Caring for Women in Prison: Health Education and Parenting Skill

Adorable small scottish kitten in wicker basket

A Bureau of Justice Report indicates that the majority of female prison inmates have minor children (62% of state and 56% of federal). More than half of these women were the primary financial support for their children.  While incarcerated, mothers depend on others to care for their children – the majority are cared for by grandparents (42%) followed by fathers (37%) and other relatives (23%). The remaining 19% are in foster care or with a friend.  This can be an additional life stress while in custody.

Health teaching and promotion is a major part of correctional nursing practice. According to the Correctional Nursing Scope and Standards of Practice, health teaching and health promotion include:

  •  Proving health teaching that addresses health lifestyles and risk reducing behaviors, developmental needs and preventive self-care
  • Using the teaching methods that are appropriate to the situation
  • Providing educational material in a variety of formats

Correctional nurses can assist mothers to better care for their children through health education and parenting skills training while they are separated. This can be a motivational time for mothers. Health education can focus on family health that will benefit both the patient and her children after re-entry into the community. Here are a few ideas for healthy living and parenting topics from the CDC:

  •  Basic first aid and safety
  • Child development
  • Check-ups and vaccinations
  • Healthy eating
  • Regular exercise

Information can be provided in a variety of methods including simple handouts, posters, individual teaching or group sessions. Family health teaching can be incorporated into the regular operations of a health unit. Five minute informational sessions can take place during other scheduled visits such as sick call or chronic care clinic.

Teach back/Show back is one method for increasing retention in patient education situations. This process evaluates comprehension by asking the patient to explain the material presented or demonstrate back the new skill. The nurse can then clarify and tailor further explanation to the remaining needs of the patient.

Parenting skills need not be limited to women’s services. Some male prisons have started healthy parenting programs in efforts to improve dysfunctional family situations among the offender population. One popular program is Parenting Inside Out. This program is available in some state and federal prisons.

Does your correctional setting provide parenting skills or family health education? Share your experiences 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 AF1209 the price is discounted by $15 and shipping is free.

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Caring for Women in Prison: Menopause and Osteoporosis

Old Lady's hands open - My mother at 90 years old

Hazel is a diminutive 56 year old state prisoner serving a life sentence for murder. She has been incarcerated for 18 years now and recently fell on the icy path while heading from her housing unit to breakfast early one morning. She sustained Colles fractures of both wrists. While being treated for the fractures she was also diagnosed with advanced osteoporosis.

Not all women in prison are dealing with pregnancy and reproductive health issues. The aging of the inmate population means that an increasing number of female inmates need assistance with menopause symptoms and protection from osteoporosis. Managing these conditions in the criminal justice system may require creativity and a bit of patient advocacy. Here are some key concerns with possible nursing interventions:

  • Nutrition: Hazel has been eating prison food for more than a decade. Unfortunately, most prison are challenged to provide a calcium-rich diet. Hazel needs counselling on the best options in both the cafeteria and commissary menus to increase her vitamin D and calcium intake. Supplementation may be necessary.
  • Exercise: Weight bearing exercise may not be convenient or even available. Hazel appears to be walking to various inmate activities; and that is a good start. She could benefit from support in developing an exercise program based on the prison gym and yard schedule. An in-cell exercise routine can also be established and encouraged.
  • Dry, Fragile Skin: Lack of estrogen dries out skin and eyes which can lead to discomfort, breakdown, and infection. Saline eye drops and therapeutic lotions may be needed and possibly provided through the healthcare unit or placed on the commissary list.
  • Body Temperature Fluctuations: Many prisons are not well ventilated in summer or heated in winter. Menopausal women may need layers of clothing for increased comfort.
  • Lack of Sleep: Sleep is a difficult commodity in many prisons and menopausal women with insomnia or hot flashes may have even more trouble obtaining rest. Correctional nurses can help patients establish good sleep hygiene habits and possibly provide natural sleeping aids such as melatonin through the commissary.

Do you have menopausal or osteoporotic inmates at your facility? How are you helping them to manage their condition while incarcerated? Share your tips 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 AF1209 the price is discounted by $15 and shipping is free.

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Caring for Women in Prison: Reproductive Health

HomelessTwenty-five year old Joanie found out she was pregnant during routine screening on intake to the city jail. She had been picked up during a street sweep over the New Year’s holiday. A series of poor decisions and an addiction to cocaine that she couldn’t shake had landed her on the street, sleeping rough, and getting by sleeping at the local shelter, doing odd jobs, and some occasional prostitution. She hadn’t noticed any pregnancy symptoms but was starting to feel anxious and irritable since she had been drug-free while detained.

Joanie is not unlike many women in jails and prisons. She is young, sexually active, and not paying much attention to her reproductive health. Like Joanie, many women in prison have not had regular healthcare, are poorly nourished and are substance involved. The jail she entered is following the American College of Obstetricians and Gynecologists (ACOG) guidelines for care of incarcerated women in screening all females for pregnancy at intake. This practice assures adequate attention to prenatal care and accommodation of pregnancy in medical treatment decisions while detained.

Like most women entering the criminal justice system, Joanie is of childbearing age. She is in the early stages of an unplanned pregnancy and has not been regularly practicing any contraceptive method. Incarceration is an opportunity to increase her knowledge of contraception options and organize her future choices. One study in a northeastern US jail/prison system found that female inmates were more likely to initiate birth control methods if information and medication was started before release. This is an interesting finding and indicates that correctional nurses should establish practices of educated about contraception while women are incarcerated. Unfortunately, this is not a widespread practice. For example, when I interviewed Piper Kerman about her experiences with correctional healthcare during her federal prison experience chronicled in the popular book turned Netflix series “Orange is the New Black”, she said she was surprised that contraception was not discussed with her in preparation for release and she had to ask about it herself.

Joanie is also going to need counseling about her options for her newly discovered pregnancy. She has a lot to think about. If she chooses to keep the baby she is likely to have a high risk pregnancy. As discussed in a prior post, poor nutrition, lack of prior healthcare, and drug and alcohol abuse put many incarcerated women at risk for complications during pregnancy; as can the high prevalence of sexually transmitted infection. If she wants to terminate this pregnancy she may face roadblocks while incarcerated as many facilities do not easily accommodate this procedure.

Correctional nurses have an opportunity to improve the health of young women by attending to reproductive health needs while they are incarcerated.

What reproductive health services would Joanie have if she was entering your facility? 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 AF1209 the price is discounted by $15 and shipping is free.

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Caring for Women in Prison: Pregnancy Management

Babybauch

With almost 80% of female inmates of child-bearing age, it is not surprising that an estimated  6-10% of incarcerated women are pregnant at any time in the criminal justice system. Correctional nurses who care for women need to know how to assess and manage pregnancy, labor, and precipitous delivery. This can be challenging in a secure environment not arranged to accommodate pregnancy and childbirth.

Risky Business

Poor prenatal care combined with poor nutrition, drug and alcohol abuse, smoking, and sexually transmitted infections contribute to the high risk nature of pregnancy while incarcerated. It is important to identify all pregnant women at intake screening in order to register them in the prenatal monitoring program and to determine housing needs. Routine perinatal visits should be arranged either with an outside obstetrical service or in-house with appropriately credentialed providers:

  • Every month to 28 weeks
  • Biweekly during 28-30 weeks
  • After 30 weeks: weekly until delivery

Substance Withdrawal

Drug charges are a primary reason for the incarceration of women and many pregnant inmates will also be abusing drugs and alcohol. Withdrawal from these substances can be difficult when considering the effect on both the mother and unborn child. Opioids like heroin, hydromoorphone and oxycodone are of greatest concern as detoxification can risk increases in miscarriage and premature labor. In all cases, withdrawal during pregnancy should be handled carefully with management by an obstetrical specialist.

Perinatal loss

Already often suffering from post-traumatic stress from past childhood and domestic trauma, incarcerated women are highly susceptible to intensified grief following pregnancy loss, whether intentional or unintentional. Therefore, correctional nurses need to be sensitive to the emotional needs of women experiencing perinatal loss and intervene with additional counseling or mental health services when appropriate.

Interventions for All

The American College of Obstetrics and Gynecology (ACOG) published excellent recommendations for the care of pregnant and post-partum incarcerated women. The committee report recommends that the following services are provided in correctional facilities housing pregnant women:

  • Pregnancy counseling and abortion services
  • If opiate-using, opioid-assistance therapy with methadone or buprenorphine while pregnant
  • HIV testing
  • Postpartum depression screening
  • Dietary supplementation
  • Postpartum contraception

Labor Disputes

Active labor can be difficult to determine in this patient population. Contractions that are strong and last from 45-60 seconds at a frequency of 3-5 minutes indicate the active labor stage. This is the time most women are admitted to the hospital. However, high risk pregnancies or women with histories of difficult or precipitous labors need to be closely monitored earlier. The high risk nature of the majority of pregnant inmates requires a high level of suspicion that labor may be progressing even if the woman is not in the final weeks of pregnancy.

Unshackled

Of particular concern is the shackling of laboring inmates. ACOG and advocacy groups such as the ACLU decry the practice of shackling laboring inmates. ACOG presents a compelling case for the detrimental health effects of this practice including increased risk of venous thrombosis and interference with the management of labor and delivery emergencies.

How do you manage pregnancy 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 AF1209 the price is discounted by $15 off and shipping is free.

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Caring for Women in Prison: Sexually Transmitted Infections

Sexually transmitted disease concept.Sexually transmitted infections (STI) are higher among the incarcerated population than the general public and female inmates have higher rates of chlamydia and gonorrhea than their male counterparts. Early detection and treatment of these conditions reduces transmission in the community and reduces the likelihood of subsequent illness and disability.

Fix It Early

Chronic inflammation from sexually transmitted infections leads to chronic pelvic pain, ectopic pregnancies, and infertility. Correctional nurses have opportunity to reduce these outcomes through assessing, treating, and educating patients about chlamydia and gonorrhea. This can start with routine screening for both conditions upon entry into the correctional setting. Treatment, then, should be guided by national standards. The CDC 2010 STI Treatment Guidelines have some recent revisions, but remain the current national standard.

Longstanding STIs lead to chronic inflammation. Pelvic inflammatory disease (PID) should be considered and receive follow-up evaluation when female patients come to sick call with a fever, nausea, vomiting and severe abdominal pain – even when the flu is making the round in the housing unit.  According to CDC STI Guidelines, the following findings are definitive for PID:

  • Oral temperature >101° F (>38.3° C);
  • Abnormal cervical or vaginal mucopurulent discharge;
  • Presence of abundant numbers of WBC on saline microscopy of vaginal fluid;
  • Elevated erythrocyte sedimentation rate;
  • Elevated C-reactive protein; and
  • Laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis.

Treating for Two

Most women with STI’s are sexually active and fertile; making pregnancy a concern when assessing for and treating infection. It is important to know the pregnancy status of any patient diagnosed with an STI in order to arrange for appropriate treatment.  The CDC recommends that all pregnant women be screened for chlamydia and gonorrhea.

Ectopic pregnancy should also be considered when a women of reproductive age experiences significant pelvic pain. This pain may or may not be accompanied by bleeding. With high rates of STIs and PID, sexually active female inmates are at high risk for this condition. Disregarding pelvic pain in this patient population can be deadly, as this unfortunate situation in one jail illustrates.

Let’s Not Talk About It

We really don’t like talking about STI’s as this research on chlamydia confirms. However, it is an important topic and we should make the effort, especially as many women are uninformed or have misconceptions about how to prevent and treat the condition. The Centers for Disease Control and Prevention have patient education resources in English and Spanish that can help in your efforts to educate yourself and your patients about STI’s.

How do you manage sexually transmitted infection 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 AF1209 the price is discounted by $15 off and shipping is free.

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Caring for Women in Prison: Reproductive Cancers

Female Body PartsTheir socioeconomic and health profile make caring for women in prison more resource intensive than caring for men as identified in an earlier post. In addition to their background, women also have gender-specific health conditions that require additional attention. One such category of medical need is reproductive cancers. Incarceration is both an opportunity to screen for these high risk conditions and  an opportunity to education women about their signs and symptoms. Consider ways to incorporate cancer screening and health education into regular patient encounters such as sick call and chronic care clinic visits. Include questions about cancer screening practices during the initial and annual physical assessment process.

Breast Cancer

Recommendations for breast cancer screening and self-evaluations have changed over the years. The following guidelines are from the American College of Obstetricians and Gynecologists (ACOG):

  • Women aged 40 years and older should be offered screening mammography annually
  • Clinical breast examination should be performed annually for women aged 40 years and older
  • For women aged 20–39 years, clinical breast examinations are recommended every 1–3 years
  • Breast self-awareness should be encouraged and can include breast self-examination. Women should report any changes in their breasts to their health care providers.

The National Library of Medicine has help for teaching breast self-examination. This patient information that can be printed for use with patients.

Cervical Cancer

Cervical cancer screening recommendations have changed, as well. In the past, Pap smears were an annual event but new research has led to an age-guided determination of cervical cancer screening timing.  The CDC has available a table comparing  American Cancer Society (ACS), American College of Obstetricians and Gynecologists (ACOG) and the US Prevention Service Taskforce recommendations. Here are some commonly held standards:

  • Cervical cancer screening begins at age 21
  • Screening should be every 3 years for women age 21-65
  • Unless there is a history of cervical cancer, screening can stop at age 65
  • Women who have had a hysterectomy do not need screened unless the cervix remains
  • These guidelines also include women who have been immunized against HPV

Be reminded that a Pap test only screens for cervical cancer so patients need to know that ovarian, uterine, vaginal and vulvar cancers are not covered with this screen. The CDC has a handy guide to reproductive cancer symptoms that might be helpful for use with patient education efforts.

Our patient population needs gentle encouragement to submit to a pelvic exam and cervical cancer screening. Significant history of emotional and physical abuse can make this experience traumatizing. A pelvic exam is frequently refused in the correctional setting.

Ovarian Cancer

Ovarian cancer is difficult to detect early and therefore remains a top cause of mortality among reproductive cancers. Patient education regarding ovarian cancer should include the four early warning signs of ovarian cancer:

  • Bloating
  • Pelvic or abdominal pain
  • Difficulty eating or feeling full quickly
  • Sudden urge to urinate or frequent urination

Reproductive cancers like breast, cervical, and ovarian cancer are a concern for female patients. Our patient population often lacks prior healthcare management and self-care skills. Incarceration is an opportunity to improve the health of our women patients and the public health of our country.

How do you screen for and teach about reproductive cancers 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 AF1209 the price is discounted by $15 off and shipping is free.

Photo Credit:  Sebastian Kaulitzki

Caring for Women in Prison: A Patient Profile

 

Omnisure-BarbedWireWomanThe Netflix series “Orange is the New Black” brings to light the invisible world of women in prison. By all accounts there are more women behind bars now than in any time in US history. This phenomenon is certainly not what was intended when the movement toward gender equity gained steam in the 1970’s. Although women still constitute less than 10% of the inmate population, their numbers are increasing at an estimated rate of 5% per year. This growing number means that correctional nurses need to understand the specific issues surrounding providing nursing care to this segment of patients.

Women entering jails and prisons have unique socioeconomic background that result in healthcare needs. For example, most incarcerated women have substance abuse histories and many work in the sex trade. A national profile of female inmates reveals a history of many difficulties:

  • Disproportionately women of color
  • Most likely to have been convicted of a drug or drug-related offense
  • Fragmented family histories, with other family members also involved with the criminal justice system
  • Survivors of physical and/or sexual abuse as children and adults
  • Multiple physical and mental health problems
  • Unmarried mothers of minor children
  • Limited vocational training and sporadic work histories

It is not surprising, then, that women prisoners frequent healthcare services. Female inmates report higher rates of arthritis, asthma, cancer, diabetes, and hypertension than male inmates. Being female also brings with it reproductive conditions such as pregnancy, menopause, and sexually transmitted infections. Reproductive cancers such as breast, ovarian, and cervical must be screened-for, diagnosed and treated.

Incarcerated women also have higher rates of mental illnesses such as depression, bipolar disorders, and post-traumatic stress. In an earlier post, Catherine described Gender-Responsive Trauma Informed Care that responds to the needs of the female inmate population. Successful healthcare interactions require attention to relationship-building and sensitivity to the patient’s traumatic past.

Our aging criminal justice facilities were originally created for the male population and continue to operate with a focus on their primary population gender. Pregnancy and menopause, challenging in normal conditions, can be brutal in poorly ventilated housing units that overheat in summer and are freezing in winter.

“Orange is the New Black” may be a fairly accurate portrayal of life in a female prison, according to one analysis. If the series increases awareness of the concerns of women in prison than it will provide us with more than merely entertainment.

How do you describe the unique aspects of providing nursing care to women in the correctional 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 AF1209 the price is discounted by $15 off and shipping is free.

What is Gender Responsive and Trauma- Informed Care in Nursing Practice?

cage lockedGender responsive and trauma-informed care are two terms that arise from a growing understanding that women experience the environment and interact in ways that are unique to their gender. Numerous studies show that the pathways women travel toward incarceration are different as well (Covington & Bloom, 2006).  Women who are incarcerated have higher incidence than their male counterparts of chronic medical and mental health diseases co-occurring with substance use disorders and infectious diseases (Guthrie, 2011; Schoenly 2013).  The majority of incarcerated women report a history of repeated trauma and victimization that is directly related to their criminal behavior. Consequences of repeated traumatization include anxiety disorders, suicidality, self-injurious behavior and addiction (Harner & Burgess, 2011).  It can be very challenging to address the complex symptoms and behaviors that women portray during incarceration. Each of the concepts described below provide rationale and guidance for nurses to effectively address the health care needs of incarcerated women.

1. Relationships: A woman’s identity is formed by patterns of interaction with others and the effects over time are cumulative. Thus, it is within relationships that a woman identifies and defines herself.  Nursing actions consistent with this concept include:

  • establishing a collaborative relationship with the patient that supports their involvement and self-determination
  • explaining the rationale for treatment recommendations
  • using conflict management, compromise, flexibility and advocacy in addressing treatment goals
  • assisting the patient to develop positive coping skills
  • understanding those aspects of the correctional environment experienced by the woman that are counter-therapeutic
  • maintaining the boundaries of the nurse patient relationship.

2. Trauma: Repeated abuse and victimization affects a woman’s world view and use of coping mechanisms.  The most important nursing actions are to:

  • observe for signs and symptoms of reactivation of traumatic memories that may trigger feelings of anxiety, shame or anger
  • provide an environment that protects the patient from self-harm or further victimization
  • support the patient’s decision to seek counseling or mental health assistance.

3. Holistic Care: The woman is more than their diagnosis, criminal sanction or lifestyle. Nursing actions that demonstrate understanding the whole person are to:

  • avoid stereotyping the patient by her diagnosis or criminal behavior
  • validate and give voice to the patient’s experience of trauma related symptoms
  • recognizing that self-destructive and unsafe behaviors are efforts to cope with trauma
  • assist patients to make sense of their behavior and support efforts to change or control coping behaviors
  • support the patient’s efforts to make positive change.

4. Self-determination: Return the sense of control and autonomy to the patient by addressing their strengths in addition to their needs. Key nursing actions consistent with this concept are to:

  • assess women’s strengths and include strategies to build on identified strengths in the treatment plan
  • provide health education and promotion to increase skills in self-care and how to access the health care system in the community
  • support women’s contact with their children and the caretakers of their children
  • develop re-entry plans and identify resources to continue health care upon return to the community.

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 AF1209 the price is discounted by $15 off and shipping is free.

How do you describe the unique aspects of providing nursing care to women in the correctional setting? Do you have experience with gender responsive and trauma-informed care that you would like to share? If so please tell us about it by writing in the comments section of this post.

References:

Covington, S.S., & Bloom, B.E. (2006). Gender responsive treatment and services in correctional settings. Women and Therapy. 29 (3/4): 9-33.

Guthrie, B. J. (2011). Toward a gender-responsive restorative correctional health care model. Journal of Obstetric, Gynecologic and Neonatal Nurses. 40: 497-505.

Harner, H., Burgess, A.W. (2011). Using a trauma-informed framework to care for incarcerated women. Journal of Obstetric, Gynecologic and Neonatal Nurses. 40: 469-476.

Schoenly, L. (2013) Women’s Health Care. In Schoenly, L. & Knox, C. Essentials of Correctional Nursing. New York: Springer.

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