Nursing Sick Call Part 3: Use and Misuse of Protocols

Diagram of ideal careProtocols are used by nurses in sick call to evaluate patients’ health care complaints. Protocols describe the steps to be taken in collecting the subjective and objective findings, the factors that lead to a diagnostic conclusion and the resulting actions taken to address the problem. Nursing actions driven by protocol may include treatment that a person would do for themselves if they were living in the community, simple first aid, health education or advice about self-care, and/ or referral to a provider. Protocols also exist for nurses to use in responding to medical emergencies. These protocols are more extensive than those used in sick call. Protocols discussed in this post are limited to those used to address non-urgent health care complaints.

The use of protocols by nurses is not in lieu of provider based care but to facilitate patient access to needed health care. Patient care is enhanced when the protocols involve the patient in self-care and support collaboration between clinicians in the management of a patient’s health status. In the Oregon Department of Corrections, for example, 80% of patient concerns can be addressed during the sick call visit. Every nursing sick call visit should provide information about the patient that is considered useful in the next clinical encounter.

Requirements for the use of protocols: The National Commission on Correctional health Care (NCCHC) provides detailed guidance about the requirements for use of nursing protocols in standard E-11 (2014). The first requirement is that the protocols are developed by the nursing administrator and responsible physician. The physician is responsible for ensuring that the protocols guide clinically necessary medical care and the nurse administrator is responsible for ensuring that nurses are allowed by law to perform the scope of work described in the protocol and that nurses are trained and competent to use the protocols. A note here is that this collaboration should include a discussion of the underlying philosophy and approach to patient care to build understanding of what each profession can contribute to patient access. Protocols are not intended to make nurses into physicians and must be written to remain consistent with the scope of nursing practice while at the same time supporting the patient to access appropriate, timely and responsive health care.

A good place to start is to review the state nurse practice act to determine if there is any guidance regarding practice that is specific to the correctional setting or the use of protocols in any setting. Another important consideration is the differentiation in state law or regulation between the scope of practice for an RN and an LPN. In some states the nurse practice act may prohibit LPNs from performing sick call and in other states there may be limitations or additional supervisory requirements.

Another requirement of the standard is that the program must demonstrate that each nurse has been trained initially in the use of protocols, annually each nurse must demonstrate knowledge and competency in the use of protocol, and training is provided whenever the protocols are revised or new protocol introduced. In addition the protocols are to be reviewed and approved for use each year by the nurse administrator and responsible physician. The annual review and resulting revisions should be based upon the results of:

  • continuous quality improvement studies,
  • clinical performance reviews and competency evaluations,
  • adverse patient events or near misses, and
  • evidence- based practice recommendations from the literature.

Misuse of protocols: The most recent issue of CorrectCare has an article by Tracey Titus, a nurse and the NCCHC accreditation manager that discusses the misuse of nursing assessment protocols. She points out that the correctional environment sometimes lends itself to the misuse of nursing protocols. The following paragraphs are some of the ways that nursing protocols can become misused in correctional healthcare.

1. Protocols do not substitute for primary care encounters: Protocols sometimes go beyond the knowledge and skills of the nursing staff perhaps in the mistaken belief that nursing sick call takes place in order to reduce the workload of physicians, nurse practitioners and physician’s assistants. Nurses do not have the same diagnostic acumen and clinical skills as a primary care provider. Protocols are most appropriate to treat problems that in the community people take care of themselves and to determine the urgency of referrals for problems that need to be seen by a primary care provider. A best practice is to schedule a providers’ clinic at the same time as nursing sick call so that the nurse can confer regarding patients whose problem exceeds the scope of the protocols.

2. Protocols do not substitute for good security practices: At the other extreme sometimes sick call is used to control access to things that can be as effectively managed by good security practices. A couple examples are dispensing and supervising use of dental floss or determining if an inmate should be authorized to receive a second pair of long underwear. This is a waste of nursing time and burdens the efficiency of sick call and sick patients have to wait longer to have their needs addressed. Clinical errors are made when sick call is overcrowded and rushed increasing the risk of adverse patient care events.

3. Protocols cannot cover every problem: In my early experience we wrote protocols for many, many different conditions. A year later when the protocols were reviewed we discovered that the nurses really needed only a few. Furthermore the nurses had no way of remembering the details of so many different protocols. In our re-write we focused only on the most common complaints (e.g. pain, skin conditions, minor trauma and HEENT complaints) and have since only gradually added additional protocols based upon actual utilization data.

4. Unqualified personnel cannot use protocols: Many systems find themselves with legacy staffing patterns and assignments that require health care and other personnel to work outside their lawful scope. Because of a lack of clinical oversight state practice acts may not have been consulted when the assignments were originally made. Do not assume that because certain personnel have been performing sick call that the practice is allowable or has been grandfathered in. Most systems work through this situation by rearranging assignments to better match the qualifications of existing staff.

5. Untrained or incompetent personnel cannot use protocols: There are very few if any other nursing settings that use protocols to manage initial requests for health care attention. Therefore nurses do not bring to corrections experience in this area and must be trained. Some nurses even after initial training are not able to demonstrate sufficient competency. Placing a nurse who is not competent in sick call undermines the nurse’s potential for eventual success and puts patients in harm’s way. Instead an individual performance improvement plan must be developed and coaching, monitoring and supervision provided for a reasonable period of time.

6. Protocols are not standing orders: Standing orders are written orders that specify the same course of treatment for each patient with a certain condition. Historically standing orders have been overused in correctional health care as a way to treat inmates when physician time was inadequate. Protocols differ from standing orders in that the action taken by a nurse to address the patient’s complaint is individualized based upon an assessment of the condition. For example every patient’s headache should not be treated the same way nor should every diabetic be on the same sliding scale for insulin. Standing orders are appropriately used for preventive care, such as immunizations and for diagnostic preparation.

How well do the protocols work at your facility? Are there too many or not enough? What kind of training did you receive in order to conduct nursing sick call? If you could make a change in nursing sick call what would it be? Please provide your thoughts and experience in the comments section of this post.

For more on nursing sick call and access to care read Chapter 15 in the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.


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Nursing Sick Call Part 2: Pitfalls with the Face- to- Face Encounter

NSPS'10_Fig 4  Nursing Process  StdsLast week’s post on nursing sick call emphasized the importance of receiving and responding in a timely and clinically appropriate manner. Each request must be triaged within 24 hours of receipt. When the request describes a clinical symptom it must be assessed in a face- to- face encounter. Obviously if the symptom is of an emergent nature the assessment must take place immediately. Examples of requests that are potentially life threatening and should be assessed immediately include statements regarding suicide or hopelessness, cardiac or respiratory distress and trauma.

However most requests received via sick call are not of an emergent nature. Patients with non-urgent clinical symptoms need to be evaluated within 48 hours from time the request was received and this timeframe can extend to 72 hours on weekends. Non-urgent health care attention is requested most often for symptoms relating to pain, skin conditions and HEENT problems. Nurses should expect to be very familiar with the assessment, evaluation and treatment of multiple conditions that manifest in these symptoms. Correctional nursing expert, Jessica Lee, as well the National Commission on Correctional Health Care (NCCHC) recommend staff with the most skill and experience in assessment be responsible for sick call.

The face-to- face encounter involves the six components of nursing process defined in the American Nurses Association (ANA) standards for correctional nursing practice (2013). These inter-related components are depicted in the diagram at the top of this post as assessment, diagnosis, outcomes identification, planning, implementation and evaluation. For a description of how the nursing process is used during nursing sick call see Chapter 15 in the Essentials of Correctional Nursing.

What are the pitfalls for nurses in the face-to-face encounter? In thirty years’ experience as a correctional nurse, manager and consultant I have observed thousands of nurses in sick call encounters and reviewed their documentation. Some of these nurses were definitely experts, others were new to the process, and many were competently performing these skills. The following are the problems and pitfalls most often seen with the face-to-face nursing encounter.

Delays: Evaluations that take place long after the request has been submitted place the nurse in a difficult spot. The patient is frustrated because of the delay and may be disrespectful; the condition may have gotten worse and the patient already been seen in an emergency or the condition grown more complex and require a referral when it could have been treated by the nurse if seen earlier. Imagine how you would react if it took three days to receive one dose of aspirin or ibuprofen for a headache. When inmates experience failures in access the response is often to flood the system with requests and soon the nurses can’t keep up. Stay on top of requests so that there are no delays and the volume will be more manageable. There are no defensible reasons for delaying access to care; it is a constitutional requirement.

Incomplete assessment: Nursing assessment involves the collection of both subjective and objective information that is relevant to the patient’s reason for requesting health care attention. The subjective assessment includes asking sufficient questions about the problem to determine additional data to be gathered during the objective exam, diagnostic testing and chart review. Failing to physically examine the patient to adequately verify and amplify subjective information is a common error in nursing sick call. Examples are sick call encounters have incomplete vital signs recorded or dental complaints that do not include an examination of the oral cavity and neck but just a referral to the dental department. This may be because of inexperience, fear or concern about touching inmates or trivializing patient complaints. Nursing assessments should be conducted and documented so that the clinical information contributes to the next provider’s assessment whether it is a provider appointment or the next sick call visit.

Inadequate patient involvement: Involving the patient in each encounter is a sure way to reduce unnecessary requests for health care attention and submission of a grievance both of which take additional time to respond to. This is not to say that a nurse should give the patient what they want. Instead it means to ask for the patient’s input about the outcome they desire and then to provide an explanation of findings, recommended plan and the rationale that takes into account the patient’s input. Involving the patient demonstrates respect and helps build the therapeutic relationship; it also gives useful clues that can help motivate the patient in their own care. If the patient doesn’t understand then another explanation may be useful especially if the patient has low health literacy. The nurse may schedule the patient back for a follow up appointment to go over the information again or to check on the patient’s symptoms. If the patient doesn’t agree with the plan the nurse should reconsider their findings or make a referral for higher level care.

Poor clinical decision making: Making clinical decisions is a skill built by thoughtful reflection on practice while gaining experience. As experience increases diagnostic conclusions are drawn more quickly by patterns recognition rather than the more deliberate process of gathering and analyzing data. The downside to pattern recognition is that the nurse’s conclusions are prone to bias based upon personal experience and cultural socialization. Two common errors in diagnostic reasoning are premature closure (coming to a conclusion before sufficient data is gathered) and confirmation bias (only seeing data that matches our conclusion and ignoring data that doesn’t). See two previous posts about how to build and hone clinical decision making skills.

Inefficient use of resources: Time, space and equipment are the resources nurses use during sick call. Examples of inefficient use of resources include conducting the face-to-face encounter in an area where the nurse cannot properly examine the patient, using a blood pressure cuff that is the wrong size or not calibrated, having to go to another area to get supplies or equipment to complete the examination, not having the chart available or not referring to the chart for data on the patient’s recent health care. See a previous post about safe practices for nurse sick call. Nurses should be able to elicit the health history at the same time observe the patient and gather objective physical assessment data. Like playing the drums the face-to-face encounter takes practice. Nurses develop these skills when they are provided support, coaching and feedback. Face-to-face encounters which are incomplete or inadequate also waste provider resources if an unnecessary referral is made or the information about why the provider appointment is needed is incomplete.

What are the challenges you experience in completing timely, responsive and clinically appropriate face-to-face encounters with patients who have symptom based requests for health care attention? Please provide your thoughts and experience in the comments section of this post.

For more on nursing sick call and access to care read Chapter 15 in the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.


 American Nurses Association. (2013). Correctional nursing scope and standards of practice. Silver Spring, MD: American Nurses Association.

Knox, C & Shelton, S. (2006). Sick Call. In Clinical Practice in Correctional Medicine (2nd ed.). Philadelphia: Mosby Elsevier.

LaMarre, M. (2006). Chapter 28: Nursing role and practice in correctional facilities. In M. Puisis (Ed), Clinicsl Practice in Correctional Medicine (2nd ed.). Philadelphia: Mosby Elsevier.

National Commission on Correctional Health Care. (2008). Standards for Health Services in Prisons. Chicago: NCCHC.

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Nursing Sick Call Part 1: Receiving and Responding to Requests for Care

PRIGIONIERONursing sick call has been described as the signature practice defining the specialty of correctional nursing. There is no experience quite like sick call in any other area of nursing practice. Nursing sick call is considered the backbone of health care delivery in correctional settings because it is the primary way inmates can access health care during incarceration. In a recent interview Jessica Lee, Vice President for Nursing Support at Corizon commented that sick call is a barometer of the quality of the entire health care program in a correctional facility.

The manner in which inmates make requests for health care attention is the first step in the sick call cycle and the focus of this post. The ability to request health care attention is a fundamental right of persons who are incarcerated. The American Correctional Association (ACA) and the National Commission on Correctional Health Care (NCCHC) both have established standards which require that:

  • requests are received by health care personnel every day,
  • each request is evaluated within 24 hours of receipt and
  • there are no impediments to making requests for health care attention.

Seems pretty simple but compliance requires that correctional officers and nursing staff act in ways that are consistent with these standards in hundreds of encounters and interactions with inmates every day. So access to health care is a high volume, high risk activity in correctional health care. Correctional facilities can protect themselves from adverse patient events and litigation by developing policies, procedures, job descriptions and assignments that meet these standards. In addition it is important to verify that actual practices are consistent with the facilities policies and procedures through supervision and audit of staff performance. The following is a breakdown of the areas that need to be considered to ensure that your facility meets accepted standards for access to care.

Communication: The facility should have one or more ways established for inmates to make requests for health care attention. Inmates must be informed of this process at the time of admission to the facility. Common methods used to request health care attention are by filling out a request slip that is given to a health care provider, signing up on a list, showing up at a particular time, or calling to request an appointment. The next consideration is whether the selected methods are working. Pitfalls to an effective request process include not giving inmates this information at admission, inmates not understanding the process, not having a secure place to put written requests, not picking up written requests every day, forms that are too complicated to fill out, not having sufficient forms, not having access to the sign up list or use of the telephone, lock down or scheduling conflicts, and intimidation of inmates requesting care by other inmates or staff. Nurses should be assigned daily to review and assure that the method(s) used to request care are working. There should be documentation that provides evidence that requests for access to care may be made daily and that there are no impediments. Having the date on each request received, each list of inmate requests, or each walk-in encounter is the kind of documentation that provides this evidence.

Triage: Every request for health care attention must be evaluated within 24 hours of receipt. This evaluation is a form of triage used to determine when and how each request will be handled. Triage is a clinical decision made by licensed health care personnel. Triage requires use of the nursing process to assess the patient, diagnosis the problem, identify the desired outcome, plan and implement intervention(s) to achieve the identified patient outcomes. Simply reading a written sick call slip is not sufficient triage of a request that involves any description of a symptom based complaint. Any inmate submitting a written request for health care attention for a complaint that is symptom based must be evaluated in a face to face encounter within 24 hours of receipt of their request. With other methods for making requests (sign- up, telephone or walk- in) as long as nursing personnel evaluate each request within 24 hours the standards are met. Documentation includes the nurse’s evaluation as well as the date and time the patient was seen. Problems with nursing triage of inmate requests for health care attention include not performing triage seven days a week, not triaging every request received on a daily basis, using inappropriate personnel to perform triage, clinically inadequate triage, trying to talk patients out of needing to be seen, minimizing patient complaints or blaming the patient.

Disposition: The outcome of triage is the disposition or decisions made in response to the patient’s request. Dispositions include treatment, referral, patient education, and advice about self- care. Many times a single request will have more than one disposition decision. In addition to the decision about what is to be done the nurse also decides who will do it and by when. Each of these decisions, including by whom and when, are documented and dated. The nurse should explain the disposition to the patient so that they know what to expect and by when. Every nursing encounter should be considered an opportunity to education that promotes the patient’s engagement in their health care. Pitfalls in the disposition of requests for health care attention include poor clinical decisions, inadequate follow through or handoffs to responsible others, silos between programs and departments that result in disruption of care, and lack of patient understanding or agreement with the plan of care.

Monitoring: When requests for health acre attention are not received and acted upon in a timely, responsive and clinically appropriate manner the efficient operation of the health care program will be in serious jeopardy. Effects of insufficient access are increases in the number of inmate grievances, increases in requests for emergent health care attention and inmates will submit multiple requests for the same problem. Health care programs should track the timeliness, completeness and appropriateness of communication, triage and disposition of health care requests. Other aspects of access to care that should be monitored are the types of requests being made as well as the subject and frequency of multiple requests. This data helps to answer two questions: Is the system to access care working and are the responses clinically appropriate, responsive and timely?

Do the practices in place at your facility meet the standards for access to health care? How does the facility monitor access to health care? What is your role in ensuring that inmates have unimpeded access to health care during incarceration?

For more on nursing sick call and access to care read Chapter 15 in the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.


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Caring for Women in Prison: Eating Disorders

schienaIncarcerated women have increased chances for eating disorders and they can be deadly. The in-custody death of a young anorexic woman several years ago points out the potentially fatal nature of these conditions when extreme. This case was complicated by communication issues and recent changes in facility processes, but it exemplifies the concern correctional nurses should have for screening and initiating treatment for eating disorders when working with women inmates.

Are eating disorders common among female inmates?

Eating disorders such as anorexia nervosa (AN) and bulimia nervosa (BN) are more common among young white women who are unhappy with their body size and shape. Added contributing factors include feelings of powerlessness and lack of control over life situations – common emotions during incarceration. Although the reported prevalence of eating disorders in the general population is less than 1%, one study found as many at 25% of female inmates in a British prison at risk for eating disorders. With the potential of one in four female inmates at risk for AN or BN, it is important to screen for this condition.

What should be done to identify patients with this disorder?

Be alert for eating disorders among the young females entering your facility. Loose-fitting garments may hide wasted torsos and boney appendages. Take a good look at muscle tone and skin thickness when performing a physical assessment. Bulimic women will usually maintain a low normal body weight but those with anorexia could show significant wasting.
In addition, consider adding a simple screening tool to subjectively evaluate for an eating disorder. The SCOFF Eating Disorder Questionnaire is widely advocated as an effective and rapid evaluation method. One point is assigned for every “yes”; a score greater than two (≥2) indicates a possible case of anorexia nervosa or bulimia nervosa.

SCOFF Questionnaire

S  - Do you make yourself SICK (vomit) because you feel uncomfortably full?

C  - Do you worry that you have lost CONTROL over how much you eat?

O  - Have you recently lost more than ONE stone (15 pounds) in a 3-month period?

F  - Do you believe yourself to be FAT when others say you are thin?

F  - Would you say that FOOD dominates your life?

What treatments are available of eating disorders?

If an eating disorder is suspected, a referral for mental health services is needed, in addition to a medical work-up. Women with eating disorders, especially AN, are at higher risk for suicide, osteoporosis, and electrolyte imbalances. Severe AN can cause dangerous electrolyte imbalances leading to cardiac arrhythmia. The in-custody death of the young female inmate in the story above may have been prevented with potassium supplementation.

How do you assess for and manage eating disorders in your setting? Share your thoughts in the comments section of this post.

To read more about the unique aspects of women’s health care in the correctional setting see Chapter 9 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1402 the price is discounted by $15 off and shipping is free.

This post originally appears in CorrectionalNurse.Net

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Caring for Women in Prison: Postpartum Depression

Mother in tears with baby childAs discussed in an earlier post, an estimated 6-10% of incarcerated women are pregnant at any time in the criminal justice system. Therefore, many of these women will give birth while behind bars and must deal with the physiologic and psychological adjustments of the postpartum period in an alien environment with little social support.

Reasons for Concern

Women who give birth behind bars are highly susceptible to postpartum depression. A review of literature on the subject found factors associated with this condition include past histories of anxiety disorders or depression, recent life stresses and poor social support. All these conditions are highly present in the female inmate population. Depression can be exacerbated by separation from the infant soon after birth. Although some progressive settings, such as this New York prison, are allowing babies to stay with mothers, most require that the child be placed with another family member, the foster care system, or given up for adoption.

Keep an Eye on Them

Correctional nurses should assess for postpartum depression in women who have recently delivered. The most common emergence of postpartum depression is in the first 4 weeks after delivery but depression can develop even a year later. Monitor for these indications of developing depression during the postpartum period:

  • Sadness and tearfulness
  • Exhaustion not relieved by sleep
  • Despair
  • Compulsive thoughts
  • Sleep difficulties
  • Loss of appetite

Use an Objective Screening Tool

The 10-question Edinburgh Postnatal Depression Scale is used in outpatient and home care settings to objectively screen for potential postpartum depression. It could easily be incorporated into a correctional setting with self-administration possible for those patients with good reading skills. Another option is for the nurse to ask the questions.

Treatment for Postpartum Depression

Although treatment options may be limited, postpartum depression must be addressed to avoid poor outcomes such as self-harm. A mental health consult is the first action to take. Management of postpartum depression is similar to any major depression and can include psychological support, cognitive therapy, and antidepressant or antianxiety medication.

How do you manage women after childbirth in your setting? Share your thoughts in the comments section of this post.

To read more about the unique aspects of women’s health care in the correctional setting see Chapter 9 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1402 the price is discounted by $15 off and shipping is free.

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Caring for Women in Prison: Psychogenic Seizures

Brain StormCalled to a housing unit on a man-down emergency, a nurse finds a female inmate on the floor flailing about, arching her back, crying, and shaking her head side-to-side. She does not lose consciousness but is holding her eyes tightly shut. The housing officer says she is just throwing a tantrum and faking a seizure. What other diagnoses should be considered?

Seizure disorders are common in the inmate patient population.  In fact, incarcerated patients are four times more likely to have a seizure disorder than the general  population. Reasons for increase seizure activity in our patient population include frequent histories of head trauma, physical abuse, and drug or alcohol involvement. There are many causes of seizures, with the most common, epileptic seizures, being the result of spontaneous and uncontrolled electrical discharge of neurons in the brain that interrupts normal body functions.

However, what the nurse is witnessing in the case above does not appear to be an epileptic seizure as the patient seems to be in control of her actions – shaking her head and holding her eyes tightly shut. Maybe the housing officer is correct and this inmate is merely pretending to be seizing to gain attention?

Another possible diagnosis in this presentation could be Psychogenic Nonepileptic Seizure (PNS) activity; a psychiatric rather than physiologic condition. PNS results most often from severe childhood trauma and manifests during a psychologically stressful situation. Individuals with PNS are not ‘faking it’ and are not in control of when and how a seizure takes place. Instead, the seizure activity is a coping mechanism to an intense emotional event.

Three times more women are diagnosed with PNS than men.  Although the exact reason is still unknown, it is suggested that these seizures are an expression of rage, fear, and helplessness that manifests most frequently in women who have histories of abuse. More than half of patients with PNS also have concurrent psychiatric illness such as post-traumatic stress disorder, anxiety disorders, depression, or dissociation disorders.

In the case presentation above, the person needs to be treated with compassion. Observations should be carefully documented and medical treatment sought. In particular, the nurse should document the nature, timing, and context of seizure activity. Psychogenic seizures are diagnosed by their presentation and EEG-video monitoring. Once diagnosed, PNS is treated based on the underlying condition and mainly through psychiatric services. Patients may benefit from supportive psychotherapy and lifestyle changes to reduce the effect of situational stressors. Underlying anxiety or depressive disorders may respond to drug treatment. Some patients are helped through behavior modification therapy.

You can learn more about psychogenic seizures in the female inmate population by listening to this podcast interview with Gregory Famiglio, MD.

What are your experiences with inmate seizure activity? Share your thoughts in the comments section of this post.

To read more about the unique aspects of women’s health care in the correctional setting see Chapter 9 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1402 the price is discounted by $15 and shipping is free.

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Caring for Women in Prison: Mental Illness and Self-Harm

The mindThe disturbing story of 19 year old Ashley Smith’s witnessed suicide in a Canadian prison highlights the complex issue of mental illness and self-harming behaviors among incarcerated women. Ashley Smith attempted self-harm over 150 times during a three year period as outlined in this report of her treatment and in-custody death. She was a very troubled young women, as so many of our patients are.

Women in the criminal justice system have higher rates of serious mental illness than male counterparts; including higher rates of depression, bipolar disorders, antisocial personality disorder, and post-traumatic stress disorder. This can be attributed to many factors including histories of childhood abuse, adult victimization, substance abuse, and traumatization.

Social problems add to emotional stress; intensifying mental and behavioral disorders. Financial hardship, parental stress, and inadequate relational support make dealing with mental illness more difficult. Higher rates of chronic illness among female inmates compound the burden of mental illness.

Deliberate Self-Harm

Some women turn their distress inward and engage in deliberate self-harm (DSH) also called self-injurious behavior (SIH). In fact, as many as 30-50% of incarcerated women may harm themselves intentionally; most often by cutting or scratching with an object. This behavior can be perplexing and frustrating for healthcare and custody staff, alike. Conflicting interpretations cloud objectivity. Healthcare staff are more likely to see self-injury as a condition in need of treatment while custody staff are more likely to see it as a behavior issue requiring control.  Although Ashley Smith received anger management interventions and participated in group activities early in her incarceration, increasingly frustrated custody staff resorted to isolation, restraint, and pepper spray to compel her to comply with security requirements.

Mental health professionals, however, see self-harm as a coping mechanism brought on by distress, like the stress of incarceration. Therefore, a therapeutic response involving a non-judgmental attitude and interventions to decrease injury events is advocated over punitive measures. Phased-in behavior management plans, for example, have been effective for self-injury reduction. In this program, individualized incentives are developed and awarded when self-injury is avoided for periods of time. Patients move into advanced phases of the program with positive behavior change or back into earlier, more restrictive, phases if self-injury returns.


Deliberate self-harm when used as a coping mechanism rarely moves to suicide. Ashley Smith, however, began attempting suicide soon after she was transferred to an adult facility at age 18. Women inmates attempt suicide more frequently than men; although men have more completed suicides. Frequent, unsuccessful suicide attempts are viewed by staff as attention-seeking behavior and can soon be disregarded. It appears that Ashley Smith was allowed to kill herself while being watched by security officers. By that time she had been transferred 17 times through 9 different institutions. She entered the system as a youth on a 30 day sentence and accrued additional time for various charges resulting in a total of 2,239 days cumulative sentence.

As noted in the ombudsman report, there is no record of a psychiatric evaluation once Ms. Smith was transferred to the adult facilities; even after beginning a string of suicide attempts. Could a concerted program of therapy and behavioral management have avoided this fatal outcome? It is hoped that something positive will come from the death of Ashley Smith. The inquest jury has made 104 recommendations for improvements in mental health care and inmate treatment. The case highlights the challenges of working with mentally ill female offenders and the need for a coordinated program of care.

What has been your experience working with incarcerated women with mental illness? Share your thoughts in the comments section.

To read more about the unique aspects of women’s health care in the correctional setting see Chapter 9 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1402 the price is discounted by $15 and shipping is free.

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