Introduction

The nurses responsible for care and health in prisons have always played a secondary role. The position of Registered Prison Nurse, regulated by article 4.2 of Law 39/70, of 22 December, on the restructuring of prison professions was created in Spain in 1970¹.

Some years later, article 324 of the Royal Decree of 1981² was the first law to give greater definition to the duties of Registered Prison Nurses. Nurses continued to apply general skills to their profession under the orders of the physician.

However, a turning point for prison nursing came in 1989, when Royal Decree 148/1989 of 10 February³ established the General Sub-Directorate of Prison Health, in which prison nurses were defined as professionals.

In 2011, the official title of Prison Nurse was finally established in article 2.2 of Royal Decree-law 20/2011 on the restructuring of the prison professions⁴.

In 2019, the General Committee of the Spanish Nursing⁵ defined nurse in the field of prison healthcare as the following: “A professional working in advanced practice, with skills acquired from their training and experience, working under the parameters of bioethical practices and scientific evidence, to plan, intervene and evaluate nursing care in order to promote, maintain and improve the health of prison inmates, and to prevent the diseases and disabilities of same, with the use of nursing skills developed and regulated within the scope of prison healthcare”⁵.

Prison healthcare management in Spain is currently under the remit of the General Sub-directorate of Prison Health, governed by the General Directorate of Criminal Procedure and Social Rehabilitation as part of the General Secretariat of Prisons⁶.

In the search for a definition of prison nursing, the General Prisons Act and Law 16/2003, of 28 May, on the Cohesion and Quality of the National Health System provide helpful guidelines⁷. Both laws concur that prison healthcare should operate under the same conditions and standards of quality as those applied in public health services.

The current duties of prison nurses are regulated by the Prison Regulations of 1996 and some articles that were not revoked in 1981, such as art. 324, which establishes nursing roles⁸.

As regards specific training for nursing, according to the Spanish National Agency of Evaluation of the Quality and Accreditation (ANECA), a nursing degree responds to a healthcare personnel profile for a person responsible for the general care of people and the community⁹.

According to a number of studies on prison nurses, the difficulties they face are linked to professional development, such as: low job satisfaction, lack of training and specific skills, etc. These limitations stop nurses from providing inmates with high quality care, which leads to conflicts with the ethical principles that are an integral part of the nursing profession¹⁰.

In such a context and to better understand this ethical conflict, the concept of moral distress needs to be considered. In the medical setting, this consists of an emotional and psychological sensation that may appear when a nurse is aware of what they have to do according to what is morally appropriate, but cannot do so because of institutional and legal obstacles and limits, such as limited autonomy in a number of settings or a lack of managerial support^11,12.

In view of the above, the general objective established for this study was as follows: to review the scientific literature on the role of nurses in prisons.

The proposed specific objectives were: to determine the importance of healthcare training for nurses in prisons and explore the ethical implications for nursing of healthcare in prison settings.

In view of the introduction and the current situation in Spain, where the nurse-patient ratio is 9.09 nurses per 1,000 inmates, with 600 nurses distributed in 73 prisons throughout the country¹³, this study sets out to shed more light on the little known role played by nurses in prisons, and the implications of their situation for providing care to the prison population.

Material and Method

The following PICO (population-intervention-comparison-outcome) question was posed for the search strategy¹⁴: “Do prison nurses receive adequate training in care and ethical implications to enable them to offer good quality healthcare?”.

For this integrative review, we carried out a search of the scientific literature in the following databases: Medline, SciELO and LILACS.

Selection of the key words: nursing education, nursing, ethics and prisons, was made possible thanks to the use of the controlled language in DeCS and MeSH, thus obtaining the results shown un Table 1.

The MeSH and DeCS terms were united with the Boolean operators AND and OR: nurse's role OR nursing AND prison; nursing education AND ethics OR ethical issues; prison AND nurse; job satisfaction AND nursing AND prison; enfermería AND penitenciaria; health professionals in controlled language AND prison; nursing care AND prison. Different filters belonging to the databases were also used to specify and reduce the results, as shown in Table 2.

The inclusion criteria were: articles published in the last five years, free access to the complete text, studies carried out on humans, publications in Spanish, English and Portuguese, and articles related to the role of nursing, the training received by this group and prison nurses' ethical issues when providing care to inmates.

The exclusion criteria consisted of the following: articles that focus on the care that prison nurses give to the prison population and articles duplicated in different databases.

To evaluate the methodological quality, the CASPe critical appraisal tool was used, based on the type of studies that were collected in this study. The templates for qualitative studies¹⁵, cross-sectional studies¹⁶ and reviews¹⁷. were used to establish the types of studies contained in this article. Each item was appraised by the CASPe guide as follows: 1 point for those that complied with the criterion; 0.5 points for those studies that partially complied and 0 points for those that did not. The following categorisation was used for listing the studies as high, medium and low quality: the articles with a score below quartile 1 were classified as low quality and were rejected; the articles between quartiles 1 and 3 were classified as medium quality and those with a score above quartile 3 were defined as high quality¹⁸. After applying the inclusion and exclusion criteria to the 18 articles that were selected, 16.67% (n = 3) were rejected by applying the above mentioned classification method.

Results

The total number of articles obtained after the bibliographical search was 264. The filters of each database were used to eliminate 157 articles (n = 107).

The duplicated articles found in the searches were then removed (n = 98), and the titles and abstracts were read in order to select the articles that matched the subject of the integrative review, which left a total of 24 studies.

18 publications remained after applying the inclusion and exclusion criteria. Finally, the CASPe tool was used to apply a critical appraisal, giving a final result of 15 articles, after eliminating the ones that received a low quality evaluation, as shown in Figure 1.

Figure 1.  Flowchart of selection articles. 

The 15 articles selected for the integrative review consisted of the following types: 40% (n = 6) were reviews of the literature, 33.33% (n = 5) were qualitative studies, while 20% (n = 3) were quantitative ones. Finally, 6.67% (n = 1) were mixed method studies (Figure 2).

Figure 2.  Classification of articles according to type of study. 

Table 3 shows the characteristics of each article in terms of the type of study, the year and country of publication, and their relevance to the objectives of the study and the conclusions.

Discussion

Firstly, when considering the importance of the role played by nursing in the prison setting, the study by Barbosa et al.¹⁹ showed that prison nursing plays a decisive and comprehensive role that matches the care provided in other healthcare sectors, while the authors of the study by Santana et al.²⁰ consider that nurses working in these settings should have a more humanised role than in other medical sectors, since they have to provide quality care without letting themselves be guided by any prejudices.

In line with Santana et al.²⁰, Dhaliwal et al.²¹ mentioned a series of recommendations to improve nursing work in the prison setting. These include: the need to know more about the work of prison nurses, create committees that operate between prison management and the medical team, and create support groups to deal with the challenges faced by prison nurses in the workplace.

On the other hand, Carrasco-Baún²² focuses on the major difference that exists between the role fulfilled by nursing in caring for inmates and the legislation that regulates the provision of healthcare in prisons, given that the law is now obsolete and far removed from the current realities of prison nursing. The author of the study considers that a series of guidelines is needed, including guarantees of equality in caring for the prison population and in the obligations of the prison nurse, to ensure that nurses can provide inmates with quality healthcare.

Likewise, the importance of the role of nursing in prisons also depends on how the prisons themselves are managed, as in the study by Newman et al.²³, which shows the need to study the level of satisfaction amongst nursing managers in the prison setting, so as to improve how such institutions are organised, and to ensure that they have the skills and abilities necessary to carry our their work in prisons.

Finally, Barbosa et al.²⁴ and Carnevale et al.²⁵ comment on the need to improve the organisational aspects of the prison system, in order to adequately develop the functions of nurses when dealing with the most common problems in the prison population, such as drug addiction and communicable diseases. Furthermore, both authors agree with Newman et al.²³ on the fact that it is essential to bring about improvements in the organisation and policies of prison institutions to enable prison nurses to progress towards a better standard of healthcare.

As regards the training of prison nurses, an interesting point on which most of the studies appear to agree is the need for specialization in this type of setting. Studies such as the one by Sánchez-Roig et al.²⁶ show the complex nature of the care that inmates need for communicable diseases, drug abuse and for mental disorders, alongside other health problems, making it necessary for nurses to receive specialised training in prison healthcare. Likewise, Lazzari et al.²⁷ and Carnevale et al.²⁵ came to the conclusion that specialised, up to date and ongoing training for nurses is necessary to work in prisons, to ensure that the inmate population receives good quality care.

Barbosa et al.¹⁹ and Brito et al.²⁸ also state that it is essential to reinforce nurses' skills and abilities to enable them to adequately care for prisoners, through continuous training adapted to the prison setting, just like any other area of medical practice. Choudhry et al.²⁹ came to the same conclusion and stated that a more accurate notion of the professional identity of prison nursing is necessary to enable better understanding of the skills required in such an institution and to be better able to apply improvements to their training, to make it continuous and specific, and so ensure that it is appropriate to needs in prison settings.

Barbosa et al.¹⁹ and Brito et al.²⁸ differ with Sánchez-Roig et al.²⁶ in stating that professionals showed adequate skills in caring for inmates and adapting to the prison environment, the reason being that the nursing staff considered the inmates to be like any other patient, with their own health problems, and were not felt to be a unique population.

Brito et al.²⁸ and Santana et al.²⁰ came to similar conclusions in that the lack of specific training for nurses in the prison setting is partly due to the shortage of work experience in such environments, the physical and psychological insecurity of work carried out there, the difficulties faced by healthcare personnel and the social stigma felt towards the prison population.

The ethical implications of prison nursing that prison nurses face in their day to day activities were also considered. Dhaliwal et al.²¹ discussed the difficulties that nurses face when providing care to inmates, such as ethical conflicts and the effort involved in not letting prejudices guide their work with inmates, and the need to provide safety and protection to nurses.

In line with the previous study, Karaaslan et al.³⁰ and González-Gálvez et al.³¹ comment on the need to investigate the working and ethical problems faced by prison nurses, such as those mentioned by Dhaliwal et al.²¹, and the need to improve the quality of healthcare and nurses' safety in the prison setting and so increase job satisfaction in this type of environment. Likewise, González-Gálvez et al.³¹ and Santana et al.²⁰ not only highlight the importance of ethical problems faced by nurses, but also the need to know more about the health needs of the prison population in order to provide prisoners with more humanised healthcare based on health issues, without allowing prejudices to intervene.

Sasso et al.³² focus on ethical education, with examples of nurses' opinions on the issue. The study comments on the need for specific ethical training to help nurses to resolve moral conflicts, such as being unable to provide healthcare to prisoners because of prejudices and the tendency to judge inmates for being in prison as a result of the crimes that they have committed.

Likewise, Barbosa et al.²⁴ also suggest that the safety of medical personnel is a priority, as is maintaining ethical conduct and the principles that govern the nursing profession, such as the duty to care for inmates.

By way of contrast, Menezes et al.³³ shows that the levels of job satisfaction amongst prison nurses are higher in the psychological and behavioural areas than in the environmental and organisational ones. Their conclusion is that the problems do not come from nurses' ethics, but rather from the management of the prison system itself.

Finally, the conclusions drawn by Lazzari et al.²⁷ match those of the previous study in highlighting the moral distress of nurses in the prison setting caused by the problems of staff in their work as a result of ethical issues, and the fragility of the prison system in managing medical responsibilities in prisons.

Conclusions

The analysis of the literature in this study shows that the role of the nurse in prisons is similar to that in other healthcare settings in terms of overall responsibilities. What comes to light is the need to determine the role played by nursing staff in this context in order to increase the quality of care that they provide and their own job satisfaction.

This will not be possible without updating current legislation on this sector, and this once again underlines the need for laws that regulate aspects of the nursing profession in prisons, given that current laws are obsolete and far removed from the realities of healthcare.

Secondly, the importance of specific healthcare training for prison nurses should be highlighted. The current Spanish nursing diploma only covers the training of nurses in general skills. This means that recently graduated nurses lack the skills and abilities to work in the prison setting, as a result of poor training and a lack of familiarity with such specific working environments.

Finally, one aspect of the ethical implications for nurses working in prisons merits special attention: the difficulties that they face in offering adequate care to inmates. In such cases, ethical conflicts and prejudices can arise in the care that they provide. It is therefore necessary to highlight the need to further investigate this type of ethical issue so as to increase the quality of care and the job satisfaction of nurses, evaluating the skills required to resolve moral conflicts and the need for psychological support in this group. The efficiency of prison management also needs to be determined so as to improve and bring about an adequate working environment.