: • • • •

An advanced illness, which is incurable, such as cancer or dementia Frailty and coexisting conditions A sudden deterioration in an existing condition An acute condition caused by a medical event such as a stroke or an accident (NHS 2022)

Further guidance is provided by the National Institute for Health and Care Excellence (NICE), which provides two specific guidelines that cover both the planning of end-of-life care and the clinical care required at the end of life. Firstly, guidance on the organisation and delivery of end-of-life care services to support the provision of end-of-life care in the final stages of an individual’s life, which may range from weeks to years, and involves the preparation for end-of-life care (NICE guideline NG142 2019). Secondly, guidance on the clinical care of adults during their last two to three days of their life, with the aim to ‘improve end of life care for people in their last days of life by communicating respectfully and involving them, and the people important to them, in decisions and by maintaining their comfort and dignity’ (NICE guideline, NG31, 2016). Important clinical care is described within this guidance, including the management of symptoms and hydration.

1.3 Palliative and End-of-Life Care Unfortunately, across both practice and policy the definitions of palliative care and end-of-life care continue to be applied interchangeably, which leads to confusion of these two specialities for patients, their families, and healthcare professionals (RCN 2022). The above section has provided definitions for both palliative care and end-­of-­life care. However, it must be recognised that these concepts overlap and palliative and end-of-life care are not provided in isolation to individuals with a life-limiting condition and their family. In the UK, the Ambitions for Palliative and End of Life Care: A National Framework for Local Action was first published in 2015 and revised in 2021 (National Palliative and End of Life Care Partnership 2021). This framework focuses on the need for collaboration and cooperation across health and social care, as well as statutory and voluntary bodies to support the provision of seamless high-quality palliative and end-of life care. The six ambitions of palliative and end-of-life care include each person is

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seen as an individual, each person gets fair access to care, maximising comfort and well-being, care is coordinated, all staff are prepared to care, and each community is prepared to help (National Palliative and End of Life Care Partnership 2021).

1.4 Advance Care Planning Advance care planning (ACP) is a formal document that records an individual’s wishes and preferences for future care, which is not legally binding but informs and guides an individual’s future care if they no longer have the capacity to engage in decisions regarding their care. The international consensus definition of advance care planning is … a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care. The goal of advance care planning is to help ensure that people receive medical care that is consistent with their values, goals and preferences during serious and chronic illness. (Sudore et al. 2017, p. 2)

Therefore, it is important for these conversations to occur over time whilst an individual still has the mental capacity to fully engage and discuss their wishes and values. These conversations should support an individual to feel a greater sense of involvement in their future care and plans for their end-of-life care. The Universal Principles for Advance Care Planning (2022) have identified and developed six principles for ACP, which should be encompassed in all settings in England. These principles support an individual to discuss their values and matters that are important to them, but also support health and social care practitioners and third-sector organisations. The principles, when applied should support equality and diversity, and the inclusion of individuals in the development of their own ACPs. The six principles of ACP are: 1. The individual creating their ACP is central to the process, and the decision of who to involve in this process, should be their decision. 2. The individual should be supported to have personalised conversations to discuss their future care, their values, what matters to them, and how their needs can be addressed. 3. The individual is involved in the decision-making process to support the development and the outcomes of their ACP. 4. The individual is provided with a copy of their ACP in a format that is shareable and the ACP will identify the individual’s preferences and decisions regarding their future care and treatment. 5. The individual is supported, encouraged, and provided with the opportunity to regularly review and revise their ACP. 6. Lastly, an individual who has created or wishes to create and implement an ACP should be able to speak up if these principles are not adhered to.

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The discussions with an individual regarding their ACPs will support the development of a number of documents, which may include an advanced statement, an advance decision to refuse treatment (ADRT), a lasting power of attorney (LPA) for health and welfare, and context-specific treatment recommendations. An advanced statement includes an individual’s wishes and preferences, and possibly the nomination of a person to become their spokesperson should the need occur, this is not legally binding. However, an ADRT and LPA are legally binding if they have been appropriately completed. An ADRT is usually discussed with an individual and their clinician, and refers to treatment preferences, with a focus on acute care, such as do not resuscitate in the event of a cardiopulmonary arrest. Other acute treatments that may be refused include the provision of intravenous antibiotics or admission to an acute hospital, although an ADRT may include elements personal to the individual and their specific circumstances. There are many tools and resources to support clinicians to lead these discussions, such as the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) (Resuscitation Council UK 2016). ADRT and LPA are discussed further later in this chapter. Conversations to support ACP may commence during the diagnosis of a life-­ limiting condition, although the timing of such conversations is recognised to be difficult, and commencing such conversations is challenging, especially if an individual’s condition is stable (Pearce and Ridley 2016; Mitchell and Dale 2015). Prior to commencing conservations to support ACP, it is essential that healthcare professionals have some understanding of how an individual perceives their own health and diagnosis as this will influence their preparedness to engage in such conversations. Both consultants and nurses have identified conversations to support the development and implementation of ACPs have achieved peaceful, dignified deaths of individuals in their preferred place of care (Mitchell and Dale 2015). The implementation and engagement with the process of ACP has been identified to support an increased use of hospices, where specialist end-of-life care is provided, reduced use of acute hospital services, reduced stress experienced by family and friends, due to clear expectations, and finally a reduction in medical care that may prolong life but may lead to a decline in the individual’s quality of life and a more painful death (Macleod et al. 2020).

1.5 Advance Care Plans in Prisons Due to the ageing population of prisons and the poor health of prisoners compared to those living in the community, there is an increasing need to support prisoners with palliative care, end-of-life care, and ACP (Marti et al. 2017; McParland and Johnston 2021). Prisoners are entitled to equitable health care as those living in the community, and access to healthcare services to support them to make informed decisions for their future healthcare is their human right (Macleod et  al. 2020). Therefore, support and guidance should be provided to prisoners to discuss their values, goals, and preferences for future and end-of-life care and create an ACP. Advance care plans need to be documented and recognised by prison staff and

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healthcare professionals to inform future support and medical care (Buck et  al. 2019). Information on the implementation or facilitation of ACP in prison settings remains very limited (Ekaireb et al. 2018). One study found that fewer than 1% of prisoners who were living with a life-limiting condition had discussed the development of an  ACP with a healthcare provider (Levine 2005). Although a focus on end-of-life care within prisons has occurred globally, in the UK an analysis of 95 foreseeable deaths within prison in 2018–2019 highlighted hospice care had been implemented for a quarter of prisoners’ end-of-life care (Hospice UK 2020). Hospice care ranged from the implementation of a hospice unit within a prison, advice from palliative care consultants on symptom management, and advice from hospice nurses to support an ACP. The closed environment of a prison is a unique setting to provide palliative and end-of-life care, and the development  of ACPs to support prisoners’ values and beliefs. Therefore, the facilitation of prisoners to develop ACPs needs to be considered within the unique prison context, which contains both barriers and facilitators. A recent review of the limited literature on the facilitation and engagement with ACP in prisons identified three overarching themes, which included system-level factors, attitudes and perceptions, and knowledge and comprehension, each of which included barriers and facilitators (Macleod et al. 2020). Firstly, system-level factors, which included two barriers, policies which restricted the process of ACP and limited access to prisoner healthcare records. Restrictive prison policies impacted on the discussion to develop an ACP as these had to occur within the prison regime, which provided limited time for such in-­ depth and personal discussions. Restrictive prison policies also impacted the decisions within an ACP, such as the preferences of prisoners, and if these preferences could be supported within the prison regime. Restrictive prison policies also prevented discussions between healthcare professionals, the prisoner and the prisoner’s family, which impacted on the prisoners’ ability to remain close to their family and appoint a substitute decision-maker. Limited access to healthcare records, both healthcare professionals and prisoners identified limited access to information on the health and possible treatments available, which prevented  discussions on ACP. Healthcare professionals also identified the limitation of how much information they could share with a prisoner, even if this involved the prisoner’s health, as some details may create a possible security risk. The process and systems to document the health of prisoners also prevented engagement with ACP, due to structured standardised formats that did not include the element of ACP. Therefore, even if an ACP was created this may not be transferred with the prisoner to another prison alongside their standardised healthcare records. However, a system-level facilitator was identified as healthcare professionals identified clear processes could be implemented to support all healthcare records to accompany a prisoner on transfer to another prison or on release (Macleod et al. 2020). Secondly, attitudes and perceptions, which included two barriers that impacted the development of ACPs, the attitudes and perceptions of healthcare professionals and prison staff, and the attitudes and perceptions of prisoners. Attitudes and perceptions of healthcare professionals and prison staff, which impacted their

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willingness to engage in ACP discussions with prisoners, included their concern of  focusing on dying in prison which may cause the prisoner great distress. Healthcare professionals also reported a lack of engagement in ACP was due to their current workload, and ACP discussions were not the focus of their healthcare provision. A lack of understanding of the importance of ACP by prison staff was evident as they believed that prisoners were opting out of completing their prison sentence by refusing medical treatment, which would lead to an early death. Attitudes and perceptions of prisoners, which impacted their willingness to engage in ACP, were their lack of trust of prison healthcare and their belief healthcare professionals were not concerned for their well-being. Therefore, this led prisoners to believe that their preferences may not be respected. Prisoners have also identified their concerns of discussing their health and end-of-life care with both prison staff and fellow prisoners as they might take advantage of them due to their ill health. However, a minority of prisoners identified they were lucky to have had the chance to discuss and implement an ACP as they felt they had control over dying due to the prison staff knowing their preferences for endof-life care (Macleod et al. 2020). Thirdly, knowledge and comprehension, a barrier identified included prisoners’ lack of knowledge and comprehension of their health and the need for and importance of an ACP. The lack of knowledge of prisoners was identified by healthcare professionals and included low levels of health literacy and a lack of understanding of their own diagnosis, the trajectory of their illness and possible treatment options. The lack of understanding prevented prisoners from engaging in ACP due to their inability to make informed decisions. However, some prisoners identified even though they lacked appropriate knowledge, they understood the need for and importance of an ACP, and appreciated the support to engage in ACP discussions (Macleod et al. 2020).

1.6 Advance Directives An advanced directive, usually referred to as an advance decision to refuse treatment (ADRT) by healthcare professionals, whilst the term advanced decisions is applied in the Mental Capacity Act (2005), or a living will by charities, all refer to decisions made by an individual to refuse a specific type of treatment at some time in the future (NHS 2022). An ADRT, which has addressed the requirements of the Mental Capacity Act (2005), is a legal document and legally binding for everyone involved in providing care to that individual. Therefore, health and social care professionals and friends and family members are legally bound to respect the wishes of the individual to refuse medical care as described in the ADRT. The legal framework within the Mental Capacity Act (2005), which supports advance directives, is the Code of Practice for ADRT, which is comprehensive and complex. The Mental Capacity Act (2005) Code of Practice for ADRT states (adapted from the National End of Life Care Programme, 2013):

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• An ADRT empowers an individual over the age of 18, who has the capacity to identify specific treatment they will refuse in the future when they may no longer have the capacity to refuse the specific treatment. • If an ADRT is both valid and applicable to current circumstances, healthcare professionals must follow the decisions within the ADRT as they would if a person with capacity was making these decisions. • Healthcare professionals who follow the decisions within an ADRT are protected from liability when they believe the ADRT is valid and applicable, but healthcare professionals are also protected from liability if they provide treatment when they believe an ADRT is not valid and applicable or in place. • An ADRT written by someone over the age of 18 with capacity must contain clear and specific information regarding the treatment they wish to refuse. However, the individual can cancel their decision or part of their decision at any time if they so wish. • If an ADRT includes the decision to refuse treatment, which is life-sustaining and without the treatment, the individual will die, which must be clearly documented in writing, signed by the individual and witness. The documentation must clearly state the refusal for treatment applies even if life is at risk. An important element for all healthcare professionals is the need to establish whether an ADRT is valid and applicable. Firstly, healthcare professionals need to identify whether the individual has done anything that goes against their ADRT, which might suggest they had changed their mind. Secondly, the need to identify whether there is any evidence the individual has withdrawn their decisions or a decision within their ADRT.  Thirdly, the need to identify whether the individual has placed the power to make decisions in an attorney, which may supersede an ADRT. Lastly, it is possible the individual would have changed their decisions if they had known more information regarding their current circumstances or if they had known medical advances in the treatment of their illness would significantly have extended their life or improved the quality of their life. An individual detained under the Mental Health Act 1983 can be treated without consent for a mental health condition, whilst their decisions within an ADRT remain valid and applicable for a physical illness (Mullick et al. 2013). The National End of Life Care Programme (2013) provides detailed information to support healthcare professionals to establish whether an ADRT is valid and applicable; the above is only a broad overview of relevant concepts. The formation and implementation of an ADRT by an individual who is a prisoner is complicated due to prison rules and regulations. Ethical issues, which require further consideration when supporting an individual in prison to form an ADRT, include the competence of the individual at the time the directive was constructed and the freedom of the individual from any form of coercion or deception (Andorno et  al. 2015). Competence refers to an individual prisoner’s capacity to make informed decisions regarding their future healthcare. Competence is an important consideration for prisoners due to the high prevalence of mental illness in prisons and the impact of mental health on their competence to complete

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complex informed decisions (WHO-ICRC 2006). The issue of freedom is important for individuals who are prisoners due to the disparity of power relationships within the prison setting. Therefore, it can be difficult to understand whether prisoners are making autonomous decisions or whether they are being influenced by existing factors, such as prison guards or other prisoners who are influencing them to decline treatment. A further factor for consideration is a prisoner’s mental well-being and whether a prisoner is unduly influenced by their current situation, which may influence their refusal of life-saving treatment that they would not normally have refused.

1.7 Lasting Powers of Attorney Lasting powers of attorney (LPA) are legal documents which allow an individual to nominate someone or two people the authority to make decisions for them if they are unable to do so in the future. An attorney can be anyone aged 18 or over, a relative, friend, or a professional, such as a solicitor, or an individual’s wife, husband, or partner. The attorney must have the capacity to make their own decisions, although it is not necessary for them to live in the UK. There are two forms of LPA; firstly, an LPA for financial decisions, which can be implemented either whilst the individual still has the capacity or only once the individual has lost capacity. An LPA for financial decisions can include all final matters or just specific financial decisions depending on the individual’s wishes documented in the LPA. Secondly, an LPA for health and care decisions can only be implemented once an individual has lost their capacity to make these decisions. Health and care decisions may include where the individual lives, their medical care, provisions of material items, and social activities. An LPA needs to be registered with the Office of the Public Guardian, whose role includes the provision of information to support the completion of appropriate forms, support of attorneys, and the investigation of complaints. An LPA must be registered with the Office of the Public Guardian whilst the individual has capacity, and the LPA does not become a legal document until registered, which may take up to 12 weeks. If an individual loses capacity during the registration of the LPA, but has already signed the document and submitted, registration of the LPA can continue (Age UK 2022).

2 Legal Frameworks and Interventions This section commences with the complexities of compassionate release for prisoners, and how, especially in England, these decisions have become more complex due to prisoners who were diagnosed to be at the end of their life, then continued to live for several years (Turner et al. 2009). The legislation regarding palliative and end-of-life care in prison will then be introduced, with a discussion on the implementation of different approaches across different countries, focusing on the role of the nurse. Examples will include the approach in the US and the

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implementation of prison hospices, in England and Wales and  the provision of palliative and end-of-­life care in prison, and lastly in Australia and the use of tertiary hospitals (Panozzo et  al. 2020). Each of these approaches will be discussed and barriers, challenges, and successes explored.

3 Compassionate Release Compassionate release, or early release on compassionate grounds as it is referred to in England and Wales, is a process within prisons around the world, which allows prisoners to apply for release prior to the completion of their sentence if extraordinary or compelling circumstances have emerged which were unknown to the court at the time of sentencing. In May 2022, the Ministry of Justice (MoJ) and Her Majesty’s Prison and Probation Service (HMPPS) updated and implemented a new policy framework to support early release on compassionate grounds for those in prisons in England and Wales. The new policy framework encompasses all those detained and the many reasons why compassionate release may be appropriate. The following discussion focuses only on the relevant elements of compassionate release due to the health and social care needs of a prisoner. The MoJ and HMPPS (2022) definition of prisoners and fundamental principles that may lead to the consideration of early release on compassionate grounds include: • When a prisoner’s health condition impacts their experience of being in prison and causes greater suffering than intended by the deprivation of their liberty as a punishment, such as those who have paralysis from a severe stroke, or those who have advanced dementia Or • A prisoner is in the last few months of their life due to a life-limiting condition and the provision of care in a hospice, hospital, or a domestic setting would be more appropriate However, • A prisoner who is released early will not put the safety of the public at risk • There is a clear and specific purpose to be served by early release. An element of the definition for early release on compassionate grounds, which has caused difficulties in the past, is the identification of when a prisoner is in the last few months of their life. This has been reinforced by high-profile cases, for example, Abdelbaset al-Megrahi was released from a Scottish prison on compassionate grounds due to a diagnosis of an aggressive form of prostate cancer. Al-Megrahi had served just over 8 years of a 27-year sentence for a bomb attack on

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the Pan Am Flight 103, which killed 270 people in 1988, he was released from prison on 20 August 2009. Al-Megrahi was returned to Libya, and on release from hospital lived with his family, until his death, which was announced on 20 May 2012 (Turner et  al. 2009). Another example is that of Ronnie Biggs, who was involved in the Great Train Robbery of 1963, although he escaped from prison in 1965 for 36 years, until his return to the UK in 2001 and was again imprisoned. Due to his age, Biggs’ health declined, and he served a third of his 30-year sentence before he was granted early release on compassionate grounds on 6 August 2009. Once released Biggs’ health continued to decline, with a number of strokes, but during this time he held a press conference to publicise the updated version of his autobiography and attended the funeral of a fellow train robber, before dying on 18 December 2013. The examples of prisoners being released early on compassionate grounds and living years rather than months have negatively impacted the applications for compassionate release due to the unpredictability of forecasting the last three months of an individual’s life (McParland and Johnston 2021). The trajectory of some life-­ limiting conditions, such as cancer, are more predictable than others, such as chronic lung disease or dementia. Therefore, applications for early release on compassionate grounds by prisoners with a diagnosis of cancer are more likely to be successful than those with non-cancer but life-limiting conditions, such as heart disease. In 2017, all successful applicants for early release on compassionate grounds had a diagnosis of cancer, whilst 39% of deaths from life-limiting conditions within prisons in England and Wales were due to non-cancer conditions (Burtonwood and Forbes 2019). An element that has been identified to delay applications of non-­ cancer conditions is that of prognostic uncertainty and the acceptance of the unpredictable trajectory of non-cancer conditions, and therefore it can be assumed it is more difficult for a prisoner with a non-cancer diagnosis to obtain an early release on compassionated grounds than prisoners with cancer.

3.1 Case Studies Two case studies are presented, which have been adapted from the learning of Prisons and Probation Ombudsman (PPO) investigations (PPO 2017). These case studies provide real-life examples of the process of obtaining early release on compassionate grounds and lessons learnt to support the process of obtaining early release for prisoners at the end of their life. The first case study identifies the process of obtaining early release on compassionate grounds is often time consuming and a high percentage are not completed prior to the death of the prisoner. Therefore, it is essential all applications are completed in a timely manner and provided the appropriate priority, and nurses are optimally placed to support this process. The second case study identifies the need to assess the risk of early release of a prisoner on

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Case Study: Time-Consuming to Approve a Compassionate Release Application

A male prisoner was serving a short sentence, just over two years, halfway through his sentence he had two consecutive chest infections and was diagnosed with chronic lung disease. Following the diagnosis, the prisoner had a stroke and was taken to hospital, where he remained for further investigations. Whilst in hospital he was diagnosed with lung cancer, which had already spread to his spine, and provided with a life expectancy of a couple of months. On the same day a nurse contacted the offender management unit at the prison regarding the possibility of compassionate release and the commencement of an application. Two weeks following the commencement of the application neither the prison GP nor the probation officer had completed their sections of the application. This prisoner died at the age of 61, two weeks following his diagnosis and his application for compassionate release remained incomplete. public safety, which needs to be contextual and include how the prisoner’s current health status impacts on their risk to the public. Adapted from PPO (2017) Learning from PPO investigations. Older Prisoners. Case Study: Risk Assessment Within a Compassionate Release Application

A male prisoner was serving a long sentence of almost 20 years, prior to his conviction he was diagnosed and treated for kidney and lymph node cancer. Once sentenced his cancer returned and spread to his one remaining kidney and his lungs. The prisoner was provided with oral chemotherapy to slow the growth of the cancer. A year later the cancer had spread to the prisoner’s liver, and he was informed that he had a life expectancy of one or two years. The prisoner’s condition continued to deteriorate, he became unable to mobilise and the cancer has spread to his bladder, he died in prison, at the age of 77. Six months prior to his death, the prison liaison officer had spoken to the prisoner and discussed the possibility of early release on compassionate grounds, however the prisoner was appealing his conviction and wanted to delay his application for early release until this process had been completed. Five months prior to his death the prison GP spoke to the prisoner again, informing him he did not have long to live, and at this point the prisoner commenced his application for early release on compassionate grounds. However, the Governor did not support the application, as he believed the prisoner was still a high risk of harm to children, and therefore the application was not processed. The PPO identified the risk assessment was not contextual and did not consider the prisoners current health status, as he was no longer mobile and in the last weeks of his life, therefore the risk of his re-offending has passed.

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Adapted from PPO (2017) Learning from PPO investigations. Older Prisoners.

4 Legislation for Palliative and End-of-Life Care in Prisons Legislation and the implementation of palliative and end-of-life care in prisons have been implemented differently across countries. As discussed, palliative and end-of-­ life care in prisons or a robust process of early release on compassionate grounds is essential due to the ageing prison population and the health of prisoners. Prisoners are more likely to require palliative care at a younger age and twice as likely to need palliative care as someone of the same age and gender living in the community (Pazart et al. 2018). This section explores the different approaches to palliative and end-of-life care, including the implementation of prison hospices in the US, and the mandate by the National Hospice and Palliative Care Organisation (2009). In England and Wales, the Dying Well in Custody Charter (Ambitions for Palliative Care and End of Life Partnership 2018), which outlines the ambitions of improving palliative care and end-of-life care in prison settings, and lastly in Australia, the approach of transporting prisoners to tertiary hospitals for palliative and end-of-­ life care.

4.1 Prison Hospices in the United States In the US, due to the increase in the number and age of prisoners a hospice programme was introduced in the 1980s (Wion and Loeb 2016). The National Hospice and Palliative Care Organisation (NHPCO) mandated all prison hospices need to provide care equivalent to the care provided in community hospices. The NHPCO Quality Guidelines provide both principles and a framework for all those involved in providing end-of-life care in prison. The framework contains 10 key components in clinical and non-clinical areas (Cloyes et  al. 2016). The 10 components support the consistency of the implementation of prison hospices across prisons and include:  1. Inmate patient and family-centred care—to include the needs of the prisoner, but also the needs of their family of choice 2. Ethical behaviour and inmate patient rights—to support staff to advocate for the rights of the prisoner and their families as well as providing high standards of care 3. Clinical excellence and safety—to ensure the safety of prisoners through high standards of practice and clinical excellence 4. Inclusion and access—to ensure prison hospices are inclusive and accessible for all prisoners, regardless of ethnicity, gender, age, sexual orientation, and disability 5. Organisational excellence and accountability—to ensure ethical business practices and accountability within the organisation

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6. Workforce and excellence—to promote an inclusive, collaborative, and interdisciplinary environment, with the continued training of all staff 7. Quality guidelines—to ensure accreditation standards are in accordance with the American Correctional Association and National Commission on Correctional Health Care accreditations standards 8. Compliance with laws and regulations—to ensure compliance with applicable laws and professional standards of practice to support the human rights of prisoners 9. Stewardship and accountability—to support the development of both a qualified and diverse governance structure 10. Performance improvement—the use of performance data to consistently assess and improve all areas of care and services A key facilitator of the US prison hospice model is the voluntary contribution of prisoners, who are trained to support and provide care for other prisoners living with life-limiting conditions (Loeb et al. 2021). Prisoners are assessed for their appropriateness to support fellow prisoners, which includes a set of criteria, such as: no recent disciplinary action, serving a long-term or life sentence, no history of either cognitive deficits or emotional health challenges, and evidence of rehabilitative and community service within the prison setting (Berry et al. 2016). Prisoners complete training to understand the core principles of hospice care, how these can be translated into the prison setting, and basic nurse assistant training (Cloyes et al. 2017; Depner et al. 2018). The prisoners’ training includes communication, comfort and symptom management, use of equipment, and an understanding of pressure ulcers and how to prevent the breakdown of a prisoner’s skin. An important element of the prisoner’s work is sitting with a fellow prisoner who is dying, to support the prisoner’s preferences, but also to tell stories, read letters, and provide comfort, perhaps through hand-holding (Cloyes et al. 2017; Depner et al. 2018). This is a unique role as healthcare professionals and prison staff do not have the capacity to support this level of support. This is especially important within a prison hospice if family members or friends are not permitted to be with the dying prisoner (Depner et al. 2018). The approach of volunteer prisoners to provide end-of-life care for fellow prisoners is to both support the needs of prisoners with life-limiting conditions and encourage altruism and a sense of reparation in prisoners providing care (Cloyes et al. 2017; Depner et al. 2018; Stone et al. 2012). The implementation of prisoners to support end-of-life care for fellow prisoners has been identified as a facilitator and an essential element of effective end-of-life care in prison hospices. The essential element of this approach was the continuity of relationships between the prisoners, and the ability of prisoners, who volunteered to care, to build rapport and maintain close relationships with the prisoners during palliative and end-of-life care (McParland and Johnston 2019). Barriers to the prison hospice model have been identified and have included the difficulty in recruiting, maintaining, and training of prisoners to support end-of-life care for fellow prisoners, alongside a lack of specialist equipment such as medical beds, both of which can impact the effectiveness of this approach (Wion and Loeb 2016). An important element that is not always addressed

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is the continuous training or even supervisory support for the prisoners who volunteer to care, which is a necessity due to the residual effect of caring for the dying (Cloyes et al. 2017).

4.2 In-Reach End-of-Life Care in Prisons in England and Wales In prisons in England and Wales, the provision of palliative and end-of-life care is a combination of both transferring a prisoner to a hospital or hospice within the community or community palliative care services providing an in-reach service for prisoners to ensure hospice care whilst in prison (Stone et  al. 2012; McParland and Johnston 2021). Therefore, in England and Wales the in-reach model of end-of-life care is different to that of the in-house model of prison hospices as described above in the US (Stone et al. 2012). In England and Wales a national framework for local action called Dying Well in Custody Charter published in 2018 (Ambitions for Palliative Care and End of Life Partnership 2018) identifies six ambitions, all of which include an i-statement and standards of care to be provided to prisoners at the end of their life, which include: Ambition 1: Each person is seen as an individual and should be treated with dignity and respect. All prisoners who require palliative care are identified and added to an end-of-life register, followed by the provision of holistic, person-centred, safe care, which supports the needs of individual prisoners. End-of-life care should be coordinated by a Family Liaison Officer, and conversations about an individual’s death and dying should be open, honest, and informed to ensure the prisoner understands and can communicate their preferences. Spiritual and religious support should also be available to meet the preferences of the prisoner. Lastly, the prison regime should be flexible to support the care and management of a prisoner’s end-of-life care. Ambition 2: Each person gets fair access to care as prisoners are entitled to equivalent health care, including an assessment of their needs, this should not be denied due to the level of security of the prison. Lastly, access to care should be available at all times for prisoners on the end-of-life care register. Ambition 3: Maximising comfort and well-being; all prisons are required to have a coordinated timely process for documenting the changing needs and/or preferences of the prisoner on the end-of-life care register. A multidisciplinary team should be available to assess and review symptom management and pain control, and medication should be available in the prison to ensure prompt administration. Advance care planning and DNACPR decisions should be discussed throughout a prisoner’s care to update and officially record all decisions. Assessments for restraints and level of risks posed for individuals on the end-oflife care register will be made jointly between health care and security. Prisons will have a process in place, when required, to initiate the ‘open door’ protocol. Ambition 4: Care is coordinated; prisoners should be given the opportunity to be involved in their care, relaying their preferences and plans, which should be

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recorded and reviewed at appointments. All plans should be shared with appropriate healthcare professionals and prison staff, which is supported through clear documentation of roles and responsibilities of staff inclusive of both internal prison staff and external partners. The roles recognised include a prison lead, a clinical lead, and a named clinical key worker/s who provide care for the prisoner. An up-to-date document should be maintained on the national SystmOne to ensure continuity of care during transfer to another prison, hospital, hospice, or release. Ambition 5: All staff are prepared to care; both staff and prisoners have a right to raise concerns they may have about a prisoner’s health and well-being who is on the end-of-life register. Any concerns raised should be listened to and acted upon appropriately. All prison staff should have access to training on palliative and end-of-life care, which should include supervision, how to share any concerns, and ensure appropriate management of prisoners on end-of-life care. Staff should have the tools, appropriate to their role, to understand the referral process to an appropriate agency for care. At a system level, key contacts should always be informed with up-to-date information. Ambition 6: Each community is prepared to help; prisons need to foster good relationships with external and internal partners to ensure appropriate, timely access to a suitable care environment. This includes appropriate equipment which enables the delivery of a good standard of palliative care, ideally in a preferred place. In addition to this, good communication of sources of support for all parties involved including people affected by or those who are involved in the care of the prisoner. The ambitions of the Dying Well in Custody Charter have not yet been fully met in prisons in England and Wales. A report published by Hospice UK in 2020, which explored the PPO fatal incident reports, identified three major concerns: Firstly, the care provided to prisoners should be equivalent to care provided in the community; of the 95 cases explored, only 8 reported care that was inequivalent to care provided in the community. However, Hospice UK (2020) identified ‘numerous instances’ in fatal incident reports where the care provided was considered to be equivalent to care in the community, although the care described was objectively substandard. For instance, a prisoner’s family was not informed of his death until a month after the death had occurred. Hospice UK (2020) recommended the application of equivalent care within fatal incident reports should be reviewed against standards of care within the community. Secondly, the inappropriate use of restraints of prisoners at the end of their life was reported in 20 out of the 95 cases explored. In a number of incidents, prisoners who were seriously ill were double handcuffed, even prisoners whose behaviour in prison had been reported as extemporary. Double handcuffed refers to when a prisoner’s hands are placed in handcuffs, and then they are handcuffed to a prison officer. This approach of restraint is usually applied when transferring healthy category A or B prisoners, not seriously ill prisoners. Hospice (2020) recommend HMPPS

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review both their policy and practice of the use of restraints on prisoners who are seriously ill and require end-of-life care. Thirdly, the delay or no consideration for early release on compassionate grounds; COVID-19 highlighted this issue. A 1000 people in custody at the beginning of the COVID-19 pandemic in March 2020 were identified as vulnerable and should be considered for temporary compassionate release, but by October 2020, only 54 had been safely released under this scheme. However, as discussed above the process of early release on compassionate grounds for those in prisons in England and Wales was updated and implemented in May 2022 by the MoJ and HMPPS.

4.3 External End-of-Life Care for Prisoners in Australia In Australia, those over the age of 50 are the fastest growing age group within the prison population (Panozzo et  al. 2020), thus the provision of equal access to palliative care for prisoners is imperative. Unlike the approaches of the US and England and Wales of in-house prison hospice and the in-reach hospice care, where prisoners are cared for in the prison, palliative and end-of-life care is not provided in prisons in Australia, but within external healthcare services, including hospitals and hospices. Prisoners who have life-limiting conditions and/or need ongoing treatments are transported via a central maximum-security prison to hospitals for either outpatient or inpatient treatment as required (Panozzo et al. 2020). The transfer to the maximum-security prison prior to the prisoner going to the hospital is a requirement irrespective of the prisoner’s security level. This added requirement of transferring a prisoner  to the maximum-security prison prior to the hospital impacts on the accessiblity of secondary or tertiary care and the possibility appointments are missed or delayed. Some prisoners refuse medical treatment due to the systems involved in getting to hospital, especially those who are not detained in a maximum security prison. Similar to the findings of Hospice UK in England and Wales, healthcare professionals providing palliative and end-of-life care to prisoners within hospitals in Australia identified constraints as a barrier (Panozzo et al. 2020). The constraints were not only the physical constraints of prisoners but included the constraints on the provision of end-of-life care for prisoners. The loss of a prisoner’s choice regarding their preferred place of death impacted how healthcare professionals could provide end-of-life care and negatively impacted their experience of providing end-of-life care. A further constraint identified by healthcare professionals was the development of a therapeutic relationship with the prisoner as prison officers were always in attendance. These constraints caused healthcare professionals moral distress as they could not provide end-of-life care to prisoners as they would their other patients. An ethical dilemma for healthcare professionals was also highlighted, which involved becoming aware of information of the prisoner’s offence and the length of their sentence. Some healthcare professionals believed it was a benefit to understand the length of a prisoner’s sentence as this would support informed

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discussions regarding diagnosis and possible treatment options, whereas other healthcare professionals did not want to know either the prisoner’s offence or the length of their sentence (Panozzo et  al. 2020). The final constraint identified by healthcare professionals was the lack of visitation as prisoners were not allowed visits from their family, which was believed to create ‘gaps in care’ (Panozzo et al. 2020, p. 988). However, the barriers and concerns raised by healthcare professionals, prison staff, and prisoners regarding palliative and end-of-life care have been acknowledged by the Australian Government and Department of Health, with the funding of a Palliative care in Prisons Project, led by Professor Jane Phillips. The aims and objectives of this ongoing project are to ‘understand how palliative care is provided in Australian prisons, identify the barriers to and facilitators of palliative and end of life care, and to co-design a National Framework for Provision of Palliative Care in Australian Prisons with key stakeholders using a collaborative and solution-­ oriented approach’ (Phillips 2020). The development and implementation of a National Framework for Provision of Palliative Care in Australian Prisons is due to be completed by September 2023. The variations in palliative and end-of-life care legislation for prisoners across the US, England and Wales, and Australia highlight the different approaches to providing care to prisoners, as well as the barriers of each approach, but also the ongoing work to improve palliative and end-of-life care in prisons. The current provision of palliative and end-of-life care in prisons identified above demonstrates some of the complexities of providing care for a prisoner who is dying. The complexities involve early release on compassionate grounds, privacy, and confidentiality when discussing dying with a prisoner, the use of restraints in hospice and hospital facilities and visitation by family and friends, within an environment with a focus on security and safety. The complexities can impact the provision of palliative and end-­ of-­life care, with an increase in both physical and psychological suffering when a prisoner dies in their prison cell (Burles et al. 2015; Maschi et al. 2014), which is in opposition to the aims of the quality indicator legislation that is in place in many countries.

5 The Role of the Nurse in Palliative and End of Life This section commences with an exploration of the role of the nurse in palliative and end-of-life care, commencing with the role of primary care nurses in the provision of palliative and end-of-life care, who are not specialists in end-of-life care. Examples of the role of primary care nurses in palliative and end-of-life care will be provided from the US, England, and Scotland, including the development and implementation of education for both primary care nurses supporting prisoners, and prison officers and other prison staff.

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5.1 The Role of the Nurse in Palliative and End-of-Life Care The role of the nurse in palliative and end-of-life care has evolved within the modern hospice movement, founded by Cicely Saunders. The philosophy of the modern hospice movement is the provision of care and support for those who are seriously ill and dying and their family, with the aim of improving their quality of life during their final months, weeks, and days of the individual who is dying and their family. Cicely Saunders emphasised the need for skilled nurses to care and manage those who are seriously ill and dying and to support their family (Saunders 1978). Nurses remain the most prominent healthcare professionals who are involved in the provision of palliative and end-of-life care, across most countries, and a wide range of settings (Phillips et al. 2020). The overarching role of primary care nurses within palliative care has recently been described by nurses as involving four main elements (Sekse et al. 2017) Firstly, being available, nurses are on duty 24 hours a day and provide the majority of care to patients, although many other healthcare professionals are also involved. Due to the time nurses spend with a patient providing care, the therapeutic relationship develops into a social connection, which supports the provision of personalised care and empowers the nurse to become an advocate for the patient and their wishes. Secondly, being a coordinator, the availability of nurses naturally leads them to become the contact for the patient and their family, as well as other health and social care providers. The coordinator and liaison role of nurses supports a patient’s continuity of care through the building of collaborations with other service providers, which is essential for the patient to receive optimal end-of-life care. The role of nurses as a coordinator includes communication skills, such as listening, facilitating, providing information, and the clarification of the patients’ needs and preferences. Thirdly, doing what is needed, nurses’ roles varied depending on the needs of the patient as nurses completed a range of activities in providing palliative care, including assessment, planning, interventions, evaluation, all of which ranged from routine to complex, and centred around physical, psychological, and spiritual needs of the patient. Nurses described doing what is needed to ensure their patients were comfortable, pain-free, and other symptoms were managed. Fourthly, being attentively present and dedicated, through their need to focus on personalised and individual care nurses are attentively present whilst providing end-of-life care. Lastly, nurses were dedicated to working with both their patient and their family, even when these relationships became difficult due to the withdrawal of other healthcare services.

5.2 Role of the Nurse in End-of-Life Care in the United States In the US, the role of the primary care nurse includes supporting prisoners who have volunteered to support palliative and end-of-life care programmes to ensure they are skilled in the provision of appropriate care for prisoners who are at the end of their life (Cloyes et al. 2017). The role of the nurse includes the training of prisoners to

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provide end-of-life care, which has been supported through the development of an e-learning module (Loeb et al. 2021). The e-learning module has been developed through the implementation of focus groups with both male and female prisoners who provided end-of-life care to fellow prisoners. This approach identified the most significant need of prisoners was support with loss and grief, but also the need to understand their role as a caregiver in the final hours of another prisoner’s life. The needs of prisoners supporting end-of-life care were addressed within the e-learning module, which has been identified as helpful. The role of the primary care nurse in the provision of end-of-life care also includes liaising with community-based hospice nurses to visit the prison to provide more specialist education and training to volunteer prisoners (Cloyes et al. 2017; Loeb et  al. 2021). The involvement of hospice nurses is essential to support the training of volunteer prisoners as primary care nurses are not specialists in end-of-­ life care. Another important element of the role of the primary care  nurse is the continued support of prisoners and taking the time to listen to the volunteers, especially with regards to the psychological implications this programme can have on the volunteers and their own existential thoughts on life and death. Primary care nurses need to support the volunteers in a professional manner acknowledging their work as part of the hospice care team, whilst maintaining the boundaries of nurse– prisoner relationship, identifying the complex navigations involved in a primary care nurse’s role in supporting palliative and end-of-life care of prisoners.

5.3 Role of the Nurse in End-of-Life Care in England In the England, the role of the primary care nurse includes acting as an advocate for vulnerable patients and challenging inequalities relating to the provision of care (Nursing and Midwifery Council 2015). This role is exemplified within a prison due to the challenging environment (Banks Howe and Scott 2012). The provision of palliative and end-of-life care by primary care nurses  in prison is supported by MacMillan nurse specialists. This approach supports a strong collaboration between primary care nurses working within the prison and community palliative care teams. The collaboration supported the development and implementation of a postgraduate education programme for primary care nurses, which included two modules. The first module was via blended learning and could be undertaken in practice, which included 13 topics, including 1. Palliative care philosophy 2. Supportive and palliative care guidance 3. Understanding cancer 4. Palliative care for long-term conditions 5. Common investigations in cancer and palliative care 6. Communication 7. Symptom control 8. The multidisciplinary team

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9. Health promotion 10. Ethical issues 11. Spirituality 12. Cultural issues 13. Loss, grief, and bereavement The second module contained 12 contact sessions and an assignment, which supported reflection on learning and how to apply palliative and end-of-life care in prison (Banks Howe and Scott 2012). The completion of the training supported the role of the primary nurse through greater confidence in discussions with prisoners to develop ACPs, and greater awareness of the services and resources available for both primary care nurses and prisoners receiving end-of-life care (Banks Howe and Scott 2012). The role of the primary care nurse in prison is  also to support prison staff to support prisoners on palliative and end-of-life care. The collaboration between primary care nurses and palliative care nurses in Scotland has also supported the development and implementation of support for prison officers and other prison staff, including DNACPR training, reflective sessions to support those providing care or support to prisoners on end-of-life care, and bereavement support following the death of a prisoner (Kemp et  al. 2017). The collaboration has also improved prisoner satisfaction with the care they have received, hospice staff have volunteered to continue to support prisoners requiring palliative and end-of-life care, and both primary care nurses and hospice nurses have demonstrated a commitment to strengthening the collaboration. The programme aims to develop and implement further initiatives to support the role of the primary nurse, which include easier access to required medication, use of subcutaneous infusion pumps to provide continuous medication, out-of-hours support by hospice nurses, and finally the role of prisoners as palliative care champions (Kemp et al. 2017).

6 Conclusion This chapter has explored the complexities and nuances involved in palliative and end-of-life care, advance care plans, and advance directives and how these processes are further complicated when applied to support prisoners who are dying with life-limiting conditions. The different approaches to palliative and end-of-life care in prisons in the United States, England, and Australia have also been discussed and the role of the nurse within these different approaches. The barriers within each of these approaches have been discussed as well as the ambitions and future initiatives to support palliative and end-of-life care in prison.

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Pérez MV, Macchi MJ, Agranatti AF (2013) Advance directives in the context of end-of-life palliative care. Curr Opin Support Palliative Care 7(4):406–410 Phillips, J. (2020) Palliative care in Prisons Project. https://www.uts.edu.au/research-­and-­ teaching/our-­research/impacct/about-­us/research-­impacct/studies/palliative-­care-­prisons-­ project#:~:text=The%20Palliative%20Care%20in%20Prisons,Palliative%20Care%20in%20 Australian%20Prisons. Accessed 24 July 2022 Phillips J, Johnston B, McIlfatrick S (2020) Valuing palliative care nursing and extending the reach. Palliat Med 34(2):157–159 Prisons and Probation Ombudsman (2017) Learning from PPO investigations. Older prisoners. https://s3-­eu-­west-­2.amazonaws.com/ppo-­prod-­storage-­1g9rkhjhkjmgw/ uploads/2017/06/6-­3460_PPO_Older-­Prisoners_WEB.pdf. Accessed 24 July 2022 Resuscitation Council UK (2016) ReSPECT for healthcare professionals. https://www.resus.org. uk/respect/respect-­healthcare-­professionals. Accessed 24 July 2022 Royal College of Nursing (2022) End of life care. https://www.rcn.org.uk/clinical-­topics/End-­of-­ life-­care. Accessed 24 July 2022 Saunders CM (1978) The philosophy of terminal care. In: Saunders CM (ed) The management of terminal disease. Edward Arnold, London, pp 193–202 Sekse RJ, Hunskar I, Ellingsen S (2017) The nurse’s role in palliative care: a qualitative meta-­ synthesis. J Clin Nurs 27(1–2):e21–e38 Sepúlveda C, Marlin A, Yoshida T, Ullrich A (2002) Palliative care: the World Health Organization’s global perspective. J Pain Symptom Manag 24(2):91–96 Stone K, Papadopoulos I, Kelly D (2012) Establishing hospice care for prison populations: an integrative review assessing the UK and USA perspective. Palliat Med 26(8):969–978 Sudore RL, Lum HD, You JJ, Hanson LC, Meier DE, Pantilat SZ, Matlock DD, Rietjens JAC, Korfage IJ, Ritchie CS, Kutner JS, Teno JM, Thomas J, McMahn RD, Heyland DK (2017) Defining advance care planning for adults: a consensus definition from a multidisciplinary Delphi panel. J Pain Symptom Manag 53(5):821–832 Turner M, Barbarachild Z, Kidd J, Payne SA (2009) How notorious do dying prisoners need to be to receive high quality end-of-life care? Int J Palliat Nurs 15(10):472–473 Universal Principles for Advance Care Planning (2022). https://www.england.nhs.uk/wp-­content/ uploads/2022/03/universal-­principles-­for-­advance-­care-­planning.pdf. Accessed 24 July 2022 Wion RK, Loeb SJ (2016) CE: original research: end-of-life care behind bars: a systematic review. Am J Nurs 116(3):24–36 World Health Organisation (2002) National cancer control programmes: policies and managerial guidelines, 2nd edn. World Health Organization, Geneva World Health Organization and International Committee of the Red Cross (2006) Mental health and prisons. Information sheet, Geneva

Recommendations and Conclusions Joanne Brooke

1 The Role of the Nurse in Prison The role of the nurse in prison was explored in chapter “The role of the nurse in prison” alongside the development of healthcare for prisoners, which was influenced by litigation in the United States (US) and the National Partnership Agreement and commissioning in England and Wales. Unlike the US, and the development of the Correctional Nursing: Scope and Standards Practice, in England and Wales there is no specific overarching guidance. However, in England and Wales, nurses working in prison are highly skilled, from different disciplines, and many have post-­ registration qualifications. The development of professional identity of nurses was discussed, with a specific focus on the professional identity of nurses working in prison, which was influenced by the unique circumstances of the prison, including prison culture, the prison regime, and working with prisoners. Other discussions included in this chapter included the complexities of developing a therapeutic relationship with a patient who is also a prisoner, collaborating with prison officers in the provision of healthcare, supporting prisoners to provide care to fellow prisoners, and working with charities. The recommendations and conclusions for this chapter concentrate on the professional identity of prison nurses, the development of therapeutic relationships in prison, care versus security, and collaborating with prison officers in the provision of healthcare. Professional Identity  The development of the professional identity of prison nurses is essential as these nurses have felt unseen, unacknowledged, undervalued, and underresourced (Goddard et al. 2019). Nurses working within the prison setting have identified specific elements that could support the development of and J. Brooke (*) Centre of Social Care, Health and Related Research, Birmingham City University, Birmingham, UK e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 J. Brooke (ed.), Nursing in Prison, https://doi.org/10.1007/978-3-031-30663-1_9

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strengthen their professional identity as a prison nurse. One element recognised by prison nurses, which had a positive impact on their professional identity, was their autonomy. Nurses believed their role supported them to be autonomous practitioners, which would not necessarily have been possible if working in either primary or secondary healthcare outside of the prison (Walsh and Freshwater 2009; Powell et al. 2010). The development of the role of the prison nurse, and the required expertise necessary to fully complete this role, needs to be further understood by nurses working in primary and secondary care in the community and included in the education of future nurses. The latter has commenced with the inclusion of clinical placements within prison healthcare. Therapeutic Relationships  A therapeutic relationship encompasses a supportive, caring, non-judgemental relationship between a nurse and a patient within a safe environment (Mottram 2009). Factors that influence the development of a therapeutic relationship between a prison nurse and a patient include nurse-related factors, such as the fear a patient may become violent, or knowledge of the crime the patient has committed. Prisoner-related factors may involve the impact of being in prison and the patient’s belief they have a lack of control over their life, including access and provision of healthcare. Organisational-related factors involve the boundaries imposed to maintain both security and safety of both nurses, prisoners, and prison staff, which may prevent nurses expressions of caring and enforce restrictive practices. These factors demonstrate the complexity of the development of therapeutic relationships between prison nurses and their patients. Therefore, prison nurses require support with the development of therapeutic relationships in the form of supervision from experienced prison nurses. The development of training, education, guidelines, and publications on this topic is required. Care Versus Security  The security of the prison and the prison regime is always a priority and takes precedence over healthcare, the prison regime creates a conflict between custody and care, as the prison regime influences how and when prison nurses can provide assessment, treatment, and care for prisoners. The need for a safe prison regime is acknowledged, and prison nurses have developed their autonomous practice and negotiated the provision of care within the boundaries of the prison regime. Prison nurses have identified the development of autonomous working to ensure healthcare is provided to prisoners, for example, the implementation of vaccination clinics that occurs on wings of the prison, rather than in healthcare, during prison movement times, to enable the provision of care without the need of prison officers. Collaborating with Prison Officers  Prison nurses are required to collaborate with prison officers in the provision of healthcare as prison officers are often responsible for unlocking prisoners and escorting them to healthcare appointments. Prison officers are also required to be present or in close proximity during the provision of healthcare for the safety of all those involved. However, the priority of the prison

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nurse is the provision of healthcare, whilst maintaining patient confidentiality, and only sharing information with those outside of the primary care team, if a risk has been identified. The impact of prison officers being in close proximity or present during healthcare appointments breaches patient confidentiality, but also the provision of care, as patients are less likely to engage with healthcare professionals if a prison officer is present (Solell and Smith 2019). There remains a need for prison nurses to work closely and collaboratively with prison officers to identify processes, which can be applied within the prison regime, but which appear to amalgamate the need for security and safety, and the provision of confidential health care. The development of health prison officers is one possible approach. Conclusions  The role of a prison nurse is both complex and challenging, which is similar for all nurses working in a prison, including primary care nurses, mental health nurses, community psychiatric nurses, or substance misuse nurses. The challenges unique to providing healthcare within a prison include: working within a strict and inflexible prison regime, where the priority is safety before the provision of healthcare, and the need to collaborate with non-healthcare professionals, such as prison officers, to support prisoners to receive appropriate healthcare. The recommendations from within this section include the further development of the professional identity of a prison nurse, within prisons and more widely within nursing, the development of training, education, and guidelines to support an understanding of developing a therapeutic relationship with a patient who is a prisoner, an appreciation of the autonomy of prison nurses, and the need for prison nurses to continue to work closely and collaborate with prison officers.

2 The Role of the Primary Care Nurse in Prison The importance of primary care in prison has been acknowledged as the majority of prisoners’ healthcare needs can be met by primary care services. The recognition of differences between the delivery of primary care in the community and within the prison setting was discussed in chapter “Primary Care in Prison”, and the different primary care models implemented within prisons in England and Wales, and Australia (Cowman and Walsh 2013; Collett et al. 2022). The role of the primary care nurse in prison is diverse and includes screening in reception to prison, referral to appropriate services, administration of medications, support of in-possession medications, responding to medical emergencies, management of long-term conditions, and the implementation of nurse-led interventions, each of which were discussed in this chapter. Due to the diverse and complex nature of the role of the primary care nurse, many have undertaken further training and education to become advanced clinical practitioners, who provide advanced levels of practice within primary care services, including within prisons. The recommendations and conclusions for this chapter will concentrate on screening, management of long-term conditions, health promotion, and nurse-led interventions.

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Screening  Primary care nurses have an important role in screening, especially the screening of prisoners in reception as this will be the first contact a prisoner has with a healthcare professional as they enter prison. Therefore, the role of the primary care nurse is to develop the trust of prisoners to engage in open and honest conversations regarding their physical and mental health, and possible substance misuse, self-harm, and suicide ideation. All of this needs to occur within a short period of time due to the nature of reception screening and the other processes that are occurring simultaneously. How this trust is developed in this unique, difficult, and stressful situation is unknown, the techniques of experienced primary care nurses could support further understanding of how to engage therapeutically with prisoners in reception. The primary care nurse is optimally placed to explore how the therapeutic relationship can be developed in reception and provide guidance and education to support the development of future primary care nurses and other healthcare professionals. Management of Long-Term Conditions  An important  element of the role of the primary care nurse is the management of long-term conditions, which is due to the increasing ageing prison population. In England, a national standardisation framework (British Medical Association 2019) has been embedded in general practices in primary care settings in the community, which is mandatory, and supports annual assessments against key clinical outcomes. However,  in primary care service provision in English prisons this framework is not mandatory, although some prisons are beginning to implement the framework. In the majority of prisons the focus of screening on reception by primary care nurses is the identification of long-term conditions, without the inclusion of key clinical outcomes. The need to identify long-term conditions is essential to ensure appropriate treatment is continued. However, the management of longterm conditions, whilst a patient is in prison, with a focus on clinical outcomes is also essential. Primary care nurses can support the implementation of annual assessments and reviews to avoid missed opportunities to engage with and possibly support an improvement in a prisoner’s long-term conditions and/or quality of life. Health Promotion  An important role of the primary care nurse in prison is that of health promotion, which includes screening, assessment, advice, education, support, and training. Health promotion by primary care nurses for prisoners also needs to recognise and include the negative impact of prison on a prisoner’s physical and mental health due to a loss of social support and the environment of the prison. Therefore, it is essential health promotion includes how prisoners can support their physical and mental health and well-being whilst in prison. The current literature explores the impact of prison on prisoners, but there is no evidence-based information, education, or training on how to support the physical and mental health and well-being of prisoners during their sentence. Primary care nurses are optimally placed to begin the exploration of health promotion activities, which supports prisoners through their sentence. Nurse-Led Interventions  The implementation of nurse-led interventions has included sexual health clinics for male prisoners (Kelly et al. 2020), mind–body relaxation technique to support prisoners’ stress and anxiety (Pralong et al. 2020), a healthy

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ageing in prison clinic (Fedele 2021), and hepatitis C virus clinics (Baines 2022; Overton et al. 2019; Papaluca et al. 2019). Nurse-led interventions need to address the needs and changing needs of the prisoners, so may vary from prison to prison. However, the world’s prison population is ageing, and therefore the need for a healthy ageing in prison clinic has arisen. The example described in this chapter was implemented in Australia and focused on long-term conditions of older prisoners, but did not include a cognitive screen, which is essential for this population due to their increased risk of dementia owing to their poor health and health behaviours. Primary care nurses are optimally placed to support routine cognitive screening of older prisoners and begin to develop robust screening tools appropriate for this population. Conclusions  The role of the primary care nurse in prison continues to develop and evolve to address the complex health issues of an ageing prison population. This is supported by the explicit training and education primary care nurses undertake, and the development and implementation of advanced clinical practitioners (ACP). The four domains and capabilities of and ACP (primary care nurse), collaborative working, assessment, investigation and diagnosis, condition management, treatment and prevention, and finally, leadership and management, education and research, clearly support the further development and recognition of the role of the primary nurse in prison. The recommendations within this section are just some examples of elements of the role of the primary care nurse, which could be developed and explored to support the implementation of evidence-based practice and support the clinical outcomes of their patients (prisoners). Although primary care nurses do engage in the development of evidence to support their practice, further and wider dissemination of their work would support the recognition and development of their profession.

3 The Role of the Mental Health Nurse in Prison An overview of the provision of mental health in-reach services within prison was discussed in chapter “Mental Healthcare in Prison”. The chapter focused on the mental health and well-being of prisoners, including elements of self-harm and suicide, from screening, referral, assessment, and interventions. The frameworks guiding the commissioning and implementation of mental health-in reach services within prisons in England were also introduced and included the Care Programme Approach (Georgiou et al. 2020), which has been superseded by the Personalised Care and Supporting Planning, which is part of the Community Mental Health Framework for Adults and Older Adults (NHS England and National Collaborating Centre for Mental Health 2019), as well as the Stepped Care Model for People with common mental health disorders, and the Standards for Prison Mental Health Services—Fifth Edition (Townsend et al. 2021). The recommendations and conclusions for this chapter concentrate on screening, assessment, interventions, and service design, and how mental health nurses and community psychiatric nurses (CPN) can support, develop, and implement evidence-based practice within each of these domains to further develop their roles within mental health in-reach team in prison.

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Screening  The development of reliable and valid screening tools for accessing a prisoner’s mental health within reception by non-mental health professionals has begun. The role of the mental health nurse or CPN is to ensure appropriate screening tools are implemented and support those applying screening tools to understand them and adhere to the guidance to ensure the reliability and validity of the tool is maintained. An important factor that requires further exploration, and mental health nurses or CPNs are optimally placed to explore, is the impact of the contextual factors of screening in reception to prison. Contextual factors, such as where the prisoner has arrived from, which could be court and sentencing or another prison, the behaviours of other prisoners in reception, the environment of the prison reception, for example, noise, the level of security, or/and a busy and rushed atmosphere. Assessment  Primary care nurses refer prisoners to a mental health nurse or CPN following the completion of a reliable and validated mental health screening tool in prison reception. The mental health nurse of CPN completes an assessment of the prisoner’s mental health, which is typically guided by a semi-structured clinical interview and their clinical experience. This assessment should include an understanding of the impact of the prison environment, although currently it is unclear how or whether this is included in the semi-structured clinical interview or how or whether the nurse has clinical expertise of the prison environment to include this information. In prisons in Melbourne, Australia, this process has been standardised to include the impact of a prison environment on a prisoner’s mental health and the development of an algorithm to begin to identify appropriate support and interventions (Schilders and Ogloff 2014). Therefore, mental health nurses and CPNs working with prisoners in the United Kingdom are optimally placed to commence the development of a semi-structured clinical interview to include explicit variables of the prison environment to support a standardised approach to assess a prisoner’s mental health. Interventions  The implementation of psychological interventions, such as cognitive-­behavioural therapy, dialectic behaviour therapy, acceptance and commitment therapy, as well as mentalisation-based therapy, has begun within prison settings. However, the role of the mental health nurse or CPN in the delivery of these interventions in the prison setting is currently unclear. There is scope for nurses involved in these interventions to explore how these interventions can be further developed to address all the needs of prisoners as it has been acknowledged prisoners receiving therapy still have unmet psychological treatment needs (Jakobowitz et al. 2017). Furthermore, both mental health nurses and CPNs are optimally placed to explore their roles, expertise, and advanced practice through either research or service evaluation to support the recognition and advancement of their profession. The proactive involvement of nurses in the development of therapies will support and justify their involvement and contribution to relevant NICE guidance and Standards for Prison Mental Health Services.

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Service Design  The delivery of mental health in-reach services within prisons in England and Wales is currently developing with the implementation of the Personalised Care and Support Planning (NHS England and National Collaborating Centre for Mental Health 2019). During the implementation of a new service design, both mental health nurses and CPNs have the opportunity to influence the practical implementation. One aspect, mental health nurses of CPNs, that could champion or support the further integration of is a probation officer in the mental health in-reach multidisciplinary team. The inclusion of a probation officer within a therapeutic approach can support a focus on preventing recidivism and incarceration, as well as supporting the prisoner’s mental health and well-being. This approach has been implemented in the United States and supported prisoners to access wider services and on transition from prison upon release (Kelly et al. 2017; Goulet et al. 2022). Conclusions  The role of the mental health nurse and community psychiatric nurse within the multidisciplinary mental health in-reach team working in prison continues to develop and evolve. The complexities of the needs of prisoners beyond mental health and well-being, still require further understanding, and support in the delivery of either psychological or supplementary therapies, and mental health nurses and CPNs are optimally placed to engage in the robust development of evidence-­based screening, assessments, interventions, and how new service designs are implemented. Both mental health nurses and CPNs currently engage in the development of evidence to support their practice, wider dissemination of their work would further support the recognition and development of their profession.

4 The Role of the Learning Disabilities Nurse in Prison An understanding of intellectual disabilities (ID) is essential for nurses working in prison due to the over-representation of people with intellectual disabilities (ID) in prison populations, and a current lack of learning disabilities nurses employed within in-reach health services within prisons. The different definitions and terminologies of ID explored within this chapter continue to impact the misinterpretation, diagnosis, and support between care providers of people with an ID, which includes the Criminal Justice System of England and Wales, who have applied their own definitions and terminology. Health inequality of people with ID was also discussed due to a lack of engagement or appropriate support and screening within primary care services. The screening of prisoners for an ID is being further developed by both the Ministry of Justice and the NHS to support reasonable adjustments for prisoners with an ID. The recommendations and conclusions for this chapter concentrate on screening of prisoners for both mental health conditions and cognitive decline, support and reasonable adjustments, training and education to support prisoners regarding ID, and service design of primary care or mental health in-reach teams to include a learning disability nurse.

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Screening  Screening of prisoners for an ID in reception is essential. However, the continued screening to support an early identification of a mental health condition or a cognitive decline is also essential. Initial screening in reception is routinely completed by a primary care nurse, although it is unclear, what knowledge, expertise or training primary care nurses have in ID. Therefore, the inclusion of the Learning Disability Screening Questionnaire, would support a robust approach to screening within reception and the identification of prisoners who would require a referral to a learning disability nurse for further assessment, identification of needs, and the development of a care plan. A focus on screening prisoners with an ID for mental health disorders and/or cognitive decline is essential due to their possible lack of insight, comprehension, and difficulties in communication. Cognitive screening should occur as soon as possible to support the identification of future cognitive decline. Therefore, a healthcare professional, such as a learning disability nurse with experience in working with people with ID, is required to complete further screening to identify any issues, which could be overlooked or wrongly attributed to ID. Support and Reasonable Adjustments  ID is a protected characteristic within the Equality Act (2010), and prisoners with ID are also legally protected from discrimination. Therefore, the implementation of reasonable adjustments needs to be considered for every aspect of the prison environment to support prisoners with an ID. Reasonable adjustments include amendments to all elements of the prison environment such as an environment that is easy to navigate, including symbols or pictures for signs, although it is recognised some prison environments are difficult to amend. Other elements include simple and concrete language in large fonts on information provided to prisoners with an ID and the provision of appropriate or adapted education and treatment programmes. Specialist wings for prisoners with an ID have begun to be implemented in Wales and Australia for the most vulnerable prisoners with an ID, which are supported by learning disability healthcare professionals. Specialist wings appear to be effective although a prison-wide approach to supporting prisoners with an ID is still required. Training and Education  The delivery of training and education regarding ID for everyone who has contact with prisoners is essential, including all prison staff, those who work for charities or outside organisations, and health and social care professionals. Prisoners with ID are five times more likely to have been subject to control and restraint, and over three times more likely to report time spent in segregation (Prison Reform Trust 2014; Murphy et  al. 2015). Learning disability awareness, training, and education have been developed and implemented, but limited resources have impacted these initiatives. The Ministry of Justice in partnership with HMPPS is currently developing a core competency framework to describe the core knowledge, skills, and behaviours to work with prisoners with an ID. However, currently, healthcare professionals with expertise in ID, such as learning disability nurses, are optimally placed to support the development and implementation of training to support an understanding of the needs of prisoners with an ID.

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Service Design  The inclusion of a learning disability nurse within primary care or mental health in-reach teams in prisons within England and Wales has commenced but remains inconsistent. The need for the support of learning disabilities across healthcare provision in prisons is due to the complex healthcare needs of prisoners with an ID, who typically present with two or more long-term physical conditions and two mental health disorders (Perera et al. 2019; McCarthy et al. 2019), and an increased likelihood of self-harm and substance misuse (Hellenbach et al. 2017). Learning disability nursing is the only healthcare profession in the United Kingdom which specialises in ID, with a 3-year degree programme and registration with the Nursing Midwifery Council. The role of the learning disability nurse within healthcare services within prisons involves the support of screening, assessment, support and reasonable adjustments, training, and education, and advocating for prisoners with ID, although this list is not exhaustive. Conclusion  The role of the learning disability nurses needs to be integrated in primary care and mental health in-reach teams in prison. This approach is essential not only to support the assessment and screening of prisoners to identify an ID, but also further mental health issues or the onset of cognitive decline, but also to support all those working in a prison to understand the needs and behaviours of prisoners with an ID. Learning disability nurses can also develop and deliver education and training of prison staff to support them to understand both behaviours and the communication styles of people with ID and how to constructively to engage differently with these prisoners to prevent behaviours, which could result in restrictive punishments.

5 The Role of the Nurse in Substance Misuse in Prison The definition and classification of substance misuse have been introduced in chapter “Substance Misuse in Prison”, with the identification of substances, which include drugs, alcohol, and nicotine, but also substances that are non-medical and non-psychoactive. In prisons in England and Wales, Australia, and the United States, it has been estimated that 65% of prisoners are sentenced with a substance misuse disorder. An understanding of substance misuse in different prison populations is required to support the implementation of appropriate services to meet the different needs within these populations. This chapter introduced the different substance misuse patterns, of men, women, older prisoners, those diagnosed with a mental health disorder, or ADHD. The implementation of substance misuse interventions needs to recognise and include comorbidities, social and environment factors within the prison and on return to the community which impact an individual as a substance use cannot be treated successfully in isolation. Computer-assisted therapy programmes for substance misuse and offending have begun to be implemented, alongside other initiatives to address substance misuse and health, such as prison need and syringe programmes. The recommendations and conclusions for this chapter concentrate on the assessment of prisoners who report substance misuse during

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screening in reception, the role of the nurse in substance misuse, nurse-led interventions, and nurse-led medicines management. Assessment  The role of the nurse in the substance misuse in prison is the continued assessment of prisoners with a substance misuse disorder. This commences with an assessment of a prisoner’s risk of withdrawal from substances on entry to prison, which may increase the risk of self-harm or suicide. However, nurses involved in the assessment of prisoners with substance misuse disorders need to understand the complexities of substances used and identify physical and mental health conditions, which may be untreated, and a lack of available clinical data to verify a diagnosis. Furthermore, nurses need to be aware of the self-reported levels of substance use, which may be either over- or underestimated, and the prescription of medication adjusted accordingly. The  role of the nurse includes the assessment of prisoners twice a day for the first week of drug treatment and continues to identify any risks of self-harm or suicide. The nurse within substance misuse is also responsible for identifying when the prisoner has become stable, and the frequency of assessments can be reduced, within prison protocols, and finally discontinued. The Role of the Nurse in Substance Misuse  Unlike the role of the nurses in many other specialities, the role of the nurse within substance misuse has been clearly described by the Royal College of Nursing, Association of Nurses in Substance Abuse, National Substance Misuse non-Medical Prescribing Forum, and Public Health England in the Role of Nurses in Alcohol and Drug Treatment services. This resource is both supportive and informative for nurses, although the role of the nurse continues to develop within substance misuse, but within a multidisciplinary team, including specialist doctors, clinical psychologists, and social workers. The role of the nurse in substance misuse is complex, and a comprehensive understanding of the development and delivery of interventions is required, with consideration of the needs of those who will complete the intervention, the setting of the intervention, with an inclusion of public health, physical health, and psychosocial interventions and medicine management. Nurse-Led Interventions  As described above, the role of the nurse in substance misuse is the development and implementation of nurse-led interventions; these vary in nature and can address the wider issues associated with substance misuse, such as the management of long-term conditions, comprehensive health assessments to identify and manage acute health problems, such as cellulitis and abscesses, dietary assessments with advice on nutrition and weight, or administration of the very brief advice with people willing to stop smoking. However, nurses also lead psychological interventions, with the use of different techniques, such as motivational interviewing. Mental health nurses undertaking this role will have the skills to engage in a number of psychological interventions, however, adult nurses may require further training and education before engaging in the delivery of psychological interventions.

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Nurse-Led Medicines Management  The role of nurse-led medicine management within substance misuse interventions occurs during the acute phase of detoxification when monitoring a prisoner’s physical and mental health, as well as their reaction to medication. Nurses’ role within detoxification may involve changes or alterations to doses of prescribed medications and administer prescribed prophylactic vitamin injections as required. However, nurses can also administer medications if a Patient Group Direction is in place, which guides the administration of a named medication for specific patients. Nurses can also undertake further education to become a non-medical prescriber, either an independent prescriber or a supplementary prescriber. Governance of prescribing by nurses is the responsibility of individual employers, and therefore it is essential nurses understand their scope of practice as defined by their employer and the Royal Pharmaceutical Society Competency Framework for all Prescribers. Conclusions  The role of the nurse in substance misuse is complex and often includes further education and training, especially if an adult nurse is working within this speciality. Nurses with substance misuse support the wider health issues of their patients and support both acute and chronic physical and mental health conditions. The role of the nurse within mental health is both autonomous and working within the multidisciplinary team as the nurse may develop and implement interventions, including psychological interventions, but may also take on the advanced role of prescribing either as an independent prescriber or a supplementary prescriber. However, due to the complex nature of substance misuse with prisoners and the need to include a focus on offending, this can only be successfully completed within a multidisciplinary team, usually with the inclusion of probation officers and prison staff, and the availability of appropriate resources.

6 The Role of the Nurse in Palliative and End-of-Life Care in Prison The concepts of both palliative care and end-of-life care were introduced in chapter “Palliative and End of Life Care in Prison”; although these are distinct and separate concepts, these terms are often applied interchangeably. However, the provision of palliative care and end-of-life care occurs on a continuum rather than in isolation. This chapter also discussed advanced care plans (ACPs), advanced decisions to refuse treatment (ADRT), and Lasting Power of Attorney (LPA) for health and welfare. The process of early release on compassionate grounds, especially to support a prisoner who has reached the last few months of their life, rarely occurs due to the outcome of historical cases, which limits the options for prisoners for at the end of their life. The recommendations and conclusions for this chapter concentrate on ACPs in prison, compassionate release, service design of palliative care and end-of-­ life care, and the role of the nurse in palliative and end-of-life care in prison.

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ACPs in Prison  The facilitation of prisoners to develop an ACP needs to encompass the unique prison context, such as the inclusion of restrictive prison policies, which may not support prisoner’s preferences, or the ability to remain close to their family, or appoint a family member as their substitute decision-maker. Prisoners acknowledged a reluctance in developing an ACP as they believed fellow prisoners would take advantage of them if it became common knowledge and they did not trust prison officers. Healthcare professionals also identified the negative impact of low levels of health literacy, which impacted on prisoners’ willingness to engage in the development of an ACP. However, nurses within prisons are optimally placed to work within these identified barriers and support prisoners with a life-limiting condition to understand their illness and possible treatment options and begin to explore their wishes and what matters to them as they approach the end of their life. This process may or may not lead to the implementation of an ACP; however, this process will support prisoners to make an informed decision. Compassionate Release  In England and Wales, the application for early release on compassionate grounds, especially for prisoners who have reached the last few months of their life, is time consuming, and are these applications are frequently not completed prior to the death of the prisoner. This process is more complex for prisoners whose diagnosis is not cancer, such as heart failure, as these applications are time dependent due to prognostic uncertainty and unpredictable trajectories of non-­ cancer conditions (Burtonwood and Forbes 2019). The completion of different elements of the form, for example, by the GP or probation officer, may not receive immediate attention. The role of the nurse who has identified the need for compassionate release, and has agreement with the prisoner concerned, is to support the timely completion of the application. This may involve chasing colleagues, who might not view this work as a priority, or supporting colleagues who are unsure of the trajectory of the prisoner’s illness. Service Design  The provision of palliative care and end-of-life care in prisons is different across countries; in the United States, prison hospices have been implemented, whilst in Australia prisoners are transferred to tertiary hospitals. However, in England and Wales, the Dying Well in Custody Charter has been implemented and a model of in-reach end-of-life care and/or transfer to a hospice or community hospital. All prisoners receiving end-of-life care are placed on an end-of-life care register to support an overview and coordination of care. However, this approach has yet to be fully implemented, and concerns remain regarding the appropriateness of this model, an example is the inappropriate use of restraints of prisoners at the end of their life, including the approach of double handcuffs. The delay in early compassionate release already discussed was further highlighted during the COVID-19 pandemic, with 1000 prisoners identified as vulnerable and should be considered for temporary release; however, only 54 were safely released. Role of the Nurse in Palliative Care and End-of-Life Care in Prison  In the prison setting, primary care nurses will be supported by a MacMillan nurse specialist in the provision of palliative and end-of-life care. Primary care nurses will provide the

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majority of care to prisoners; the provision of continuous care supports the nurse to become an advocate for the patient and their wishes. The role of the primary care nurse is that of coordinator and liaison with other healthcare professionals and external agencies to support optimal end-of-life care for the prisoner. The MacMillan nurse specialist will also support the primary care nurse, who may have limited experience in providing end-of-life care, with training and implementation of processes to support prison staff to support a prisoner at the end of their life. Primary care nurses understand the prison regime and prison regulations and can identify the needs of prisoners and can develop interventions within these restrictions to provide the best possible end-of-life care for a prisoner. Conclusions  The role of the primary care nurse includes the provision of palliative and end-of-life care within the prison, with the support of a MacMillan nurse specialist. There is an increasing need for end-of-life care due to the ageing prison population, and the process to support prisoners at the end of life in prisons in England and Wales continues to evolve, although as highlighted within the recommendations above there are a number of elements that still need to be addressed. However, it is important to identify some prisoners with a life-limiting condition who have engaged with and implemented an ACP, which supported them to feel empowered of the end of their life. Primary care nurses are supporting prisoners with end-of-life care and further developing processes to ensure prisoners receive their preferred care when possible.

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