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Challenges in correctional nursing from role ambiguity

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Title:
Challenges in correctional nursing from role ambiguity
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Kilgore, Brandon ( author )
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Denver, Colo.
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University of Colorado Denver
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1 electronic file (56 pages) : ;

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Master's ( Master of arts)
Degree Grantor:
University of Colorado Denver
Degree Divisions:
Department of Sociology, CU Denver
Degree Disciplines:
Sociology

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Subjects / Keywords:
Corrections ( lcsh )
Nurses ( lcsh )
Nursing ( lcsh )
Corrections ( fast )
Nurses ( fast )
Nursing ( fast )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

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Correctional nurses are the primary health providers to inmates in US jails. Understanding what they deal with in the correctional environment allows researchers to gauge the functionality of correctional institutions and monitor job satisfaction among its staff. The body of literature regarding correctional nursing stress and job satisfaction has increased but is limited in scope regarding role theory. In this study, a phenomenological approach was taken to determine how much role ambiguity correctional nurses faced concerning the work they do. The results indicate that role ambiguity affected correctional nurses in three ways. First, correctional nursing has stigma associated with it. Second, the experiences working in jail were burdensome on correctional nurses. Third, the institutional rules and policies were ineffective in deterring workplace stress. These three areas are examined and related to the role ambiguity faced by correctional nurses. Limitations, implications, and policy reform are discussed.
Bibliography:
Includes bibliographical references.
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System requirements: Adobe Reader.
Statement of Responsibility:
by Brandon Kilgore.

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University of Colorado Denver Collections
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Auraria Library
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All applicable rights reserved by the source institution and holding location.
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987265696 ( OCLC )
ocn987265696
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LD1193.L66 2016m K55 ( lcc )

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Full Text
CHALLENGES IN CORRECTIONAL NURSING FROM ROLE AMBIGUITY
by
BRANDON KILGORE B.A., Western Washington University, 2009
A thesis submitted to the Faculty of the Graduate School of the University of Colorado in partial fulfillment of the requirements for the degree of Master of Arts Sociology Program
2016


This thesis for the Master of Arts degree by Brandon Kilgore has been approved for the Sociology Program by
Candan Duran-Aydintug, Chair Kari Alexander Leigh Ingram
December 17, 2016


Kilgore, Brandon (M.A., Sociology)
Correctional Nursing and Role Ambiguity
Thesis directed by Associate Professor Candan Duran-Aydintug
ABSTRACT
Correctional nurses are the primary health providers to inmates in US jails. Understanding what they deal with in the correctional environment allows researchers to gauge the functionality of correctional institutions and monitor job satisfaction among its staff. The body of literature regarding correctional nursing stress and job satisfaction has increased but is limited in scope regarding role theory. In this study, a phenomenological approach was taken to determine how much role ambiguity correctional nurses faced concerning the work they do. The results indicate that role ambiguity affected correctional nurses in three ways. First, correctional nursing has stigma associated with it. Second, the experiences working in jail were burdensome on correctional nurses. Third, the institutional rules and policies were ineffective in deterring workplace stress. These three areas are examined and related to the role ambiguity faced by correctional nurses. Uimitations, implications, and policy reform are discussed.
The form and content of this abstract are approved. I recommend its publication.
Approved: Candan Duran-Aydintug
n


To my adoring wife Bree, whose support and love allowed this project to happen.


TABLE OF CONTENTS
CHAPTER
I. INTRODUCTION....................................................1
II. LITERATURE REVIEW...............................................3
Burnout/Turnover................................................5
Stigma..........................................................5
Autonomy........................................................6
Inmates.........................................................6
III. THEORETICAL FRAMEWORK...........................................9
Phenomenology..................................................10
Role Theory....................................................11
IV. METHODS........................................................14
V. ANALYSIS.......................................................17
Role ambiguity from Stigma..............................18
Public Stigma.....................................18
Private Stigma....................................20
Nature of Work Creating Role Ambiguity..................20
Unclear Directions and Perceptions................21
Issues With Non-Conventional Setting..............22
Challenges From Correctional Officers.............23
Challenges From Inmates...........................26
Institutional Rules and Policies........................29
Lack of Resources.................................29
Policy Issues.....................................29
Understaffing.....................................31
V. DISCUSSION.....................................................33
Limitations....................................................39
Conclusion.....................................................40
IV


REFERENCES........................................................42
APPENDIX..........................................................48
A. Interview Schedule and Voluntary Consent.................48
v


CHAPTER I
INTRODUCTION
The Bureau of Justice Statistics reports that in 2014 more than 6.8 million people were under the supervision of US corrections in some capacity (Kaeble et al. 2014:1). When not looking at those under parole or probation, the US still holds over 2.3 million people in correctional institutions. This translates into 1 in every 100 adults detained in a US jail or prison (The Pew Center 2008:5-7). Such statistics emphasize the fact that housing, feeding, and basic care for inmates is an arduous goal. The eighth amendment created basic inmate rights in 1791. It states that those convicted of a crime will not receive cruel and unusual punishment. During the 20th century many alterations were made that advanced a prisoners general rights and well-being. This included the right to basic medical needs (Dolovich 2009; NCCHC 2010).
Despite health care existing in US corrections for well over a century, correctional nursing only became recognized as a medical specialty by the US Supreme Court in 1976 and the American Nurses Association in 1985 (Schoenly 2013; Clayton 2015). Nurses are the primary health providers to the millions incarcerated in the United States. These nurses face challenges that are unique to their job setting (Flanagan and Flanagan 2002; Maroney 2005). Correctional nurses exist in an interesting continuum. They give the same care as their hospital counterparts with the exception that their work environment is a correctional facility; their patients are inmates; and their peers correctional officers. How do these nurses feel about the roles they play as caretakers for the incarcerated? How are their roles as medical professionals challenged? The purpose of this study is to develop a preliminary
1


understanding of correctional nurses and examine how their role as a nurse is being challenged.
2


CHAPTER II
LITERATURE REVIEW
Given the uniqueness of the correctional nurse profession, correctional nursing has been viewed in a different light than other types of nursing. It is important to make clear distinctions between correctional nursing and more conventional nursing. Correctional nurses have things in common with their conventional nurse counterparts, such as education requirements and offering care for a myriad of healthcare needs. Looking at the differences between correctional and conventional nursing offers a clearer understanding of how different the roles are.
Conventional nurses work in a setting where direct healthcare is the primary aspect of their work. These settings often include hospitals, clinics, and other healthcare facilities. In these settings nurses usually establish a specialization such as Oncology Nurse or Surgical Nurse where they can fine-tune their skills in an area of medicine. They are known for providing care, giving council to families, and educating their patients regarding long term healthcare needs (American Nurses Association 2016).
Correctional nursing demands all the same prerequisites that hospital nursing requires but with the addition of operating in a hyper controlled and secure setting, with very established rules and boundaries (Flanagan and Flanagan 2002). Unlike hospitals, nursing homes, etc. that are specifically designed for healthcare, a correctional facilitys first obligation is to secure inmates from the outside population. Healthcare becomes secondary in such a setting, as it is not as strongly built into institutional needs (Schoenly 2013; White and Larsson 2012; Weiskopf 2005). This is the primary difference between correctional health care and care received virtually anywhere else. As Maroney aptly put it, There is an ever-
3


present struggle to find the balance between the health care needs of the prisoner and the security limitations of the institution (2005:159-160).
Nursing in a correctional setting is unique and has been compared to working in psychiatric and military hospitals (Flanagan and Flanagan 2001; Hardesty 2007). The myriad responsibilities, the unpredictability, and day-to-day challenges in corrections is often seen as positive and rewarding for some correctional nurses (Schoenly 2013). Largely though, past research shows that working in a correctional setting is challenging for nurses. It makes sense that previous research has mostly focused on the difficulties of the occupation as there is a constant influx of inmates that need screening and often abrupt care. This leads the medical side of corrections to be fast paced and often stressful (Hardesty, Champion and Champion 2007).
Literature on this subject makes it clear that correctional nurses (CN) have a unique occupation. CNs agree that the correctional setting sets their work apart from other types of nursing. In one study 97.5% of CNs felt that working in corrections made their jobs different from conventional nursing (Flanagan and Flanagan 2001:75). Common explanations included the type of patients they cared for and the restrictions placed on them by security protocols. Some argued that true nursing care is personable and more intimate than a correctional facility can allow. Touching a patient is more limited and even using an inmates first name has been discouraged. Also, being the main health care providers for incarcerated patients has the potential for risk. This can be direct physical risk by dealing with an unruly or aggressive patient, or psychological risk from prolonged exposure to the environment itself. CNs also run the risk of facing lawsuits or job loss from correctional institutions when attempting to advocate for their patients rights (Weiskopf 2005).
4


Burnout and Turnover
Due to poor funding, lack of personnel, and a difficult work environment, the rate of job burnout is frequent with correctional workers. Maslach and Jackson first wrote about job burnout as a state of emotional exhaustion and cynicism that is associated with frustrations related to ones work (1981:99). Stress, job satisfaction, and level of involvement are all associated with correctional workers facing burnout. Correctional staff deal with a difficult population that can keep them from meeting goals and enjoying their work. Such stress cause workers to lose ambition, care less about administrative wants, and act callously and impersonally towards others (Griffin et al. 2010:240). Correctional work is challenging and many learn the environment is not for them. This has led to considerably high turnover rates. A recent study reported that one facility only retained 20% of its nursing staff within a three-year time span (Chafin and Biddle 2013). Another issue stems from managements lack of support, which is a factor contributing to stress. Management often demands long hours and ever increasing workloads that are burdensome for CNs (Flanagan 2006). Correctional centers are also notorious for being poorly funded regarding staffing, medical supplies, and equipment (Droes 1994).
Stigma
Correctional Nurses also face stigmatization in the work they do. In one study over 70% of CNs agreed that their occupation is stigmatized when compared to other kinds of nursing (White and Larson 2012:72). A great deal of this stigma comes from the publics view on correctional work. Nurses report that community members, friends, and other nursing professionals have viewed CN work as dangerous and dirty (Hardesty 2007; White
5


and Larson 2012). Other times CNs are embarrassed to talk about what they do because others may see them as not capable of finding a traditional hospital job, or their work is the only work they could find (Clayton 2015). Finally, CNs take care of a population that society cares less about. This can cause a CN to internalize their work as less important and less contributing to society (Christensen 2014).
Autonomy
Correctional Nurses, like other specialized nurses, report that professional autonomy is very important to them (Flanagan and Flanagan 2001; Flanagan 2006). Unfortunately, CNs have their autonomy challenged in several ways. As mentioned above, health care is secondary to security in a facility where, priorities of the secure environment center on order, control, and discipline and not health care needs (Maroney 2005:159). Consequently, CNs perceived level of autonomy may be high in one sense but low in others. For instance, they may have decision making ability over health care decisions, but at the same time face restrictions associated with lack of resources, strict security protocols, and non-nursing staffs interference with health care efforts (Flanagan and Flanagan 2001).
Inmates
Compared to the general population, the incarcerated represent a unique group that shows the larger public health problem that exists. Less than 50% of the incarcerated have graduated high school. They also have lower literacy rates and higher learning disabilities than the general population (Greenberg, Dunleavy, and Kutner 2007). The prevalence of infectious disease is higher in prison and jails, especially concerning tuberculosis, HIV/Aids, and Hepatitis C (Baillargeon et al. 2004; Gerber 2012; MacNeil, Lobato, and Moore 2005).
6


Sexually transmitted diseases such as gonorrhea and syphilis are dramatically higher among the inmate population (NCCHC 2002).
Mental health and substance abuse are also major issues that CNs face. Mental health problems are more prevalent in jails and prisons than the general population (Gerber 2012). The prevalence of mental health issues are so high that several studies report rates at or near 50% of jail and prison populations (Sung and Mellow 2010; Lincoln et al. 2015). For comparison, the general public only has an 11% rate of mental illness, a rate five times lower than the incarcerated population (James and Glaze 2006).
More than two-thirds of the jail and prison populations suffer from drug or alcohol abuse or addiction (American Correctional Association 2005). This puts CNs, especially ones that work in jails, in a challenging position as there is a higher intake of new inmates that often involves careful screening and immediate care (Schoenly 2013).
Inmates are also known to be challenging patients as they are prone to manipulating the correctional system and individuals who work in them. Past research has shown that CNs have frustrations with inmates attempting to manipulate them for personal gain (Maroney 2005). Trust issues arise from such interactions which complicates a CNs ability to provide adequate care (Shields and Moya 1997).
Working in corrections can be a challenging job and correctional nurses are an important group to study. Given the magnitude of the population they care for, the specialization of their job, and the difficulties they face, it is surprising the research is as limited as it is. Much of the research done is conflicting; offering inconsistent data on the subject. This is likely due to a lack of cohesion in research as CNs working in different types of corrections are lumped together. Some research fails to understand the important
7


distinction between jails and prisons and how the environments are dramatically different. Even just looking at the jail setting, from one facility to the next there may exist funding discrepancies and policy changes. A clearer foundation regarding the details of correctional nursing is needed. Having CNs explain their experiences and feelings about their work would offer a more fundamental understanding of what they do, think, and feel about their work.
8


CHAPTER III
THEORETICAL FRAMEWORK
A more comprehensive analysis is needed to gain further insight on CNs. Quantitative research has gathered important statistics regarding inmate populations such as rates of incarceration, drug and alcohol addictions, and suicide rates. Qualitative research has performed studies for those housed in jails and prisons and those whom work in them. Unfortunately, attempts at a cohesive understanding of correctional nursing is limited from both qualitative and quantitative approaches. Reasons include: poor methodology; asking too many or too confusing questions; and performing multi-site (often multi-state) research that has skewed analysis. The lack of quality data likely comes from not appreciating fundamental differences between one jail or prison from another; i.e. population density, private vs publicly run, and maximum security prisons vs small town jails.
Past research has uncovered aspects of correctional nursing. Unfortunately, the population is rather unique and creates challenges to research. With that in mind, this research project will attempt to gain insight of what correctional nurses experience by using a more focused approach. To offer a more comprehensive base for the phenomenon, qualitative methods will be used to gather more detail about the occupation and experiences therein. A phenomenological approach will be used to aid in data collection on such a specific group. This will allow participants to define the work and experiences from their point of view. Finally, the effect of role ambiguity on correctional nurses is examined to determine the wide sweeping stressors associated with the occupation. These methods used in unison is what sets this research apart from others, making this preliminary study an ideal launching point for future research projects.
9


Phenomenology
The Mathematician and Philosopher Edmund Husserl began the discussion of Phenomenology in the 1930s and explained the method as a tool to see past our preconceived notion of a situation, event, or thing (Schiitz 1945). The method has been built upon a great deal over the years and is now used as a social scientific tool that allows researchers to overcome preexisting assumptions regarding a given phenomenon (Giorgi 2012). It is argued that to truly understand a phenomenon, the researcher ... does not deny the existence of the outer world, but for his analytical purpose he makes up his mind to suspend belief in its existence... (Schiitz 1945:82). This means one suspends all doubt and preconceptions about the subject at hand and see it for what it is, not how others define it (Mayoh and Onwuegbuzie 2013). More simply, ...a phenomenological study describes the meaning for several individuals of their lived experience of a concept or phenomenon (Creswell 2013:57).
Using this method aids the researcher in describing the nature of a phenomenon from the point of view of those who have experienced it. For example, there are plenty of definitions and ideas of what it means to be an astronaut. Asking an actual astronaut would offer the actual lived experiences instead inferring information from the outside world. This perspective gives the opportunity to add richness to a study, especially studies that involve hard to reach or unique populations (Creswell 2013).
This is pertinent to the current study as the researcher has posited that a fundamental issue with past research may be that preconceived notions of what a correctional nurse does are used to measure their experiences. Also, correctional nurses have a unique occupation that may benefit from reexamination through a more focused lens. Using the
10


phenomenological method, the researcher plans to interpret the experiences of correctional nurses from their perspective. This research will ask them questions about how they feel their role as a nurse is affected by their work.
Phenomenological research has been done on correctional nurses, but is very limited. Weiskopf noted in her phenomenological study on CNs that past research on nurses have avoided the correctional environment (2005). In that project, the researcher specifically focused on issues associated with caring for inmate patients. In the current study, the focus is on how a correctional nurses role as a professional nurse is challenged by their work and the work setting.
Role Theory
In this study, role theory is used to learn and evaluate correctional nurses. Early work on self, identity, and role theory come from the writings of George Herbert Mead, who paved the way for modern symbolic interactionism. In giving us insight into the process of interaction, Mead showed how individuals are an extension of society. This offered researchers tools to help understand identity formation (Tuner, Beeghley, and Powers 2007; Dodd, Lawrence, and Valsiner 1997). Our sense of self is derived from the culmination of ones various identities. Our identities come from our interactions with our perceived roles. Roles are, ... a collection of patterns of behavior which are thought to constitute a meaningful unit and deemed appropriate to a person occupying a particular status in society (Turner 1956:316).
A role is a set of behaviors that have implied meaning given to it by society and are used to satisfy a particular status. By performing roles, we often take them on as important aspects of ourselves (Burke and Tully 1977; Stryker 1968). Ones commitment to the role is
11


what attaches us to our identities. When we fully accept the role as a part of our identity we are participating in role embracement (Goffman 1961). These roles are extremely important and are foundations into ones own personality (Turner 1978).
Roles give labels to individuals who behave in a manner appropriate to how social norms define expectations for roles. Through socialization, people participate in the concept role-taking, where they learn and execute the patterns, meaning, and shared ideas of a certain role. Individuals act out certain roles because the role aligns with the kind of person they want to be or see themselves as. Instead of having a single role, people take on many roles with varying degrees of importance (Stryker and Macke 1978).
The power a role holds can vary and with more power comes higher role expectations. Stryker and Macke explain that roles, .. .can carry little or no normative freight or be heavily ladened with insistent norms. (1978:58). When these expectations of roles are not met, sanctions may arise. When a role is compromised the severity of the sanction depends on the importance of the role. For instance, if a role is compromised in a social setting vs a formally structured setting the sanctions will be different (Stryker & Macke 1978). A simple example may be doing something embarrassing at a dinner party compared to doing something embarrassing at a board meeting. The simple social setting offers less scrutiny than the high expectations of a professional job.
Individuals strive to fit neatly into their roles but have so many that not all of them will have equal importance. When individuals believe a role to be central to their identity, they make it one of their top roles. This is known as role salience which refers to the value one places on their core roles. An example of this would be listing the top four roles an individual has and gauging the importance of those roles. Imagine ones main roles are:
12


Mother, artist, teacher, and wife. If those are the central roles one has, they still have weight over one another, yet all make up core roles (Greer and Egan 2012).
An individual doesnt just act out their roles smoothly. Roles can be directly challenged by outside forces. Often, interruptions can affirm role status but sometimes that status can be impeded upon. Role conflict arises when an individual receives contradictory demands that do not coincide with the nature of their roles. Usually this involves one role status not aligning with another (Stryker and Macke 1978). Such as the need to be a father who spends time with his children but also a professional in a high demand job.
Finally, role ambiguity is .. .a lack of clarity as to what is expected, appropriate, or effective behavior (Harrison 1980:32). Originally conceived by Kahn et al., the early research looked at how job related stress and job satisfaction came about from a lack of clarity in ones work (1964). Role ambiguity arises when expectations are put on an individual that are felt to be incompatible with the perceived role. Often, role ambiguity occurs when superiors or bosses demand tasks that dont fit the description of what a worker thought the job demanded (Brunetto, Farr-Wharton, and Shacklock 2011).
This preliminary study aims to uncover how correctional nurses experience role ambiguity from their experiences working in a jail. It will be determined if the nature of correctional nurse work challenges roles traditionally established in the nursing profession. Since correctional nurses are so unique, it is assumed that the power to challenge a nurses perception of their role exists, causing role ambiguity. This logic appears sound as nurses are educated and trained to be nurturing caretakers, yet the correctional environment they work in is not conducive to meet the role requirements expected.
13


CHAPTER IV
METHODS
The current study looks at correctional nurses working in jails in a major metropolitan area of the southwestern United States. The reason for limiting this research to the jail setting and not including prisons are several fold. Firstly, past research has studied prison environments for a long time and the researcher felt adding to the lesser examined jail setting was of better scientific inquiry. Second, the jail environment offers a very different experience for medical professionals. Despite prisons having many people incarcerated, state and county jails rotate over 11 million people annually, far more than the prison population (Prison Policy Initiative 2016). This happens for several reasons: People cannot make bail when arrested or are awaiting trial; people are being transferred to other facilities/prisons; and people are held on short sentences. This translates to a lot of rotation and new people coming into local jails. Thirdly, many people who are sent to jail are sent immediately after arrest. The immediacy of the inmate/CN interaction makes the jail setting interesting to study.
In the fall of 2015, the researcher was approached by a friend, Beth (pseudonyms used throughout) who thought I would be intrigued by her new job as a correctional nurse. Beth had recently graduated nursing school and had been searching for full-time nursing jobs when she was hired on by a local jail. I quickly became intrigued by the uniqueness of her occupation and the challenges she faced as a nurse taking care of an inmate population. I was inspired by my unfamiliarity of the occupation and the potential to uncover new information on such a topic. I decided to conduct phenomenological research on correctional nurses and
14


learn more about their lives and experiences. Beth became the key informant of this study and offered details of her occupation as well as access to other correctional nurses.
As a preliminary study, only a small number of correctional nurses were asked questions about their work. The projects key informant was asked to offer my email address, and general information regarding the project to co-workers at her local jail. From there, correctional nurses could contact me if they were intersected in participating. The technique of utilizing a key informant to inform and recruit others is known as snowball sampling (Biemacki and Waldorf 1981).
The researcher first sought a basic understanding of correctional nursing from past research on the subject. This would aid in determining what questions would to ask in the interview schedule. The researcher also examined studies regarding role ambiguity as it was of interest from the advent of the current study. Following this the researcher spoke to the key informant and asked her to describe the profession with detail. All of this gave the researcher a general knowledge and clearer direction regarding what questions to ask correctional nurses about their job. The interview schedule asked CNs to describe several aspects of their jobs. These included at work stressors, relationships with co-workers and patients, frustrations with management, just to name a few. Generally, CNs were asked to describe their work experiences and how they felt about those experiences in detail.
All the participants in this study were female, had graduated from nursing school within the last five years, and all worked less than two years as a correctional nurse. A total of six CNs participated in the open-ended interview schedules and two gave face-to-face interviews.
15


When the open-ended interviews were completed they were then re-typed and any traces of personal information were removed or changed to insure participant confidentiality. The original interview schedules were destroyed and the re-typed copies were used for the study.
Beth, the projects key informant and Hailey, another interested participant, offered face-to-face interviews. I met them individually at a public setting of their choosing. I took notes and digitally audio recorded the interviews. The interviews took about an hour each to complete. Upon completion of the interview the digital audio recordings were transcribed and the digital copy erased. Just like the open-ended interview schedule, the transcriptions were edited to omit or change any personal information to insure participant confidentiality.
As I familiarized myself with the material I found common themes that coincided with issues regarding stressors at work. Such topics would be helpful in gauging role ambiguity. Using Grounded Theory the feedback was analyzed by coding data into various concepts (Glaser and Strauss 1967). With these categories, the researcher developed theoretical explanations to interpret the feedback of the correctional nurses. The data used was looked at in all dimensions until it reached a point of theoretical saturation and no new information could be drawn out (Glaser and Strauss 1967).
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CHAPTER V
ANALYSIS
As mentioned above, role ambiguity exists when expectations are put on an individual that are perceived as incompatible with ones perception of their role. In reviewing the responses from correctional nurses, it became obvious they experience a great deal of role ambiguity. Three clear forms of role ambiguity were identified through the coding process.
1. ) Stigma exists for correctional nurses that challenges their role, leading to role ambiguity. This occurs both publicly and privately in the form of stigmatization. Publicly, stigma comes from family, friends and professional peers offering negative opinions or judgement on correctional nursing. Privately, nurses carry their own negative feelings with them with how they personally view their occupation and how it is perceived by others. Both forms of stigmatization can be said to cause role ambiguity as the nature of their role is challenged. Having their nursing role scrutinized or falsely judged may cause CNs to feel they do not fit as neatly into their nursing role as they desire. Public and private stigma working together causes the outside world and the CNs to view correctional nursing in an ambiguous light. Role ambiguity may be difficult to shake for CNs as public perception of corrections is deep seeded.
2. ) The correctional work itself brings about role ambiguity. This occurs as nurses perceived ideas of their role is challenged by the experiences they have at work. In other words, when the duties and experiences of a nurse were not embodied by CNs. This causes a disassociation from the larger nursing community. The categories are as follows: unclear directions, nurse role challenged, issues with the non-traditional setting, and role challenged by correctional officers and patient inmates.
17


3.) The larger institutional rules and policy are often in direct conflict with what is perceived as a functional nursing environment. A lack of resources, ineffective policy, and understaffing was a major burden for nurses leaving them challenged in performing their work adequately. Not only did this meddle with expectations of nursing roles, it went as far as CNs not wanting to work in corrections at all.
Role Ambiguity from Stigma
The correctional nurses from this study all reported stigma surrounding the type of work they do. They felt stigma in two distinct ways. One way was publicly, from outside sources such as friends, family, and even professional peers. The other was privately, and involves feeling the job has stigma associated with it.
Public Stigma
Correctional nurses expressed discomfort from what others had to say regarding their line of work. Correctional nursing was viewed by some as dirty, unsafe, or beneath mainstream nursing. Most of the feedback CNs received was fear of personal safety. Hailey, a former correctional nurse, recently found a position at a big city hospital. When asked how her new co-workers felt about her former jail position she responded:
Most people at the hospital I now work seem appalled, at the least, that I worked at a jail.
The first thing people ask me is: Why? Does it scare you? Do you feel safe?
This echoes what other CNs reported. Surprisingly, a great deal of the negative feedback came from professional peers. When asked why she thought they responded in such a way Hailey explained:
18


Most have a sense of judgement towards this population in particular. It's as if the inmate population doesn't deserve proper healthcare like upstanding citizens do.
The judgement passed on the type of patient correctional nurses give care for was a point
of contention from CNs. Their frustrations arose from a lack of care for people who need
care, despite the reasons why. CNs try their best to look past the reasons why an inmate is in
jail and focus on giving care to those who need it. One CN explained how non-correctional
nurses bias is unfounded because many of the inmate patients are awaiting trial or cannot
afford bail, thus making them innocent until proven guilty. Marie explained her thoughts
regarding non-correctional nurse bias towards her inmate patients:
In school, were told that you're supposed to be compassionate caregivers, and having the people in there that are being treated like criminals when a lot of them are waiting for a court date for a traffic ticket. They're waiting for their trial. That has just been super frustrating to me. I still like making inmates smile and we don't know what they're going through or what their situation is and as nurses we're not supposed to pass judgement. Being a correctional nurse has given me a wonderful opportunity to leam how to provide unbiased care to my patients, regardless of their history or past. It has helped me not to judge. I am not perfect, we all judge to some extent, but I am much more cognizant of biases and have learned to dismiss them.
CNs explained that the work is challenging but the safety factor is largely misunderstood by the outside world. The security measures put in place are not merely to keep inmates from escaping incarceration, they are there to prevent harm to correctional staff in general. Bridget explains that inmate patients are still people and that the safety issues perceived by others are inaccurate:
I have never (other than the inmate who was rude about TB shot) had an inmate be rude or aggressive towards me. If we as nurses are respectful to them and dont look down on them, they are in general pleasant in return. If someone is sick and in need of medical care regardless of who or where they are, they just want to feel better.
Marie further explains how personal safety is less of an issue due to security protocols
built into the jail:
19


We were accompanied by deputies at every exchange with the inmates. When we were short staffed, the deputies would go as far as helping us place the VS equipment on the inmates, while we were preparing medications to help quicken the workflow.
Nurses explained the environment is not a dangerous place to work. Despite this CNs
still carry the burden of public stigma by working in a correctional setting.
Private Stigma
CNs didnt just receive stigma from non-correctional staff, friends, etc. They also brought their own bias in when starting the position. Many explained they always wanted to work in a conventional hospital setting, but due to competition and lack of experience, had to start somewhere. This simple acknowledgement of correctional nursing being temporary and a starting point shows how the CNs themselves have stigma toward the work. Hailey explains her thoughts on how both she and the outside world view her work:
I think other medical professionals almost look down on correctional nursing. I only worked there to get experience under my belt, as I was a newly graduated nurse competing for hospital positions with nurses who had years of experience... All in all, I'm happier to be in the hospital setting. People are a lot more appreciative of the work I am doing, and I personally feel I am making a bigger difference in people's lives.
Not only did CNs have personal bias, they often perceived their job as scrutinized by outsiders despite personally feeling their positions were professional and important. They feared that others viewed their work as less than other kinds of nursing, and less contributing to society.
Nature of Work Creating Role Ambiguity
The very nature of correctional nursing challenged CNs internalized definition of what a nurse is to them. The day-to-day activities, environment, and co-workers challenged the definition CNs had regarding themselves. This study reports on three factors that cause
20


role ambiguity for correctional nurses while they are at work. These factors include unclear directions and perceptions, issues with the work setting, and being challenged by correctional officers and inmates.
Unclear Directions and Perceptions
CNs reported unclear directions and unattainable goals when superiors delegated tasks that CNs were not trained for or didnt feel was in their job description. Marie offers examples of unattainable and unclear expectations from her superiors:
I was constantly receiving directions for other peoples job duties. I knew how to perform most of the tasks, but there were times I was receiving unclear directions for something I had never done. Most of the time this results in something not getting done.
Here, Hailey expresses frustrations not just over a lack of clarity, but a lack of any
direction at all:
We were just basically trying to leam everything on our own and I felt guilty for asking questions because everyone acted like I was an inconvenience for asking something and not realizing that I'm beginning to begin this process. I'm taking the intake and I need to know what I'm doing. And there should never be a stupid question. I get scared asking someone a question. I was coming home in tears because I didn't feel like anyone liked me and I didn't feel welcome.
Another example from Hailey shows how unattainable managements expectations could
be when asked to complete more work than could be performed in the time offered:
They added more and more ridiculous, time consuming logs and steps to our already overwhelming list of duties and then complained about the amount of overtime each of us logged in each week.
Here is an example from Bridget recalling one of her co-workers being judged by an officer for helping a hurt inmate:
I would constantly get questioned by deputies about my actions. I remember a situation where a deputy questioned one of the other nurses for helping an inmate that was bleeding on the ground.
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Here again, Hailey shares an experience where she was scrutinized by a correctional
officer for offering care to an upset and hurt inmate.
The other night I had a gentleman who had sustained a head injury. He had a concussion and he had bruises all over his face and his left eye had this huge hematoma and it had so much fluid under it he could hardly open his eyes. He is sitting here crying, telling me about the situation. I'm there to console him and take care of him and so I got his medications right away. The deputies judged the fact that I was taking care of this guy.
The CNs in this study were constantly challenged by judgmental officers. They expressed
a lack of autonomy when custody officers scrutinized their work, especially when it regarded
feeling remorseful for inmates.
Issues with the Non-Conventional Setting
Correctional nurses experienced role ambiguity when their work environment was less conducive to that of a more traditional hospital setting. CNs explained that their experiences would be better in a traditional hospital setting:
I've been working since I could work and I'm a hard worker and I've never had this negative feeling when I'm at work. I guess it was just hard for me to work through that and I don't think that it would be like that at a hospital where people want to help you. That's how it should be. I can be a good team member and you want people to be on the same page as you. I would think a hospital is a good place with a good system to work.
Marie backs up the claim that the hospital setting would not only be more enjoyable, but also a better place to offer care and to learn:
I want to work in a hospital. I think I'd enjoy the environment more. My first stint at a correctional facility was a very negative regarding the environment and I'm not used to that. During clinicals my preceptor said they were really happy to have me and teach me and ask me questions that I can answer in a learning environment. The families [during clinicals] are positive and it's all viewed as a positive experience that you're helping someone. Whereas corrections you have inmates that are coming in with a negative state of mind because they were arrested. When I came in [to work in the jail] there were so many bullies and no one wanted to help at all. I know personally I didn't know how hard
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correctional nursing would be compared to other medical settings. You dont understand the extent of it until you work under the tough conditions.
Correctional nurses believe that in a hospital setting, there may be more appreciative
patients with families to interact with, changing the kind of care they offer. The opportunity
to learn new things may be more accessible, if not promoted when working in a hospital.
Also, several CNs believed that the funding would be better in a hospital, so more staff and
better equipment would be available. The prospect of working around more medical staff and
less security measures and personnel were also important to them. The potential to work in a
more positive environment where their abilities would be appreciated was important as well.
Challenges from Correctional Officers
Aside from other nurses, CNs work the closest with correctional officers.
Correctional officers (COs) were the main instrument in providing security in the jail setting. Their position was to insure the containment of inmates, but also provide security to the other employees at the jail. CNs understood and appreciated the work of the COs since it made the environment safer to work in.
Bridget expressed the importance of the COs work and how a part of their job is to insure the safety of the staff:
It is their job to ensure that the staff is safe given the environment we work in. The officers can be very firm at times but this is to establish ground rules... working with the deputies and officers is a fine balance and it is so vitally important to have good communication by all staff.
Bridget explains that the staff may be firm at times, but that it is necessary in their line of work. She goes on to explain there is a fine balance between security staff and medical. The relationship is sustainable if good communication can be maintained. Unfortunately, not all COs are the same and often, good communication was not sustainable.
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When communication and cooperation broke down the attitudes and behaviors of COs often hindered the work of CNs, which in turn puts stress on their nursing role.
Hailey explains how important communication is, but that they as CNs have maintain the integrity of the communication:
When you have a good system like that it's nice. I think it's important to build a good rapport. But if you won't work on communication with them they won't work on communication with you.
Even when lines of communication were maintained the COs could be unpredictable in the way they carry themselves at work:
If the guards were in a good mood, patient, kind and understanding to the inmates, our days were much smoother. If the guards were rude to the inmates, short and impatient with us, the entire day was much more difficult to get through.
In the above except Marie explains how the COs are difficult to gauge. She went on to explain that some COs were nice and patient with inmates, but some were aggressive and rude to them. The same thing occurred with new nursing staff. Some COs would be kind to new staff while others were rude and bullying towards them. This created an unpredictable and confusing environment for some of the CNs.
Hailey explained a situation where a CO questioned her intentions while processing an inmate. The inmate was an elderly man who was very intoxicated and potentially a safety risk in jail. Hailey explored the option of admitting him to the local hospital:
I told the officer it's because I don't even want him trying to walk. He's older and in nursing school you leam one of the easiest ways for injury or death for the elderly is falling. When I said that the officer got upset. He got very angry with me. I didn't feel comfortable taking [the inmate] and if something happens it's going to be on me.
In this instance the CO challenged her ability to care and to make decisions as a
professional nurse. Her authority to make health care decisions and to give care were met
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with anger instead of accepting that she knew what she was doing. After offering the above response, Hailey was asked how much authority she has over inmate health:
Theres a certain hierarchy in the jail. The inmates are under the custody of the law enforcement personnel, therefore when it comes to most decisions being made about the inmates, the healthcare staff does not have much of a say. This makes caring for the inmates very difficult. Unless there is a medical emergency, the deputies dont give much of a damn about what you have to say. Caring for the inmates is seen as a weakness to them.
My role as a nurse was constantly challenged by the deputies and other law enforcement personnel. In the jail facility, the deputies have the upper hand over most situations.
These are clear instances of CNs decision making ability being challenged by COs. A common example of communication breakdown occurred out of the CNs and COs having totally different perspective regarding the care for inmates. Sometimes the COs opinion of inmates were in direct conflict with CNs. In this instance one CN explains how it can be difficult to work around their aggressive attitudes:
A lot of them, it seems, are on power trips. You can just tell by the stuff they say. I heard one of the officers yell, Shut up or I'll wok you in the supply closet. Inmates have told me other things, other stories about abuses and stuff like that. Obviously, you can't believe everything you hear from them, but sometimes the more you hear the more you start to believe it a little bit.
CNs expressed and understanding that COs had to exhibit authority from time to time, but they disagreed with power being abused. They expressed that when COs acted in such ways, the work environment became less professional and that they could not give the proper care needed.
COs also interrupted the CNs from inappropriate behaviors and interactions. The COs would flirt with and sometimes even sexually harass CNs. Marie shared an unfortunate experience she had with a CO:
There was one officer in minimum security who was sexually inappropriate with me during a medication pass. He rubbed up against me from behind and asked if I needed a shoulder
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rub, at which time I said "nope, I'm good," which he responded with "Yeah, I bet you are good." He intentionally tried pushing his genitals over a trashcan I use. At one point, he was so out of line that day, I actually felt more comfortable with the inmates. There were several inmates who offered to jump in and mediate the situation. I finished up quickly, left the POD [inmate living area] and filed a report which was never dealt with as far as my knowledge goes. I later learned that he had several sexual complaints from female inmates.
In this instance the CO inappropriately exerted authority by harassing a nurse in front of inmates, with little or no regard for repercussions due to abusing his power. Sometimes COs simply do not listen to the directions from CNs regarding inmate care:
There are times when officers have not understood the process for triaging inmates medically. They lack the understanding of what an immediate need is.
Some nights Ive told an officer that someone needs to go on suicide watch, which means they can't be in the normal uniform [inmate attire] and they should be housed down in SHOE [solitary confinement]. So, I communicated that with one of them and they didn't communicate it with the other CO and that person got into the wrong housing instead of where they needed to be. And that's happened a few times.
In these instances, the COs were either ignorant of the needs of the medical staff or
cared too little to do their jobs correctly. The CNs were especially bothered by the ineffective
work of officers when it put their patients in harm.
Challenges from Inmates
Inmate patients proved to be challenging to CNs. At times, some inmates were untrustworthy and uncooperative which impeded the care CNs could offer to individual patients and the rest of those housed in the jail. Despite the challenges in offering care to inmate patients, nurses showed a great deal of resilience in caring for those in jail:
Caring for individuals with very serious charges (crimes against children, murder etc.) or individuals who are repeat offenders and take no initiative to care for themselves on the outside can be difficult. Regardless, one must put their nursing duty in the forefront and not ever let this be a hindrance to the care provided. Its not our role to judge or decide when to help.
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Despite acknowledging the need to give care no matter who receives it, that didnt
stop the CNs from expressing frustrations toward their inmate patients:
Once in jail they are very demanding with the care they receive despite having not cared to address the issues on their own. This is obviously a blanket statement and does not pertain to all inmates, but it is a trend seen often and at the jail.
The CNs from this study were all very companionate and professional in the work they did. This didnt stop them from experiencing stressful situations that arise from the uniqueness of their work and patients. One nurse told a story about an inmate who just arrived in the jail after losing a friend to gun violence he was involved in:
It was really, really intense. He was around my age and it was weird because it was like me or you. Like I could have seen him in this setting [gesturing around our public setting] and it was a really eye-opening situation. I'm going through our mental health questions and asking him if hes suicidal and he said, How would you feel if you were in the situation? and I don't know how I would feel for me. It was like communicating with someone that I could have known.
This is an example of a nurse having to cope with patients dealing with very stressful and often depressing situations. CNs expressed that caring for the inmate population is not easy and often depressing.
CNs agreed that another form of stress from inmates comes from the lack of trust they have with inmates. Inmates would lie about medical emergencies and manipulate situations which was a constant nuisance to the CNs. When asked for an explanation of such behavior, Hailey responded:
Something you or I wouldnt even think about suddenly equates to power and then medical is a road into that stuff and sometimes we get taken advantage of...
Bridget elaborates how staff is manipulated so the inmates can gain access to medicine and other goods:
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When they see people [staff] who are new they try and get as much out of you as they can.
In general, most things that are not given a second thought like Tylenol, Gatorade or peanut butter and crackers, suddenly become a hot commodity while incarcerated. TheyTl give you any line they can to try and get these things out of you.
When asked if inmates manipulated staff, Marie responded:
Yes, every day. Most patients manipulated staff by either having fake medical emergencies such as chest pain, shortness of breath, seizures, etc. to either get controlled substances or sent to the hospital. We even had a guy who would swallow objects to get sent to the hospital. I never trusted any inmate.
A lack of trust towards the inmates was a major stressor for nurses, but the lack of trust ended up being in both directions. Inmates were often weary of trusting the staff at the jail. This was for several reasons, some being not trusting the system that incarcerated them, not respecting authority, or having feelings that the staff and inmates are different kinds of people. Hailey gives an excellent explanation why inmates lack trust in CNs:
A lot of the time when the guards are on their power trip, they make the inmates upset and they end up taking on a mentality where none of the workers [CNs and COs alike] are okay.
So even when we need to talk to them as nurses they associate us with the guards. They build up a wall and then they don't want to communicate with me. And a lot of the comments from them are like yu guys and I'm saying don't associate with me with them.
I'm here for your well-being and then I'm stuck breaking down that wall that they created before I can get anywhere.
In this example, all the correctional staff are lumped together and viewed negatively. This challenges the CNs as honesty is an important part of offering good healthcare. Sometimes this worked in such a way that an inmates distrust of CNs put their own health at risk. When asked how the mistrust inmates have can hinder their work, Marie shared a concerned example:
It's super stressful. That's the thing about protocol, somebody could be saying they're doing one or two grams of heroin and you have to trust them despite being kind of an untrustworthy population. We often dont know what to give them for withdrawals because they wont tell you. Its not safe.
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Marie explains that the inmates are not being honest with them about drug usage so CNs dont know what kind of withdrawal medicine to put them on. This was very important to her as starting the wrong treatment could be a life or death situation.
Institutional Rules and Policies
CNs explained that the imbedded rules and policies were problematic in correctional facilities. This caused major disruptions in their work.
Lack of Resources
Many CNs complained about the lack of resources available to them at the jail. They
noted that the funding is very different than at one of the larger city hospitals. This led to
limited medications and basic supplies the CNs required to make their jobs run smoothly.
Bridget explained her frustrations with the lack of resources:
I do remember frequently running out of medications that were extremely important, such as BP meds, seizure medications, HIV meds etc. That was a major problem that we experienced.
CNs repeatedly expressed that their work was professional and that they offered the best care they could. They also expressed that their work would have been easier and more proficient with the right tools and medical supplies for the job.
Policy Issues
CNs reported frustrations with the way the jail operated. In the jail setting there are security and healthcare protocols in place to assist in daily operations. Often these go as planned but they are ineffective at times. One CN expresses her concern over the health of drug addicted patients that had not been taken care of while she was on vacation:
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I was doing intake on people who hadnt been seen in three days, so some people had already gone through withdrawals.
CNs from this study all took addictions and withdrawing patients very seriously. They expressed that misdiagnosing or overlooking such a thing was the easiest way for someone to die while in custody.
Another major area of concern from CNs was the lack of training they received by the
jail, especially considering how unique and specialized inmate care is. Even nurses who had
past experience working in a jail setting expressed frustrations:
I did my cap stone (final project) at the jail. I was already employed as an EMT at the jail during this process so it was not new but I do feel I was pushed to the floor sooner than Ed have liked, but I went along with it because in my opinion there is no better way to leam.
Other CNs had it far worse and felt unprepared for the job. They were all surprised by
the lack of training that went into the position:
Brandon: Did you feel your education prepared you for a job working at the jail?
Marie: Somewhat. For the most part, correctional nursing is divided into substance abuse, which we had absolutely no education to prior to entering the facility: Psychiatric conditions, suicide screenings, wound care, medication administration, emergency triage, obstetric care [pre/post delivery], gyno exams, STD screenings etc. I received most of my preparation at the facility itself, training as I worked.
Brandon: Did you feel ready for the job by the time they finished training you?
Marie: Not at all. It was astounding how underprepared each one of us felt. They usually promised two weeks of full time training, but they were usually so short staffed, they would often call you to pick up shifts after your first few days of training. There was a lot of pressure from management to pick up shifts before you were ready to help the team out.
As a result, their staff turnover was immense and most of us never really felt like we knew exactly what we were supposed to be doing.
CNs had very similar responses regarding education and training. Hailey was asked if
her education from nursing school prepared her for the correctional setting:
Hailey: It did, and it didnt. I would say no schooling can prepare you for the experience youre going to have working in a jail facility. I was able to tap into things I learned in school for certain things, like assessments, medical procedures, and giving medications. I noticed my psychology nursing class actually helped me the most. I was constantly dealing
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with people with types of personality disorders, depression, drug addictions, etc. I was able to practice my therapeutic communication, which will really help me in the future.
Brandon: Were you given proper training at the jail?
Hailey: Absolutely not. Unfortunately, I started at a time where a lot of the nursing staff was quitting. I was scheduled for three training days, which would have equaled 36 hours of training. I ended up only training for one shift (12 hours) with a nurse who didnt even work at the jail facilityshe was filling in from another facility. The next day, I came into my shift and they were so understaffed that they had to ask me to work on my own and ask questions if I needed. When I would ask questions, I would hardly get an answer or any assistance really. It was such hard work learning the system on my own, and Im honestly surprised I stuck around.
Understaffing
Another common issue among CNs was the ever-burdensome understaffmg at their jail facilities. It appeared that for all the nurses, staffing was probably the biggest problem at work. The environment was not for a lot of people which led to a high turnover rate as nurses would try the job out and then realize they do not want to work in the environment. This is what some of the CNs expressed when asked about staffing issues at their work:
Bridget: The turnover rate at the jail is never ending. I feel that there are new faces every time I pick up a shift.
Marie: We were rarely, if ever, fully staffed. This is one of the major issues with correctional care. It is extremely stressful and scary. It wasn't uncommon for me to work 19 hours a day at the jail, when things were really bad. We were constantly asked and expected to work our 12-hour shift and then stay over for an additional 4 hours to help the next shift with med pass. It was always like this. One of the most stressful jobs I have ever had.
Hailey: Usually only around 5 nurses at a time. For the whole population like 50 or 60 inmates per nurse.
The inability to keep the jail staffed with nurses created a great deal of problems at the jail and stress for the CNs. Here is an example of a nurse being understaffed when an emergency code was announced:
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Only 2 of us could go but not a whole team and I was really new at the time still. I had responded to a code before but never so short-staffed. So, I was always worried, what if somebody needs to be responded to who is trying to hang themselves and only two people who are very inexperienced had to perform CPR in an emergency setting? I was literally terrified. Then we had 2 codes happen at once! We went from one side of the jail to the other where there was a female fainting and it wasn't a big deal, but the next code was trying to hang herself by her bed sheets! The two pods are very close to each other fortunately. But if I was on the opposite side of the jail?
When the jail was understaffed the work would pile up and become a serious burden on the CNs.
So, every day I was in, there were like thirty people who hadnt been seen plus the thirty or so I would see throughout my shift. I was leaving every night with horrible migraines. I wasnt taking breaks, drinking water. Its just unsafe. You have the deputies calling you and other nurses calling you and saying people are withdrawing and havent been seen.
Even more shocking was the nurse to inmate ratio. When asked how many nurses worked compared to the inmate population one CN answered:
I have this one module [holding area] where people go from booking and they wait a couple days before they are moved and there's probably 50 to 75 people in that one spot-maybe 50 to 100. No exaggeration. Usually the infirmary has one nurse in there and then they switch to another job [still nursing, just different duty] while one is on intake, another doing med pass, and others doing different things. Usually only around 5 nurses at a time. For the whole population like 50 or 60 inmates per nurse.
Numbers like these were reflected by the other CNs from their experiences working in the jail. All the nurses from this study now work in non-correctional settings, still as nurses. When asked how many patients they have now the response was between one and six.
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CHAPTER VI
DISCUSSION
This research offered a clearer and more detailed understanding of the correctional nurse experience for those working in a jail facility. Stigma, at work stress, issues with policy, etc. have been explored in past research, but this study provided a closer examination regarding those issues and more. This was accomplished by allowing the nurses to explain their occupation and experiences from their own perspective. Also, this study reported stressors faced by correctional nursing staff with its relation to role ambiguity.
In this study, it was clear that correctional nurses expectations of their nurse role severely lacked harmony with their perceived definitions of the role itself. The nurse role was constantly challenged and distorted causing role ambiguity. This project researched how these nurses experienced role ambiguity in several ways.
First, stigmatization was examined to unearth sources of role ambiguity that occurred outside of the work setting. Both public and private forms of stigmatization were experienced by all participants. Stigmatization occurs when individuals attributes are questioned by other societal members. The rejection of their attribute is discrediting and spoils ones identity (Goffman 1963). This devaluation occurs for CNs publicly when they are misunderstood by friends, family, and professional peers. This also occurs when that same group exaggerates, oversimplifies, or jump to conclusions about what CN work entails.
This was common for nurses in this study and echoes past research regarding psychiatric nurses feeling stigma coming from friends, family, and medical peers. Non-correctional individuals asked if CN work was dangerous, scary, and even easier than
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traditional hospital settings. CNs understood that people are generally ignorant to the details of their work, but often scrutiny is difficult to overcome.
In one study, psychiatric nurses reported very similar results with some of the worst scrutiny faced from professional peers. These peers referred to them as neurotic and lazy compared to other nursing types (Sercua, Ayalaa, and Bracke 2015:308). Professional peers perceptions of CN work were the most challenging on CNs. CNs explained that this was frustrating because in their eyes, taking such a negative position negated the concept of care. CNs were protective of their inmate patients and did not appreciate them being viewed as less deserving. Similarly, psychiatric nurses stuck up for their mentally ill patients much the same way CNs defended their inmate patients. Psychiatric nurses have described their patients as being in a challenging part of their life, or still being human, thus deserving of care (Sercua, Ayalaa, and Bracke 2015).
Devaluation also occurs for CNs privately as they deal with the perceived stigma they place on themselves. CNs from this study reported an internalized negativity surrounding their occupation. CNs reported a feeling of being looked down on by others for the work they do. They also expressed that the outside world judged them for caring for criminals.
This parallels findings from yet another psychiatric nursing study. Psychiatric nurses felt their stigma came in the form of association with an underappreciated and uncared for population-the mentally ill. In the case of CNs, the undeserving population is the incarcerated. Much like the CNs in this study, psychiatric nurses felt that outside members viewed them as under skilled and less caring than other nursing types (Halter 2008).
These internalized self-perceptions of their work and themselves offered serious frustrations on CNs. The malleability of the nurse role for CNs was apparent when it is
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misunderstood and easily scrutinized by others. Challenging that role weakens the strength and weight of the role, making it feel out of place in the larger nursing community. Role ambiguity may be said to arise when concepts of the outside world push back on the expectations CNs have for their nursing role.
Next, the nature of the work itself and its effect on CNs was examined. It was clear that many at-work stressors played havoc on their nursing role identity. One way this was executed was from unclear or vague demands from superiors and management. This also occurred when non-medical staff questioned the methods of the CNs.
CNs reported a lack of clear instruction and even no instruction at all from superiors. The absence of clear and precise expectations was a point of contention for CNs. Furthermore, CNs reported being overburdened with tasks and given impractical goals to attain. CNs feeling a lack of support and understanding of goal attainment from their superiors is a major source of stress (Flanagan 2006). CNs feeling stress regarding goal attainment and a lack of understanding of ones day to day duties at work has a strong association with role ambiguity (Griffin, Marie et al. 2010).
CNs reported issues with the non-traditional medical setting. CNs agreed that nursing in a hospital would be more enjoyable, less stressful, and their work would be taken more seriously. They also reported the job would be more meaningful to them and that they would enjoy the learning environment more. Most CNs in this study had past experiences working in hospitals as part of their training in nursing school. This mandatory training, known as clinicals offer nursing students important hands on training surrounding the day-to-day operations of a hospital setting (Dahlkea et al. 2016). Many CNs explained it was difficult to work in corrections having seen what the traditional hospital setting offers. They explained
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the hospital setting as nice with everyone seemingly working together with shared goals. Past research has shown that nurses in the correctional setting face more role ambiguity than nurses working in traditional settings (Gulotta 1986). For the CNs in the current study, clinical training offered a glimpse of the hospital setting. This created a perception of what a real medical setting could be for them. This seemed especially pertinent when hearing from nurses who had moved on from corrections. They unanimously agreed that they were happier working in a conventional setting versus the correctional setting.
The correctional officers that CNs work with also challenged their nursing roles. This was especially apparent when lines of communication became ineffective. The importance of care was usually respected by officers, yet at any time they had the ability to restrict care, stripping CNs of their autonomy in making medical decisions. Past research has shown COs vary in their level of support for CNs and patient care. Some COs are perceptive and helpful, while others pass judgment or impede care in more direct ways (Droes 1994). Former research explains that CNs enjoy their work more when officers respect them and when communication is stronger (Garland and McCarty 2009).
In this study, CNs explained that COs often participated in unprofessional behavior that impeded their ability to offer care. Correctional officers were unpredictable and often didnt follow medically related instructions which put inmate patients at risk. For a professional nurse, not providing quality care is contradictory to their role. When the officers judge CNs actions and get in the way of giving care, the role of nurse is disturbed.
The inmate patients that CNs cared for were also able to cause stress on CNs. Past findings explain that caring for inmate patients is not the same as caring for non-inmate patients (Weskopf 2005). CNs in this study reported that inmates were often difficult and
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demanding when receiving care. An even greater source of frustration was from inmates being untrustworthy and manipulating. Inmates would lie and manipulate to receive medications and special luxuries. Inmates often did not trust the CNs as they saw them in the same light as the officers on duty or that they are affiliated with a corrupt correctional system. Faking symptoms, lying about drug usage, and not trusting medical staff were all ways that impeded a CNs job. CNs reported that not only does such behavior cause them frustration, it is also dangerous to their inmate patients.
Thirdly, the built in institutional rules and policies were either poorly implemented or non-functional in providing a good working environment. The day-to-day operations were often ineffective, leaving CNs with a lack of resources needed for their job. A lack of training in their positions was a severe stressor on CNs. The environment was so challenging and difficult to work in that nursing staff would not stick around, leading to high rates of turnover. This caused the remaining CNs to be overworked and stressed which may have led to burnout.
Role ambiguity being reported at rates such as this should be taken seriously. The consequences of role ambiguity can lead CNs to experience high rates of at work stress, tension, futility, and lower rates of self-confidence. (Cooney 2014; Pearce 1981; and Kahn et al. 1964). Furthermore, role ambiguity may have the power to alter the nurse role for CNs in a negative way.
In this study, outside approval concerning their work was important to CNs and role theory explains why. The concept of role-taking involves imagining how others view you when acting out a role to legitimate the role for oneself. The behaviors that are acted out in a role add weight that the role belongs to them, especially if others offer confirmation. That
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confirmation from the outside world helps to legitimize the role for the participant. If someone fits a role, then specific actions and knowledge must be internalized by the participant that are congruent with what society determines appropriate. If that action or knowledge is absent, then role expectations become challenged (Cast 2004; Turner 1956; Stryker and Macke 1978).
Since roles are legitimized by the internal definition of a role and the outside confirmation by others, alterations can be made to assist the individual in fortifying the role for them. One way is for individuals to amend their behavior to better fit the perception others have of the role (Cast 2004). Taking action to better fit the role in this way is called role-taking. Small modifications are made so the role fits as close as it can between the expectations given to the role from society and the perceived internalized construct the individual has for the role (Heimer and Matsueda 1994; Turner 1974; Turner 1978).
As mentioned above, role ambiguity may cause a lack of confidence, stress, etc. which can be hard to face for CNs. To avoid the effects of role ambiguity, CNs may go through their own kind of role alterations to feel more a part of their role. It was clear in the analysis that CNs felt that the outside world did not understand their work and often passed judgement on them. CNs showed frustration regarding institutional processes, co-workers, etc. They also shared a viewpoint that they worked in another realm compared to a conventional medical setting. It may be possible that all those frustrations could lead CNs to alter the way they see the nursing role to better align with the expectations they experience at work and how society views them.
Though this is merely an observation and not a central theme of the research, such a transition could have negative effects on the correctional nursing occupation. CNs in this
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research believed they were competent, effective, and caring nurses. Accepting a societal definition that correctional nursing is less than other kinds of nursing could sour the occupation even more. The consequences could be dire for an occupation already riddled with stressors.
Limitations
The limitations of this research are noted by the small sample size, which greatly limits generalizability. This restricts the findings and observations to only those who participated in the study. As this is a preliminary study, the researcher wanted a close look at the phenomenon at hand and accomplished this through interviews, follow up questions, and generous analysis. Regardless, a larger sample size focusing on the areas studied in this research would be a benefit to the existing literature. The use of the open-ended interview schedules was helpful in creating perspective of what correctional nurses face in their unique work. More face-to-face interviews would likely have given even richer feedback regarding the lived experiences of these nurses.
A strength of this study was the focus given to in role ambiguitys effect on correctional nurses lives. Understanding how the nursing role was challenged from the built-in regulations, the day-to-day experiences, and stigma offered clarity into the reach of role ambiguity. Finally, limiting the research to only correctional nurses working in jails gave clearness in data that would have been muddled by attempting to make comparisons between other types of correctional institutions.
More quantitative research regarding role ambiguitys effect on correctional nurses would benefit the literature. New scales need to be developed that better gauge the existence
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of role ambiguity for quantitative research. More focused questions regarding the experiences of correctional nurses also need to be developed to honor the uniqueness of their work.
This study offered a clearer view of how correctional nurses experience role ambiguity. For the nurses in this study it became apparent that role ambiguity existed as an obstacle to a positive nurse identity. These findings are important as professional nurses are experiencing high amounts of stress in an arguably important yet underappreciated job. Nurses in all positions should be free of role ambiguity as it can affect their ability to offer care over the long run-both in a corrections job or in another medical setting.
Conclusion
This study sought to use the thoughts, feelings, and experiences of correctional nurses to better understand their connection to role ambiguity. It was evident that ambiguity challenged part of the nursing role identity. In doing so, nurses in this study expressed negativity about their jobs. The nurses in this study all expressed a deep passion for giving care to their patients despite their inmate status. Unfortunately, the stress of the job overpowered the want to work in their correctional environments.
The need for policy change is evident from the findings in this study. Whether funded publicly or privately, correctional facilities should offer better training for nurses before they start working with a difficult and potentially dangerous work setting. Education programs for nurses would likely benefit from more schooling in psychology, addiction, total institution care, and correctional health care in general. Correctional institutions need to create a more welcoming environment. High turnover, burnout, and job dissatisfaction are far too high in correctional nursing. If institutional goals include maintaining long-term professional staff,
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then an immediate set of policy changes need to be put in place. Ways to incentivize medical staff to dissuade high turnover rates need to be explored. Correctional officers and correctional nurses would benefit from training together and learning stronger communication skills. A clearer understanding of hierarchal power for nurses is needed with autonomy given to them when making medical decisions while also maintaining jail security.
Finally, the associated stigma with correctional nursing needs to be countered. Nursing educators and correctional nurse trainers need to offer better background into what the job details and how it is important work for society.
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REFERENCRES
American Correctional Association. 2005. In 2002, more than two-thirds of jail inmates were found to be dependent on or to abuse alcohol or drugs. Corrections Compendium 30(5):38.
American Nurses Association.2016. What Is Nursing? What is Nursing? Retrieved November 28, 2016 (http://www.nursingworld.org/EspeciallyForYou/What-is-Nursing).
Baillaigeon, Jacques et al. 2004. The Infectious Disease Profile of Texas Prison Inmates. Preventive Medicine 38(5).
Biernacki, Patrick and Dan Waldorf. 1981. Snowball Sampling: Problems and Techniques of Chain Referral Sampling. Sociological Methods and Research 10(2): 14163.
Brunetto, Yvonne, Rod Farr-Wharton, and Kate Shacklock. 2011. Supervisor-Subordinate Communication Relationships, Role Ambiguity, Autonomy and Affective Commitment for Nurse. Contemporary Nurse 39(2):227-39.
Burke, Peter and Judy Tully. 1977. The Measurement of Role Identity. Social Forces 55(4):881-897.
Cast, Alicia. 2004. Role-Taking and Interaction. Social Psychology Quarterly 67(3): 296-309.
Cast, Alicia and Sharon R. Bird. 2005. Participation in Household and Paid Labor: Effects on Perceptions of Role-Taking Ability. Social Psychology Quarterly 68(2): 143-159.
Chafin, Sue and Wendy Biddle. 2013. Nurse Retention in a Correctional Facility: A Study
of the Relationship Between the Nurses Perceived Barriers and benefits. Journal of Correctional Health Care 19(2): 124-134.
Christensen, Stacy. 2014. Enhancing Nurses Ability to Care Within the Culture of Incarceration. Journal of TransculturalNursing 25(3):223-231.
Elaine, Clayton. 2015. Correctional Nurses-Time to Overcome the Stigma! Arizona Nursing Association. Retrieved August 5, 2016
(http://www.nursingald.com/uploads/publication/pdf/1138/Arizona_Nurse_2_15.pdf).
42


Cooney, Teresa, Christine Proulx, Linley Snyder-Rivas, and Jacquelyn Benson. 2014. Role Ambiguity Among Women Providing Care for Ex-Husbands. Journal of Women & Aging 26(1):84-104.
Creswell, John. 2013. Qualitative Inquiry and Research Design: Choosing Among Five Approaches. 3rd ed. Thousand Oaks, CA: SAGE Publications.
Dahlkea, Sherry, Maureen O'Connor, Teresa Hannessonb, andKarleen Cheethamb. 2016. Understanding Clinical Nursing Education: An Exploratory Study. Nurse Education in Practice 17:145-52.
Dodd, Agnes, Jeanette Lawrence and Jaan Valsiner. 1997. The Personal and The Social: Mead's Theory of The Generalized Other'. Theory & Psychology 7(4):483-503.
Dolovich, Sharon. 2009. Cruelty, Prison Conditions, and The Eighth Amendment. New York University Law Review 84(4):881
Droes, Nellie. 1994. Correctional Nursing Practice. Journal of Community Health Nursing 11 (4): 201 -210.
Finney, Caitlin et al. 2013. Organizational Stressors Associated with Job Stress and Burnout in Correctional Officers: A Systematic Review. BMC Public Health 13(1):82.
Flanagan, Nancy and Timothy Flanagan. 2001. Correctional Nurses' Perceptions of Their Role, Training Requirements, and Prisoner Health Care Needs. Journal of Correctional Health Care 8(l):67-85.
Flanagan, Nancy and Timothy Flanagan. 2002. An Analysis of The Relationship Between Job Satisfaction and Job Stress in Correctional Nurses. Research in Nursing and Health 25(4):282-294.
Flanagan, Nancy. 2006. Testing the Relationship Between Job Stress and Satisfaction in Correctional Nurses. Nursing Research 55(5):316-327.
Garland, Brett and William McCarty. 2009. Job Satisfaction Behind Walls and Fences:
A Study of Prison Health Care Staff. Criminal Justice Policy Review 20(2): 188-208.
Gulotta, Kleanthe. 1986. Factors Affecting Nursing Practice In a Correctional Health Care Setting. Journal of Prison and Jail Health 6(l):3-22.
43


Giorgi, Amedeo. 2012. The Descriptive Phenomenological Psychological Method. Journal of Phenomenological Psychology 43(1):3-12.
Glaser, Barney and Anselm Strauss. 1967. The Discovery of Grounded Theory: Strategies for Qualitative Research. Chicago, IL: Aldine Publishing Co.
Goffman, Erving. 1961. Asylums: Essays on The Social Situation of Mental Patients and Other Inmates. Garden City, N.Y.: Anchor Books.
Gerber, Lois. 2012. An Inside Look at Correctional Health Nursing. Nursing 42(4):52-56.
Greenberg, Elizabeth, Eric Dunleavy, and Mark Kutner. 2007. Literacy Behind Bars:
Results From the 2003 National Assessment of Adult Literacy Prison Survey. U.S. Department of Education. Retrieved August 5, 2016 (http://nces.ed.gov/pubs2007/2007473.pdf).
Greer, Tomika and Toby Egan. 2012. Inspecting the Hierarchy of Life Roles: A Systematic Review of Role Salience Literature. Human Resource Development Review 11(4): 463-49.
Griffin, Marie et al. 2010. Job Involvement, Job Stress, Job Satisfaction, and Organizational Commitment and the Burnout of Correctional Staff. Criminal Justice and Behavior. 37(2):239-255.
Halter, Margaret. 2008. Perceived Characteristics of Psychiatric Nurses: Stigma by Association. Archives of Psychiatric Nursing, 22(l):20-26.
Hardesty, Katherine, Janice Champion and David Champion. 2007. Jail Nurses:
Perceptions, Stigmatization, and Working Styles in Correctional Health Care. Journal of Correctional Health Care 13(3 ): 196-205.
Harrison, David. 1980. Role Strain and Burnout in Child-Protective Service Workers. Social Service Review 54(1):31-44.
Heimer, Karen and Ross Matsueda. 1994. Role-Taking, Role Commitment, and
Delinquency: A Theory of Differential Social Control. American Sociological Review 59(3):365-390.
44


Hepburn, John and Celesta Albonetti. 1980. Role Conflict in Correctional Institutions: An Empirical Examination of the Treatment-Custody Dilemma Among Correctional Staff. Criminology 17(4):445-460.
James, Doris and Lauren Glaze. 2006. Bureau of Justice Statistics Special Report: Mental Health Problems of Prisons and Jails. Bureau of Justice Statistics. Retrieved Auguest 5, 2016 (http://purl.access.gpo.gov/GPO/LPS75138).
Kaeble, Danielle, Lauren Glaze, Anastoasios Tsoutis and Todd Minton. 2014.
Correctional Populations In The United States, 2014. Bureau of Justice Statistics. Retrieved August 5, 2016 (http://www.bjs.gov/content/pub/pdf/cpusl4.pdf).
Kahn, Robert, Donald Wolfe, Robert Quinn, and J. Dedriek Snoek. 1964. Studies in Role Conflict and Ambiguity. New York, New York: John Wiley & Sons.
Lobato, Mark, Jessica MacNeil, and Marisa Moore. 2005. An Unanswered Health Disparity: Tuberculosis Among Correctional Inmates, 1993 Through 2003. American Journal of Public Health 95(10): 1800-1805.
Maslach, Christina and Susan Jackson. 1981. The Measurement of Experienced Burnout. Journal of Occupational Behavior 2(2): 99-113.
Maroney, Mary. 2005. Caring and Custody: Two Faces of the Same Reality. Journal of Correctional Health Care 11(2): 157-169.
Mayoh, Joanne and Anthony Onwuegbuzie. 2013. Toward a Conceptualization of Mixed Methods Phenomenological Research. Journal of Mixed Methods Research 9(1):91107.
NCCHP. 2002. The Health Status of Soon-to-Be-Released Inmates: A Report to Congress. National Commission on Correctional Health Care. Retrieved August 5, 2016 (http://www.ncchc.org/filebin/Health_Status_vol_l.pdf).
NCCHP. 2002. The Health Status of soon-to-be-released Inmates: A Report to Congress. National Commission on Correctional Health Care. Retrieved August 5, 2016 (http://www.ncchc.org/filebin/Health_Status_vol_l.pdf).
NCCHP. 2010. Certification for Registered Nurses in the Correctional Setting. National Commission on Correctional Health Care. Chicago, Illinois. Retrieved August 5,
1016 (http://www.ncchc.org/CCHPRN/index.html).
45


Pearce, Jone. 1981. Bringing Some Clarity to Role Ambiguity Research. The Academy of Management Review 6(4):665-674.
Prison Policy Initiative. 2016. Mass Incarceration: The Whole Pie 2016. Prison Policy Initiative. Retrieved August 5, 2016 (http://www.prisonpolicy.org/reports/pie2016.html).
Schoenly, Lorry and Catherine M. Knox. 2013. Essentials of Correction Nursing. New York, NY: Springer Publishing Company, LCC.
Schoenly, Lorry. 2013. Context of Correctional Nursing. Essentials of Correction Nursing, edited by Lorry Schoenly and Catherine M. Knox. New York: Springer Publishing Company, LCC.
Schiitz, Alfred. 1945. Some Leading Concepts of Phenomenology. Social Research
12(l):77-97.
Sercua. Charlotte, Ricardala Ayalaa, and Piet Bracke. 2015. How Does Stigma Influence Mental Health Nursing Identities? An Ethnographic Study of the Meaning of Stigma for Nursing Role Identities in Two Belgian Psychiatric Hospitals. International Journal of Nursing Studies 52(1):307-316.
Shields, Kristine and Dorothy de Moya. 1997. Correctional Health Care Nurses' Attitudes Toward Inmates. Journal of Correctional Health Care 4(l):37-59.
Smith, Sue. 2005. Stepping Through the Looking Glass: Professional Autonomy in Correctional Nursing. Corrections Today 67(1):54.
Stryker, Sheldon. 1968. "Identity Salience and Role Performance: The Relevance of
Symbolic Interaction Theory for Family Research." Journal of Marriage and the Family 30(4):558-64.
Stryker, Sheldon and Anne Statham Macke. 1978. Status Inconsistency and Role Conflict. Annual Review of Sociology 4(l):57-90.
Sung, Hung-En and Jeff Mellow. 2010. Jail Inmates with Co-Occurring Mental Health and Substance Use Problems: Correlates and Service Needs. Journal of Offender Rehabilitation 49(2): 126-145.
46


The Pew Center On the States. 2008. 1 in 100: Behind Bars in America. 2008. The Pew Center on the States. Retrieved August 5, 2016
(http://www.pewtrusts.Org/~/media/legacy/uploadedfiles/pcs_assets/2008/one20in201
00pdf.pdf).
Turner, Jonathan, Leonard Beeghley, and Charles Powers. 2007. The Emergence of Sociological Theory. 7th ed. Belmont, CA: Thomson Wadsworth.
Turner, Ralph. 1956. Role-Taking, Role Standpoint, and Reference-Group Behavior. American Journal of Sociology 61(4):316-328.
Turner, Ralph. 1974. Life as Theater: A Dramaturgical Sourcebook, edited by D. Brissett and C. Edgley. Chicago, IL: Aldine Publishing Co.
Turner, Ralph. 1978. The Role and the Person. American Journal of Sociology 84(1): 1-23.
Weiskopf, Constance. 2005. Nurses Experience of Caring for Inmate Patients. Journal of Advanced Nursing 49(4): 3 3 6-343.
White, Amanda and Laura Larsson. 2012. Exploring Scope of Practice Issues for
Correctional Facility Nurses in Montana. Journal of Correctional Health Care 18(l):70-76.
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APPENDIX A
INTERVIEW SCHEDULE AND VOLUNTARY CONSENT
Thank you for volunteering to be a part of this project. As former and current correctional nurses, you know better than most that giving care in a correctional environment has many challenges. The reason for this project is to learn more about the fascinating field of correctional nursing and attempt to learn specifics about the profession that have yet to be covered in existing literature. This projects main purpose is to learn how nurses feel challenged in their roles compared to nursing environments outside of corrections.
Your participation is strictly confidential and any names, locations, or specific details regarding people or places will be altered or given pseudonyms to further insure confidentiality. Since your participation is voluntary you have the right to withdraw from the project at any time. My personal information along with my department project chair for this project is listed at the bottom.
The following document asks several questions regarding your experiences as a correctional nurse. Please answer all questions completely and feel free to add as much detail as you like. The longer your response, the more richness in data I will have, which gives me more to work with during my analysis. If you are unsure exactly what a question is asking, just answer to the best of your knowledge or feel free to contact me for clarification. With that said, feel free to add more space between questions if you feel you need more room to type. This should take around 30 minutes to complete. Again, thank you for your assistance with my project. If you have questions or concerns, you may contact: Brandon.Kilgore@UCDenver.edu or Candan.Duran-Aydintug@UCDenver.edu.
The following questions relate to how correctional nurses feel about the role they play while working in the jail setting. Your definition of what a nurses role is completely up to your interpretation. Please answer the questions and explain why you answered in that way.
Correctional Nursing Roles
Did you ever feel like your role as a nurse was challenged while working at the jail?
Did you ever feel pressure between the caring for and custody of the inmates?
Were you ever given conflicting/confusing directions that didnt seem to be a part of your job, or that made your job more challenging?
Do you feel there is stigma being a correctional nurse compared to another medical setting? If you answer yes, please explain why you feel that way.
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Did you ever receive stigma from people outside the jail setting? If so, describe what they said?
While a nurse at the jail, did you actively pursue other nursing positions outside of corrections?
Did your nursing education prepare you specifically for the correctional nursing environment?
When you started at the jail, do you feel you were not given the proper training?
Do you believe the care received by inmates is at an acceptable level?
Please give your thoughts on the following areas. Feel free to explain how each area has or has not affected your nursing experience or your ability to give care.
Guards
Have you had good relations with correctional officer staff?
How would you describe their interactions with inmates?
Describe a positive experience, or a time an officer assisted you while at work.
Describe a negative experience, or a time an officer has impeded your work.
Inmates
Have you ever had any trust issues with patients, or have you ever been manipulated by inmates?
What is your opinion on giving education to the inmates who have problems with drug and alcohol addiction?
What is your opinion on giving education to the inmates who have infectious or debilitating diseases?
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Have you ever felt challenged in giving an inmate medical care due to their reason for incarceration?
Describe an experience where you had an incident with an inmate that impeded their care.
Setting
What about the jail setting do you like the least?
Explain how you would feel working in a conventional hospital setting compared to working in corrections.
Give me your thoughts on the rules and policies that existed while working at the jail. What worked? What did not work?
Resources
Have you experienced staffing issues or felt overworked at the jail?
Do you feel there are enough nurses on site to care for the inmate population? Please give an explanation for your answer.
Is the proper type, amount, and quality of medical equipment and other resources available?
As a professional nurse, do you feel your pay was appropriate while working at the jail?
Management
In your opinion, did management ever impede your ability to make professional judgment calls?
Was management more focused on security measures or medical care of inmates?
Has management offered realistic goals for correctional nurses to complete?
Demographic Questions
Age:
Level of education:
Years of nursing experience:
Years worked as correctional nurse:
Type of work currently in:
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Full Text

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CHALLENGES IN CORRECTIONAL NURSING FROM ROLE AMBIGUITY by BRANDON KILGORE B.A., Western Washington University, 2009 A thesis submitted to the Faculty of the Graduate School o f the University of Colorado in partial fulfillment of the requirements for the degree of Master of Arts Sociology Program 2016

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This thesis for the Master of Arts degree by Brandon Kilgore has been approved for the Sociology Program by Candan Duran Aydintug, Chair Kari Alexander Leigh Ingram December 17, 2016

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ii Kilgore, Brandon (M.A., Sociology) Correctional Nursing and Role Ambiguity Thesis directed by Associate Professor Candan Duran Aydintug ABSTRACT Correctiona l nurses are the primary health providers to inmates in US jails. Understanding what they deal with in the correctional environment allows researchers to gauge the functionality of correctional institutions and monitor job satisfaction among its staff. The body of literature regarding correctional nursing stress and job satisfaction has increased but is limited in scope regarding role theory. In this study, a phenomenological approach was taken to determine how much role ambiguity correctional nurses faced concerning the work they do. The results indicate that role ambiguity affected correctional nurses in three ways. First, correctional nursing has stigma associated with it Second, the experiences working in jail were burdensome on correctional nurses. Thi rd, the institutional rules and policies were ineffective in deterring workplace stress. These three areas are examined and related to the role ambiguity faced by correctional nurses. Limitations, implications, and policy reform are discussed. The form a nd content of this abstract are approved. I recommend its publication. Approved: Candan Duran Aydintug

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iii To my adoring wife Bree whose support and love allowed this project to happ en.

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iv TABLE OF CONTENTS CHAPTER I. II. LITERATU Burnout/Turnover. .5 Stigma... III. IV. 14 V. Role ambiguity from Stigma ... 18 Nature of Work Creating Role Ambiguity .. Issues W ith Non 22 Institutional Rules and Policies ... V. 39

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v A. Interview Schedule and Voluntary Consen t... ...

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1 CHAPTER I INTRODUCTION The Bureau of Justice Statistics reports that in 2014 more than 6.8 million people were under the supervision of US corrections in some capacity (Kaeble et al. 2014:1). When not looking at those under parole or probation, the US still holds over 2.3 million people in correctional institutions. This tr anslates into 1 in every 100 adults detained in a US jail or prison (The Pew Center 2008:5 7). Such statistics emphasize the fact that housing, feeding, and basic care for inmates is an arduous goal. The eighth amendment created basic inmate rights in 1791 It states that those convicted of a crime will not receive cruel and unusual punishment. During the 20 th general rights and well being. This included the right to basic medical needs (Dolovich 2009; NCCHC 2010). Despite health care existing in US corrections for well over a century, correctional nursing only became recognized as a medical specialty by the US Supreme Court in 1976 and the American Nurses Association in 1985 (Schoenly 2013; Clay ton 2015). Nurses are the primary health providers to the millions incarcerated in the United States. These nurses face challenges that are unique to their job setting (Flanagan and Flanagan 2002; Maroney 2005). Correctional nurses exist in an interesting continuum. They give the same care as their hospital counterparts with the exception that their work environment is a correctional facility; their patients are inmates; and their peers correctional officers. How do these nurses feel about the roles they p lay as caretakers for the incarcerated? How are their roles as medical professionals challenged? The purpose of this study is to develo p a preliminary

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2 understanding of correctional nurses and examine how their role as a nurse is being challenged.

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3 CHAPTER II LITERATURE REVIEW Given the uniqueness of the correctional nurse profession, correctional nursing has been viewed in a different light than other types of nursing. It is important to make clear distinctions between correctional nursing and more conventional nursing. Correctional nurses have things in common with their conventional nurse counterparts such as education requirements and offering care for a myriad of healthcare needs. Looking at the differences between correctional a nd conventional nursing offers a clearer understanding of how different the roles are. Conventional nurses work in a setting where direct healthcare is the primary aspect of their work. These settings often include hospi tals, clinics, and other healthcare facilities In these settings fine tune their skills in an area of medicine. They are known for providing care, giving council to families, and educating their patients regarding long term healthcare needs (American Nurses Association 2016). Correctional nursing demands all the same prerequisites that hospital nursing requires but with the addition of operating in a hyper controlled and secure setting, with very established rules and boundaries (Flanagan and Flanagan 2002). Unlike hospitals, nursing obligation is to secure inmates from the outside population. Healthcare becomes secondary in such a setting, as it is not as strongly built into institutional needs (Schoenly 2013; White and Larsson 2012; Weiskopf 2005). This is the primary difference between correctional health ere is an ever

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4 present struggle to find the balance between the health care needs of the prisoner and the 160). Nursing in a correctional setting is unique and has been compared to working in psychiatric a nd military hospitals (Flanagan and Flanagan 2001; Hardesty 2007). The myriad responsibilities the unpredictability, and day to day challenges in corrections is often seen as positive and rewarding for some correctional nurses (Schoenly 2013). Largely tho ugh, past research shows that working in a correctional setting is challenging for nurses. It makes sense that previous research has mostly focused on the difficulties of the occupation as there is a constant influx of inmates that need screening and often abrupt care. This leads the medical side of corrections to be fast paced and often stressful (Hardesty, Champion and Champion 2007). Literature on this subject makes it clear that correctional nurses (CN) have a unique occupation. CNs agree that the corre ctional setting sets their work apart from other types of nursing. In one study 97.5% of CNs felt that working in corrections made their jobs different from conventional nursing (Flanagan and Flanagan 2001:75). Common explanations included the type of pati ents they cared for and the restrictions placed on them by security protocols. Some argued that true nursing care is personable and more intimate than a correctional facility can a llow. Touching a patient is more first na me has been discouraged. Also, being the main health care providers for incarcerated patients has the potential for risk. This can be direct physical risk by dealing with an unruly or aggressive patient or psychological r isk from prolonged exposu re to th e environment itself. CNs also run the risk of facing lawsuits or job loss from correctional institutions when

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5 Burnout and Turnover Due to poor funding, lack of personnel, and a difficul t work environment, the rate of tress, job satisfaction, and level of involvement are all associated with correctional workers facing burnout. Correctional staff deal with a difficult population that can keep them from meeting goals and enjoying their work. Such stress cause workers to l and many learn the environment is not for them. This has led to considerably high turnover r ates. A recent study reported that one facility only retained 20% of its nursing staff within a three of support, which is a factor contributing to stress. Management often demands long hours and ever increasing workloads that are burd ensome for CNs (Flanagan 2006). Correctional centers are also notorious for being poorly funded regarding staffing, medical supplies, and equipment (Droes 1994). Stigma Correctional Nurse s also face stigmatization in the work they do. In one study over 70% of CNs agreed that their occupation is stigmatized when compared to other kinds of nursing (White and Larson 2012:72). A great deal o f this stigma co mes from the public s view on cor rectional work. Nurses report that community members, friends, and other nursing professionals have viewed CN work as dangerous and dirty (Hardesty 2007; White

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6 and Larson 2012). Other times CNs are embarrassed to talk about what they do because others may see them as not capable of fin ding a traditional hospital job, or their work is the only work they could find (Clayton 2015). Finally, CNs take care of a population that society cares less about. This can cause a CN to internalize their work as less impo rtant and less contributing to society (Christensen 2014). Autonomy Correctional Nurses, like other specialized nurses, report that professional autonomy is very important to them (Flanagan and Flanagan 2001; Flanagan 2006). Unfortunately, CNs have thei r autonomy challenged in several ways. As mentioned above, health care is they may have dec ision making ability over health care decisions, but at the same time face restrictions associated with lack of resources, strict secur ity protocols, and non nursing Inmates Compared to the general population, the incarcerated represent a unique group that shows the larger public health problem that exists. Les s than 50% of the incarcerated have graduated high school. They also have lower literacy rates and higher learning disabilities than the general population (Greenberg, Dunleavy, and Kutner 2007). The prevalence of infectious disease is higher in prison and jails especially concerning tuberculosis, HIV/Aids, and Hepatitis C (Baillargeon et al. 2004; Gerber 2012; MacNeil, Lobato, and Moore 2005).

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7 Sexually transmitted diseases such as gonorrhea and syphilis are dramatically higher among the inmate pop ulation (NCCHC 2002). Mental health and substance abuse are also major issues that CNs face. Mental health problems are more prevalent in jails and prisons than the general population (Gerber 2012). The prevalence of mental health issues are so high that several studies report rates at or near 50% of jail and pris on populations (Sung and Mellow 2010; Lincoln et al. 2015). For comparison, the general public only has an 11% rate of mental illness, a rate five times lower than the incarcerated population (James and Glaze 2006). More than two thirds of the jail and prison populations suffer from drug or alcohol abuse or addiction (American Correctional Association 2005). This puts CNs, especially ones that work in jails, in a challenging position as there is a highe r intake of new inmates that often involves careful screening and immediate care (Schoenly 2013). Inmates are also known to be challenging patients as they are prone to manipulating the correctional system and individuals who work in them. Past research has show n that CNs have frustrations with inmates attempting to manipulate them for personal gain (Maroney 2005). Trust issues arise from such interactions which complicates a CNs ability to provide adequate care (Shields and Moya 1997). Working in correction s can be a challenging job and correctional nurses are an important group to study. Given the magnitude of the population they care for, the specialization of their job, and the difficulties they face, it is surprising the research is as limited as it is. Much of the research done is conflicting; offering inconsistent data on the subject. This is likely due to a lack of cohesion in research as CNs working in different types of corrections are lumped together. Some research fails to understand the important

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8 distinction between jails and prisons and how the environments are dramatically different. Even just looking at the jail setting, from one facility to the next there may exist funding discrepancies and policy changes. A clearer foundation regarding the det ails of correctional nursing is needed. Having CNs explain their experiences and feelings about their work would offer a more fundamental understanding of what they do, think, and feel about their work.

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9 CHAPTER III THEORETICAL FRAMEW ORK A more comprehensive analysis is needed to gain further insight on CNs Quantitative research has gathered important statistics regarding inmate populations such as rates of incarceration, drug and alcohol addictions, and suicide rates. Qualitative research has performed studies for those housed in jails and prisons and those whom work in them. Unfortunately, attempts at a cohesive understanding of correctional nursing is limited from both qualitative and quantitative approaches. Reasons include: poo r methodology; asking too many or too confusing questions; and performing multi site (often multi state) research that has skew ed analysis. The lack of quality data likely comes from not appreciating fundamental differences between one jail or prison from anothe r; i.e. population density, private vs public ly run, and maximum security prisons vs small town jails. Past research has uncovered aspects of correctional nursing. Unfortunately, the population is rather unique and creates challenges to research. With that in mind, this research project will attempt to gain insight of what correctional nurses experience by using a more focused approach. To offer a more comprehensive base for the phenomenon, qualitative meth ods will be used to gather more detail a bout the occupation and experiences therein A phenomenological approach will be used to aid in data collection on such a specific group. This will allow participants to define the work and experiences from their point of view. Finally, the effect of role ambiguit y on correctional nurses is examined to determine the wide sweeping stressors associated with the occupation. These methods used in unison is what sets this research apart from others makin g this preliminary study an ideal launching point for future research projects.

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10 Phenomenology The Mathematician and Philosopher Edmund Husserl began the discussion of Phenomenology in the 1930s and explained the method as a tool to see past our pre conceived notion of a situation, event, or thing (Schtz 1945). The method has been built upon a great deal over the years and is now used as a social scientific tool that allows researchers to overcome preexisting assumptions regarding a given phenomenon (Giorgi 2012). It is argued that to truly understand a phenomeno the existence of the outer world, but for his analytical purpose he makes up his mind to is means one suspends all doubt and preconceptions about the subject at hand and see it for what it is, not how others define it (Mayoh and Onwuegbuzie 2013). More simply, (Creswell 2013:57). Using this metho d aids the researcher in describing the nature of a phenomenon from the point of view of those who have experienced it. For example, there are plenty of definitions and ideas of what it means to be an astronaut. Asking an actual astronaut would offer the actual lived experiences instead inferring information from the outside world. This perspective gives the opportunity to add richness to a study, especially studies that involve hard to reach or unique populations ( Creswell 201 3 ) This is pertinent to the current study as the resea rcher has posited that a fundamental issue with past research may be that preconceived notions of what a correctional nurse does are used to measure their experiences. Also, correctional nurses have a unique occupation that may benefit from reexamination t hrough a more focused lens. Using the

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11 phenomenological method, the researcher plans to interpret the experiences of correctional nurses from their perspective This research will ask them questions about how they feel their role as a nurse is affected by their work. Phenomenological research has been done on correctional nurses, but is very limited. Weiskopf noted in her phenomenological study on CNs that past research on nurses have avoided the correctional environment (20 05). In that project, the researcher specifically focused on issues associated with caring for inmate patients. In the current study, the focus is role as a professional nurse is challenged by their work and the work setting. Role Theory In this study, role theory is used to learn and evaluate correctional nurses. Early work on self, identity, and role theory come from the writings of George Herbert Mead, who paved the way for modern symbolic interactionism. In giving us in sight into the process of interaction, Mead showed how individuals are an extension of society. This offered researchers tools to help understand identity formation (Tuner, Beeghley, and Powers 2007; Dodd, Lawrence, and Valsiner 1997). Our sense of self is derived from the culmination of a collection of patterns of behavior which are thought to constitute a meaningful unit and deemed appropriate to a p (Turner 1956:316). A role is a set of behaviors that ha ve implied meaning given to it by society and are used to satisfy a particular status. By performing roles, we often take them on as important aspe

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12 what attaches us to our identities. When we fully accept the role as a part of our identity we are participating in role embracement (Goffman 1961). These roles are extr emely important Roles give labels to individuals who behave in a manner appropriate to how social norms define expectations for roles. Through socialization, people participate in the concept role taking where they learn and execute the patterns, meaning, and shared ideas of a certain role. Individuals act out certain roles because the role aligns with the kind of person they want to be or see themselves as. Instead of having a single role, pe ople take on many roles with varying degrees of importance (Stryker and Macke 1978). The power a role holds can vary and with more power comes higher role freight or b roles are not met, sanctions may arise. When a role is compromised the severity of the sanction depends on the importance of the role. For instance, if a role is compromised in a social setting vs a formally structured setting the sanctions will be different (Stryker & Macke 1978). A simple example may be doing something embarrassing at a dinner party compared to doing something embarrassing at a board meeting. The simple social setting offers less scrutiny than the high expectations of a professional job. Individuals strive to fit neatly into their roles but have so many that not all of them will have equal importance. When individuals believe a role to be central to their ident ity, they make it one of their top roles. This is known as role salience which refers to the value one places on their core roles. An example of this would be listing the top four roles an individual has and gauging the importance of those roles. Imagine o

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13 Mother, artist, teacher, and wife. If those are the central roles one has, they still have weight over one another, yet all make up core roles (Greer and Egan 2012). e directly challenged by outside forces. Often, interruptions can affirm role status but sometimes that status can be impeded upon. Role conflict arises when an individual receives contradictory demands that do not coincide with the nature of their roles. Usually this involves one role status not aligning with another (Stryker and Macke 1978). Such as the need to be a father who spends time with his children but also a professional in a high demand job. Finally, role ambiguity o what is expected, appropriate, or research looked at how job related stress and job satisfaction came about from a lack of arises when expectations are put on an individual that are felt to be incompatible with the perceived role. Often, role ambiguity thought the job demanded (Brunet to, Farr Wharton, and Shacklock 2011). This preliminary study aims to uncover how correctional nurses experience role ambiguity from their experiences working in a jail. It will be determined if the nature of correctional nurse work challenges roles tradi tionally established in the nursing profession. perception of their role exists, causing role ambiguity. This logic appears sound as nurses are educated and traine d to be nurturing caretakers, yet the correctional environment they work in is not conducive to meet the role requirements expected.

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14 CHAPTER IV METHODS The current study looks at correctional nurses working in jails in a major metropolitan area of the sou thwestern United States. The reason for limiting this research to the jail setting and not including prisons are several fold. Firstly, past research has studied prison environments for a long time and the researcher felt adding to the lesser examine d jail setting was of better scientific inquiry. Second, the jail environment offers a very different experience for medical professionals. Despite prisons having many people incarcerated, state and county jails rotate over 11 million people annually, far more than the prison population (Prison Policy Initiative 2016). This happens for several reasons: People cannot make bail when arrested or are awaiting trial; people are being transferred to other facilities/prisons; and people are held on short sentences This translates to a lot of rotation and new people coming into local jails. Thirdly, many people who are sent to jail are sent immediately after arrest. The immediacy of the inmate/CN interaction makes the jail setting interesting to study. In the fall used throughout) who thought I would be intrigued by her new job as a correctional nurse. Beth had recently graduated nursing school and had been searching for full time nursing jobs w hen she was hired on by a local jail. I quickly became intrigued by the uniqueness of her occupation and the challenges she faced as a nurse taking care of an inmate population. I was inspired by my unfamiliarity of the occupation and the potential to unco ver new information on such a topic. I decided to conduct phenomenological research on correctional nurses and

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15 learn more about their lives and experiences. Beth became the key informant of this study and offered details of her occupation as well as access to other correctional nurses. As a preliminary study, only a small number of correctional nurses were asked and general in formation regarding the project to co workers at her local jail. From there, correctional nurses could contact me if they were intersected in participating. The technique of utilizing a key informant to inform and recruit others is known as snowball sampling (B iernacki and Waldorf 1981). The researcher first sought a basic understanding of correctional nursing from past research on the subject This would aid in determining what questions would to ask in the interview schedule. The researcher also examined studies regarding ro le ambiguity as it was of interest from the advent of the current study. Following this the researcher spoke to the key informant and asked her to describe the profession with detail. All of this gave the researcher a general knowledge and clearer directio n regarding what questions to ask correctional nurses about th eir job. The interview schedule asked CNs to describe several aspects of their jobs. These included at work stressors, relationships with co workers and patients, frustrations with management, just to name a few. Generally, CNs were asked to describe their work experiences and how they felt about those experiences in detail All the participants in this study were female, had graduated from nursing school within the last five years, and all worked less th an two years as a correctional nurse. A total of six CNs participated in the open ended interview schedules and two gave face to face interviews.

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16 When the open ended interviews were completed they were then re typed and any traces of personal informa tion were removed or changed to insure participant confidentiality. The original interview schedules were destroyed and the re typed copies were used for the study. face to face interviews. I met them individually at a public setting of their choosing. I took notes and digitally audio recorded the interviews. The interviews took about an hour each to complete. Upon completion of the interview the digital audio recordings were transcribed and the digital copy erased. Just like the open ended interview schedule, the transcriptions were edited to omit or change any personal information to insure participant confidentiality. As I familiarized myself with the material I found common themes that coincided with issues regarding stressors at work. Such topics would be helpful in gauging role concepts (Glaser and Strauss 1967). With these cate gories, the researcher developed theoretical explanations to interpret the feedback of the correctional nurses. The data used information could be drawn out (Glaser and Strauss 1967).

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17 CHAPTER V ANALYSIS As mentioned above, role ambiguity exists when expectations are put on an the responses from cor rectional nurses, it became obvious they experience a great deal of role ambiguity. Three clear forms of role ambiguity were identified through the coding process. 1.) Stigma exists for correctional nurses that challenges their role, leading to role ambig uity. This occurs both publicly and privately in the form of stigmatization. Publicly, stigma comes from family, friends and professional peers offering negative opinions or judgement on correctional nursing. Privately, nurses carry their own negative feel ings with them with how they personally view their occupation and how it is perceived by others. Both forms of stigmatization can be said to cause role ambiguity as the nature of their role is challenged. Having their nursing role scrutinized or falsely ju dged may cause CNs to feel they do not fit as neatly into their nursing role as they desire. Public and private stigma working together causes the outside world and the CNs to view correctional nursing in an ambiguous light. Role ambiguity may be difficult to shake for CNs as public perception of corrections is deep seeded. perceived ideas of their role is challenged by the experiences they have at work. In other words, wh en the duties and experiences of a nurse were not embodied by CNs. This causes a disassociation from the larger nursing community. The categories are as follows: unclear directions, nurse role challenged, issues with the non traditional setting, and role c hallenged by correctional officers and patient inmates.

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18 3.) The larger institutional rules and policy are often in direct conflict with what is perceived as a functional nursing environment. A lack of resources, ineffective policy, and understaffing was a major burden for nurses leaving them challenged in performing their work adequately. Not only did this meddle with expectations of nursing roles, it went as far as CNs not wanting to work in corrections at all. Role Ambiguity from Stigma The correctiona l nurses from this study all reported stigma surrounding the type of work they do. They felt stigma in two distinct ways. One way was publicly, from outside sources such as friends, family, and even p rofessional peers. The other was privately, and involves f eeling the job has stigma associated with it. Public Stigma Correctional nurses expressed discomfort from what others had to say regarding their line of work. Correctional nursing was viewed by some as dirty, unsafe, or beneath mainstream nursing. Most of the feedback CNs received was fear of personal safety. Hailey, a former correctional nurse, recently found a position at a big city hospital. When asked how her new co workers felt about her former jail position she responded: Most people at the hospit al I now work seem appalled, at the least, that I worked at a jail. The first thing people ask me is: Why? Does it scare you? Do you feel safe? This echoes what other CNs reported. Surprisingly, a great deal of the negative feedback came from professional peers. When asked why she thought they responded in such a way Hailey explained:

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19 Most have a sense of judgement towards this population in particular. It's as if the inmate population doesn't deserve proper healthcare like upstanding citizens do. The j udgement passed on the type of patient correctional nurses give care for was a point of contention from CNs. Their frustrations arose from a lack of care for people who need care, despite the reasons why. CNs try their best to look past the reasons why an inmate is in jail and focus on giving care to those who need it. One CN explained how non correctional afford bail, thus making them innocent until proven guilty. Ma rie explained her thoughts regarding non correctional nurse bias towards her inmate patients: people in there that are being treated like criminals when a lot of the m are waiting for a court date for a traffic ticket. They're waiting for their trial. That has just been super frustrating to me. I still like making inmates smile and we don't know what they're going through or what their situation is and as nurses we're not supposed to pass judgement. Being a correctional nurse has given me a wonderful opportunity to learn how to provide unbiased care to my patients, regardless of their history or past. It has helped me not to judge. I am not perfect, we all judge to some extent, but I am much more cognizant of biases and have learned to dismiss them. CNs explained that the work is challenging but the safety factor is largely misunderstood by the outside world. The security measures put in place are not merely to keep i nmates from escaping incarceration, they are there to prevent harm to correctional staff in general. Bridget explains that inmate patients are still people and that the safety issues perceived by others are inaccurate: I have never (other than the inmate who was rude about TB shot) had an inmate be rude them, they are in general pleasant in return. If someone is sick and in need of medical care regardless of who or wher e they are, they just want to feel better. Marie further explains how personal safety is less of an issue due to security protocols built into the jail:

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20 We were accompanied by deputies at every exchange with the inmates. When we were short staffed, the d eputies would go as far as helping us place the VS equipment on the inmates, while we were preparing medications to help quicken the workflow. Nurses explained the environment is not a dangerous place to work. Despite this CNs still carry the burden of public stigma by working in a correctional setting. Private Stigma correctional staff, friends, etc. They also brought their own bias in when starting the position. Many explained they always wanted to work in a c onventional hospital setting, but due to competition and lack of experience, had to start somewhere. This simple acknowledgement of correctional nursing being temporary and a explains her thoughts on how both she and the outside world view her work: I think other medical professionals almost look down on correctional nursing. I only worked there to get experience under my belt, as I was a newly graduated nurse competing for h be in the hospital setting. People are a lot more appreciative of the work I am doing, and I personally feel I am making a bigger difference in people's lives. Not only d id CNs have personal bias, they often perceived their job as scrutinized by outsiders despite personally feeling their positions were professional and important. They contribut ing to society. Nature of Work Creating Role Ambiguity The very nature of correctional nursing challenged CNs internalized definition of what a nurse is to them. The day to day activities, environment, and co workers challenge d the definition CNs had reg arding themselves. This study reports on three factors that cause

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21 role ambiguity for correctional nurses while they are at work. These factors include unclear directions and perceptions, issues with the work setting, and being challenged by correctional of ficers and inmates. Unclear Directions and Perceptions CNs reported unclear directions and unattainable goals when superiors delegated tasks examples of unattainable and unclear expectations from her superiors: most of the tasks, but there were times I was receiving unclear directions for something I had never done. Most of the time this results in something not getting done. Here, Hailey expresses frustrations not just over a lack of clarity, but a lack of any direction at all: We were just basically trying to learn everything on our own and I felt guilty for asking questions because everyone acted like I was an inconvenience for asking something and not realizing that I'm beginning to begin this process. I'm taking the intake and I need to know what I'm doing. And there should never be a stupid question. I get scared asking someone a question. I was coming home in tears because I didn't feel like anyone liked me and I didn't feel welcome. be when asked to complete more work than could be perfo rmed in the time offered: They added more and more ridiculous, time consuming logs and steps to our already overwhelming list of duties and then complained about the amount of overtime each of us logged in each week. Here is an example from Bridget recal ling one of her co workers being judged by an officer for helping a hurt inmate: I would constantly get questioned by deputies about my actions. I remember a situation where a deputy questioned one of the other nurses for helping an inmate that was bleedi ng on the ground.

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22 Here again, Hailey shares an experience where she was scrutinized by a correctional officer for offering care to an upset and hurt inmate. The other night I had a gentleman who had sustained a head injury. He had a concussion and he had bruises all over his face and his left eye had this huge hematoma and it had so much fluid under it he could hardly open his eyes. He is sitting here crying, telling me about the situation. I'm there to console him and take care of him and so I got his me dications right away. The deputies judged the fact that I was taking care of this guy. The CNs in this study were constantly challenged by judgmental officers. They expressed a lack of autonomy when custody officers scrutinized their work, especially when it regarded feeling remorseful for inmates. Issues with the Non Conventional Setting Correctional nurses experienced role ambiguity when their work environment was less conducive to that of a more traditional hospital setting. CNs explained that their experiences would be better in a traditional hospital setting: Marie backs up the claim that the hospital setting would not only be more enjoyable, but also a better place to offer care and to learn: I want to work in a hospital. I think I'd enjoy the environment more. My first stint at a correctional facility was a very negativ e regarding the environment and I'm not used to that. During clinicals my preceptor said they were really happy to have me and teach me and ask me questions that I can answer in a learning environment. The families [during clinicals] are positive and it's all viewed as a positive experience that you're helping someone. Whereas corrections you have inmates that are coming in with a negative state of mind because they were arrested. When I came in [to work in the jail] there were so many bullies and no one wa nted to help at all. I know personally I didn't know how hard

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23 the extent of it until you work under the tough conditions. Correctional nurses believe that in a hospita l setting, there may be more appreciative patients with families to interact with, changing the kind of care they offer. The opportunity to learn new things may be more accessible, if not promoted when working in a hospital. Also, several CNs believed that the funding would be better in a hospital, so more staff and better equipment would be available. The prospect of working around more medical staff and less security measures and personnel were also important to them. The potential to work in a more posit ive environment where their abilities would be appreciated was important as well. Challenges from Correctional Officers Aside from other nurses, CNs work the closest with correctional officers. Correctional officers (COs) were the main instrument in prov iding security in the jail setting. Their position was to insure the containment of inmates, but also provide security to the other employees at the jail. CNs understood and appreciated the work of the COs since it made the environment safer to work in. Bridget expressed the importance of the COs work and how a part of their job is to insure the safety of the staff: It is their job to ensure that the staff is safe given the environment we work in. The officers can be very firm at times but this is to est working with the deputies and officers is a fine balance and it is so vitally important to have good communication by all staff. Bridget explains that the staff may be firm at times, but that it is necessary in their line of work. S medical. The relationship is sustainable if good communication can be maintained. Unfortunately, not all COs are the same and often, good communication was not sustainable.

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24 When communication and cooperation broke down the attitudes and behaviors of COs often hindered the work of CNs, which in turn puts stress on their nursing role. Hailey explains how important communication is, but that they as CNs have maintain the integ rity of the communication: Even when lines of communication we re maintained the COs could be unpredictable in the way they carry themselves at work: If the guards were in a good mood, patient, kind and understanding to the inmates, our days were much smoother. If the guards were rude to the inmates, short and impati ent with us, the entire day was much more difficult to get through. In the above except Marie explains how the COs are difficult to gauge. She went on to explain that some COs were nice and patient with inmates, but some were aggressive and rude to them. The same thing occurred with new nursing staff. Some COs would be kind to new staff while others were rude and bullying towards them. This created an unpredictable and confusing e nvironment for some of the CNs. In this instance the CO challenged her ability to care and to make decisions as a professional nurse. Her authority to make health care decisions and to give care were met

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25 with anger instead of accepting t hat she knew what she was doing. After offering the above response, Hailey was asked how much authority she has over inmate health: enforcement personnel, therefore when it comes to most decisions being made about the inmates, the healthcare staff does not have much of a say. This makes caring for the inmates about what you have to say. Caring for the inmates is seen as a weakness to them. My role as a nurse was constantly challenged by the deputies and other law enforcement personnel. In the jail facility, the deputies have the upper hand over most situations. These are clear in A common example of communication breakdown occurred out of the CNs and COs having totally different perspective regarding the care for inmates. Sometimes the COs opinion of inmates were in d irect conflict with CNs. In this instance one CN explains how it can be difficult to work around their aggressive attitudes: CNs expressed and understanding that COs had to exhibit authority from time to time, but they disagreed with power being abused. They expressed that when COs acted in such ways, the work environment became less professional and that they could not give the proper care needed. COs also interrupted the CNs from inappropriate behavior s and interactions. The COs would flirt with and sometimes even sexually harass CNs. Marie shared an unfortunate experience she had with a CO: There was one officer in mini mum security who was sexually inappropriate with me during a medication pass. He rubbed up against me from behind and asked if I needed a shoulder

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26 rub, at which time I said "nope, I'm good," which he responded with "Yeah, I bet you are good." He intentiona lly tried pushing his genitals over a trashcan I use. At one point, he was so out of line that day, I actually felt more comfortable with the inmates. There were several inmates who offered to jump in and mediate the situation. I finished up quickly, left the POD [inmate living area] and filed a report which was never dealt with as far as my knowledge goes. I later learned that he had several sexual complaints from female inmates. In this ins tance the CO inappropriately exe r ted authority by harassing a nurse in front of inmates, with little or no regard for repercussions due to abusing his power. Sometimes COs simply do not listen to the directions from CNs regarding inmate care: There are times when officers have not understood the process for triaging inmates medically. They lack the understanding of what an immediate need is. S In these instances, the CO s were either ignorant of the needs of the medical staff or care d too little to do their jobs correctly. The CNs were especially bothered by the ineffective work of officers when it put their patients in harm. Challenges from Inmates Inmate patients prov ed to be challenging to CNs. At times, some inmates were untrustworthy and uncooperative which impeded the care CNs could offer to individual patients and the rest of those housed in the jail. Despite the challenges in offering care to inmate patients, nur ses showed a great deal of resilience in caring for those in jail: Caring for individuals with very serious charges (crimes against children, murder etc.) or individuals who are repeat offenders and take no initiative to care for themselves on the outside can be difficult. Regardless, one must put their nursing duty in the forefront and when to help.

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27 Despite acknowledging the need to give care no matter who receiv stop the CNs from expressing frustrations toward their inmate patients: Once in jail they are very demanding with the care they receive despite having not cared to address the issues on their own. This is obviously a blanket statement a nd does not pertain to all inmates, but it is a trend seen often and at the jail. The CNs from this study were all very companionate and professional in the work uniqueness of their work and patients. One nurse told a story about an inmate who just arrived in the jail after losing a friend to gun violence he was involved in: It was really, really intense. He was around my age and it was weird because it was like m e or you. Like I could have seen him in this setting [gesturing around our public setting] and it was a really eye opening situation. I'm going through our mental health questions in the someone that I could have known. This is an example of a nurse having to cope with patients dealing with very stressful and often depressing situations. CNs expr essed that caring for the inmate population is not easy and often depressing. CNs agreed that another form of stress from inmates comes from the lack of trust they have with inmates. Inmates would lie about medical emergencies and manipulate situations w hich was a constant nuisance to the CNs. When asked for an explanation of such behavior, Hailey responded: is a road into that stuff and sometimes we get taken advanta ge of... Bridget elaborates how staff is manipulated so the inmates can gain access to medicine and other goods:

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28 When they see people [staff] who are new they try and get as much out of you as they can. In general, most things that are not given a secon d thought like Tylenol, Gatorade or peanut you any line they can to try and get these things out of you. When asked if inmates manipulated staff, Marie responded: Ye s, every day. Most patients manipulated staff by either having fake medical emergencies such as chest pain, shortness of breath, seizures, etc. to either get controlled substances or sent to the hospital. We even had a guy who would swallow objects to get sent to the hospital. I never trusted any inmate. A lack of trust towards the inmates was a major stressor for nurses, but the lack of trust ended up being in both directions. Inmates were often weary of trusting the staff at the jail. This was for sev eral reasons, some being not trusting the system that incarcerated them, not respecting authority, or having feelings that the staff and inmates are different kinds of people. Hailey gives an excellent explanation why inmates lack trust in CNs: A lot of t he time when the guards are on their power trip, they make the inmates upset and they end up taking on a mentality where none of the workers [CNs and COs alike] are okay. So even when we need to talk to them as nurses they associate us with the guards. The y build up a wall and then they don't want to communicate with me. And a lot of the I'm here for your well being and then I'm stuck breaking down that wall that they c reated before I can get anywhere. In this example, all the correctional staff are lumped together and viewed negatively. This challenges the CNs as honesty is an important part of offering good healthcare. Sometimes this worked in such a way that an inma tes distrust of CNs put their own health at risk. When asked how the mistrust inmates have can hinder their work, Marie shared a concerned example: It's super stressful. That's the thing about protocol, somebody could be saying they're doing one or two gr ams of heroin and you have to trust them despite being kind of an

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29 Marie explains that the inmates are not being honest with them a bout drug usage so to her as starting the wrong treatment could be a life or death situation. Institutional Rules and Policies CNs explained that the imbedded rules and policies were problematic in correctional facilities. This caused major disruptions in their work. Lack of Resources Many CNs complaine d about the lack of resources available to them at the jail. They noted that the funding is very different than at one of the larger city hospitals. This led to limited medications and basic supplies the CNs required to make their jobs run smoothly. Bridge t explained her frustrati ons with the lack of resources: I do remember frequently running out of medications that were extremely important, such as BP meds, seizure medications, HIV meds etc. That was a major problem that we experienced. CNs repeatedly expressed that their work was professional and that they offered the best care they could. They also expressed that their work would have been easier and more proficient with the right tools and medical supplies for the job. Policy Issues CNs reported f rustrations with the way the jail operated. In the jail setting there are security and healthcare protocols in place to assist in daily operations. Often these go as planned but they are ineffective at times. One CN expresses her concern over the health of drug addicted patients that had not been taken care of while she was on vacation:

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30 Another major area of concern from CNs was the lack of training they received by the jail, especially cons idering how unique and specialized inmate care is. Even nurses who had past experience working in a jail setting expressed frustrations: I did my cap stone (final project) at the jail. I was already employed as an EMT at the jail during this process so it have liked, but I went along with it because in my opinion there is no better way to learn. Other CNs had it far worse and felt unprepared for the job. They were all surprised by the l ack of training that went into the position: Brandon: Did you feel your education prepared you for a job working at the jail? Marie: Somewhat. For the most part, correctional nursing is divided into substance abuse, which we had absolutely no education to prior to entering the facility: Psychiatric conditions, suicide screenings, wound care, medication administration, emergency triage, obstetric care [pre/post delivery], gyno exams, STD screenings etc. I received most of my preparation at the facility itse lf, training as I worked. Brandon: Did you feel ready for the job by the time they finished training you? Marie: Not at all. It was astounding how underprepared each one of us felt. They usually promised two weeks of full time training, but they were us ually so short staffed, they would often call you to pick up shifts after your first few days of training. There was a lot of pressure from management to pick up shifts before you were ready to help the team out. As a result, their staff turnover was immen se and most of us never really felt like we knew exactly what we were supposed to be doing. CNs had very similar responses regarding education and training. Hailey was asked if her education from nursing school prepared her for the correctional setting: Hailey: It did, and it I would say no schooling can prepare you for the experience going to have working in a jail facility. I was able to tap into things I learned in school for certain things, like assessments, medical procedures, and givi ng medications. I noticed my psychology nursing class actually helped me the most. I was constantly dealing

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31 with people with types of personality disorders, depression, drug addictions, etc. I was able to practice my therapeutic communication, which will r eally help me in the future. Brandon: Were you given proper training at the jail? Hailey: Absolutely not. Unfortunately, I started at a time where a lot of the nursing staff was quitting. I was scheduled for three training days, which would have equaled 36 hours work at the jail facility she was filling in from another facility. The next day, I came into my shift and they were so understaffed that they had to ask m e to work on my own and ask questions if I needed. When I would ask questions, I would hardly get an answer or any surprised I stuck around. Understaffing Another common issue among CNs was the ever burdensome understaffing at their jail facilities. It appeared that for all the nurses, staffing was probably the biggest problem at work. The environment was not for a lot of people which led to a high turnover rate as nurses would try the job out and then realize they do not want to work in the environment. This is what some of the CNs expressed when asked about staffing issues at their work: Bridget: The turnover rate at the jail is never ending. I feel that there are new faces every time I pick up a shift. Marie: We were rarely, if ever, fully staffed. This is one of the major issues with correctional care. It is extremely stressful and scary. It wasn't uncommon for me to work 19 hours a day at the jail, when things were really bad. We were constantly asked and expected to work our 12 hour shift and then stay over for an additional 4 hours to help the next shift with med pass. It was always like this. One of the most stressful jobs I have ever had. The inability to keep the jail staffed with nurses created a great deal of problems at the jail and stress for the CNs. Here is an example of a nurse being understaf fed when an emergency code was announced:

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32 Only 2 of us could go but not a whole team and I was really new at the time still. I had responded to a code before but never so short staffed. So, I was always worried, what if somebody needs to be responded to who is trying to hang themselves and only two people who are very inexperienced had to perform CPR in an emergency setting? I was literally terrified. Then we had 2 codes happen at once! We went from one side of the jail to the other where there was a fema le fainting and it wasn't a big deal, but the next code was trying to hang herself by her bed sheets! The two pods are very close to each other fortunately. But if I was on the opposite side of the jail? When the jail was understaffed the work would pil e up and become a serious burden on the CNs. Even more shocking was the nurse to inmate ratio. When asked how many nurses worked compared to the inma te population one CN answered: I have this one module [holding area] where people go from booking and they wait a couple days before they are moved and there's probably 50 to 75 people in that one spot maybe 50 to 100. No exaggeration. Usually the infirma ry has one nurse in there and then they switch to another job [still nursing, just different duty] while one is on intake, another doing med pass, and others doing different things. Usually only around 5 nurses at a time. For the whole population like 50 o r 60 inmates per nurse. Numbers like these were reflected by the other CNs from their experiences working in the jail. All the nurses from this study now work in non correctional settings, still as nurses. When asked how many patients they have now the r esponse was between one and six.

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33 CHAPTER V I DISCUSSION This research offered a clearer and more detailed understanding of the correctional nurse experience for those working in a jail facility. Stigma, at work stress, issues with policy, etc. have b een explored in past research, but this study provided a closer examination regarding those issues and more This was accomplished by allowing the nurses to explain their occupation and experiences from their own perspective Also, this study reported stressors faced by correctional nursing staff with its relation to role ambiguity. In this study, it was clear that corr severely lacked harmony with their perceived definitions of the role itself. The nurse role was constantly challenged and distorted causing role ambiguity. This project researched how these nurses experienc ed role ambiguity in several ways. First, stigmatization was examined to unearth sources of role ambiguity that occurred outside of the work setting. Both public and private forms of stigmatization were experienced by all participants. Stigmatization occu (Goffman 1963). This devaluation occurs for CNs publicly when they are misunderstood by friends, family, an d professional peers. This also occurs when that same group exaggerates, oversimplifies, or jump to conclusions about what CN work entails. This was common for nurses in this study and echoes past research regarding psychiatric nurses feeling stigma comin g from friends, family, and medical peers. Non correctional individuals asked if CN work was dangerous, scary, and even easier than

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34 traditional hospital settings. CNs understood that people are generally ignorant to the details of their work, but often scr utiny is difficult to overcome. In one study, psychiatric nurses reported very similar results with some of the worst compared to other nursing types ( Sercu a Ayalaa, and Br perceptions of CN work were the most challenging on CNs. CNs explained that this was frustrating because in their eyes, taking such a negative position negated the concept of care. CNs were protective of their inmate pat ients and did not appreciate them being viewed as less deserving. Similarly, psychiatric nurses stuck up for their mentally ill patients much the same way CNs defended their inmate patients. Psychiatric nurses have described their patients as being in a ch allenging part of their life, or still being human, thus deserving of care (Sercua, Ayalaa, and Bracke 2015). Devaluation also occurs for CNs privately as they deal with the perceived stigma they place on themselves. CNs from this study reported an intern alized negativity surrounding they do. They also express ed that the outside world judged them for caring for criminals. This parallels findings from yet another psyc hiatric nursing study. Psychiatric nurses felt their stigma came in the form of association with an underappreciated and uncared for population the mentally ill. In the case of CNs, the undeserving population is the incarcerated. Much like the CNs in this study, psychiatric nurses felt that outside members viewed them as under skilled and less caring than other nursing types (Halter 2008). These internalized self perceptions of their work and themselves offered serious frustrations on CNs. The malleability of the nurse role for CNs was apparent when it is

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35 misunderstood and easily scrutinized by others. Challenging that role weakens the strength and weight of the role, making it feel out of place in the larger nursing community. Role ambiguity may be said to arise when concepts of the outside world push back on the expectations CNs have for their nursing role. Next, the nature of the work itself and its effect on CNs was examined. It was clear that many at work stressors played havoc on their nursing role id entity. One way this was executed was from unclear or vague demands from superiors and management. This also occurred when non medical staff questioned the methods of the CNs. CNs reported a lack of clear instruction and even no instruction at all from s uperiors. The absence of clear and precise expectations was a point of contention for CNs. Furthermore, CNs reported being overburdened with tasks and given impractical goals to attain. CNs feeling a lack of support and understanding of goal attainment fro m their superiors is a major source of stress (Flanagan 2006). CNs feeling stress regarding goal association with role ambiguity (Griffin, Marie et al. 2010). CNs repor ted issues with the non traditional medical setting. CNs agreed that nursing in a hospital would be more enjoyable, less stressful, and their work would be taken more seriously. They also reported the job would be more meaningful to them and that they woul d enjoy the learning environment more. Most CNs in this study had past experiences working in hospitals as part of their training in nursing school. This mandatory train ing, known as nursing students important hands on training surroundi ng the day to day operations of a hospital setting ( Dahlke a et al. 2016). Many CNs explained it was difficult to work in corrections having seen what the traditional hospital setting offers. They explained

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36 ogether with shared goals. Past research has shown that nurses in the correctional setting face more role ambiguity than nurses working in traditional settings (Gulotta 1986). For the CNs in the current study, clinical training offered a glimpse of the hos pit al setting. This created a perception of what a real medical setting could be for them. This seemed especially pertinent when hearing from nurses who had moved on from corrections. They unanimously agreed that they were happier working in a conventional sett ing versus the correctional setting. The correctional officers that CNs work with also challenged their nursing roles. This was especially apparent when lines of communication became ineffective. The importance of care was usually respected by officers, y et at any time they had the ability to restrict care, stripping CNs of their autonomy in making medical decisions. Past research has shown COs vary in their level of support for CNs and patient care. Some COs are perceptive and helpful, while others pass j udgment or impede care in more direct ways (Droes 1994). Former research explains that CNs enjoy their work more when officers respect them and when communication is stronger (Garland and McCarty 2009). In this study, CNs explained that COs often participa ted in unprofessional behavior that impeded their ability to offer care. Correctional officers were unpredictable and often professional nurse, not providing quality care is contradictory to their role. When the officers The inmate patients that CNs cared for were also able to cause stress on CNs. Past findings explain that caring for inm ate patients is not the same as caring for non inmate patients (Weskopf 2005). CNs in this study reported that inmates were often difficult and

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37 demanding when receiving care. An even greater source of frustration was from inmates being untrustworthy and ma nipulating. Inmates would lie and manipulate to receive medications and special luxuries. Inmates often did not trust the CNs as they saw them in the same light as the officers on duty or that they are affiliated with a corrupt correctional system. Faking symptoms, lying about drug usage, and not trusting medical staff were all ways that impeded a CNs job. CNs reported that not only does such behavior cause them frustration, it is also dangerous to their inmate patients. Thirdly, the built in institutional rules and policies were either poorly implemented or non functional in providing a good working environment. The day to day operations were often ineffective, leaving CNs with a lack of resources needed for their job. A lack of training in their positions was a severe stressor on CNs. The environment was so challenging and difficult to work in that nursing staff would not stick around, leading to high rates of turnover. This caused the remaining CNs to be overworked and stressed which may have led to burnou t. Role ambiguity being reported at rates such as this should be taken seriously. The consequences of role ambiguity can lead CNs to experience high rates of at work stress, tension, futility, and lower rates of self confidence. (Cooney 2014; Pearce 1981; and Kahn et al. 1964). Furthermore, role ambiguity may have the power to alter the nurse role for CNs in a negative way. In this study, outside approval concerning their work was important to CNs and role theory explains why. The concept of role taking in volves imagining how others view you when acting out a role to legitimate the role for oneself. The behaviors that are acted out in a role add weight that the role belongs to them, especially if others offer confirmation. That

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38 confirmation from the outside world helps to legitimize the role for the participant. If someone fits a role, then specific actions and knowledge must be internalized by the participant that are congruent with what society determines appropriate. If that action or knowledge is absent, then role expectations become challenged (Cast 2004; Turner 1956; Stryker and Macke 1978 ). Since roles are legitimized by the internal definition of a role and the outside confirmation by others, alterations can be made to assist the individual in fortif ying the role for them. One way is for individuals to amend their behavior to better fit the perception others have of the role (Cast 2004). Taking action to better fit the role in this way is called role taking Small modifications are made so the role fi ts as close as it can between the expectations given to the role from society and the perceived internalized construct the individual has for the role (Heime r and Matsueda 1994; Turner 1974 ; Turner 1978). As mentioned above, role ambiguity may cause a lack of confidence, stress, etc. which can be hard to face for CNs. To avoid the effects of role ambiguity, CNs may go through their own kind of role alterations to feel more a part of their role. It was clear in the analysis that CNs felt that the outside wor ld did not understand their work and often passed judgement on them. CNs showed frustration regarding institutional processes, co workers, etc. They also shared a viewpoint that they worked in another realm compared to a conventional medical setting. It ma y be possible that all those frustrations could lead CNs to alter the way they see the nursing role to better align with the expectations they experience at work and how society views them. Though this is merely an observation and not a central theme of t he research, such a transition could have negative effects on the correctional nursing occupation. CNs in this

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39 research believed they were competent, effective, and caring nurses. Accepting a societal definition that correctional nursing is less than other kinds of nursing could sour the occupation even more. The consequences could be dire for an occupation already riddled with stressors. Limitations The limitations of this research are noted by the small sample size, which greatly limits generalizabili ty. This restricts the findings and observations to only those who participated in the study. As this is a preliminary study, the researcher wanted a close look at the phenomenon at hand and accomplished this through interviews, follow up questions, and ge nerous analysis. Regardless, a larger sample size focusing on the areas studied in this research would be a benefit to the existing literature. The use of the open ended interview schedules was helpful in creating perspective of what correctional nurses fa ce in their unique work. More face to face interviews would likely have given even richer feedback regarding the lived experiences of these nurses. Understanding how the nursing role was challenged from the built in regulations, the day to day experiences, and stigma offered clarity into the reach of role ambiguity. Finally, limiting the research to only correctional nurses working in jails ga ve clearness in data that would have been muddled by attempting to make comparisons between other types of correctional institutions. would benefit the literature. New sca les need to be developed that better gauge the existence

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40 of role ambiguity for quantitative research More focused questions regarding the experiences of correctional nurses also need to be developed to honor the uniqueness of their work. This study offered a clearer view of how co rrectional nurses experience role ambiguity. For the nurses in this study it became apparent that role ambiguity existed as an obstacle to a positive nurse identity. These findings are important as professional nurses are experiencing high amounts of stres s in an arguably important yet underappreciated job. Nurses in all positions should be free of role ambiguity as it can affect their ability to offer care over the long run both in a corrections job or in another medical setting. Conclusion This study sought to use the thoughts, feelings, and experiences of correctional nurses to better understand their connection to role ambiguity. It was evident that ambiguity challenged part of the nursing role identity. In doing so, nurses in this study expressed ne gativity about their jobs. The nurses in this study all expressed a deep passion for giving care to their patients despite their inmate status. Unfortunately, the stress of the job overpowered the want to work in their correctional environments. The need f or policy change is evident from the findings in this study. Whether funded publicly or privately, correctional facilities should offer better training for nurses before they start working with a difficult and potentially dangerous work setting. Education programs for nurses would likely benefit from more schooling in psychology, addiction, total institution care, and correctional health care in general. Correctional institutions need to create a more welcoming environment. High turnover, burnout, and job d issatisfaction are far too high in correctional nursing. If institutional goals include maintaining long term professional staff,

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41 then an immediate set of policy changes need to be put in place. Ways to incentivize medical staff to dissuade high turnover r ates need to be explored. Correctional officers and correctional nurses would benefit from training together and learning stronger communication skills. A clearer understanding of hierarchal power for nurses is needed with autonomy given to them when makin g medical decisions while also maintaining jail security. Finally, the associated stigma with correctional nursing needs to be countered. Nursing educators and correctional nurse trainers need to offer better background into what the job details and how it is important work for society.

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42 REFERENCRES American Correction al Association. 2005. In 2002, more than two thirds of jail inmates were found to be dependent on or to abuse alcohol or drugs. Corrections Compendium 30 (5):38. What is Nursing? Retrieved November 28, 2016 (http://www.nursingworld.org/EspeciallyForYou/What is Nursing). Preventive Medicine 38(5). Sociological Methods and Research 10(2):141 63. Brunetto, Yvonne, Rod Farr Wharton, and Kate Shacklo Subordinate Communication Relationships, Role Ambiguity, Autonomy and Affective Contemporary Nurse 39(2):227 39. Social Forces 55( 4 ): 881 897. Social Psychology Quarterly 67( 3 ): 296 309. on Perceptions of Role Social Psychology Qu arterly 68( 2 ): 143 159. Journal of Correctional Health Care 19(2): 124 134. Christensen, S Within the Culture of Journal of Transcultural Nursing 25(3): 223 231. Arizona Nursing Association Retrieved August 5, 2016 (http://www.nursingald.com/uploads/publication/pdf/1138/Arizona_Nurse_2_15.pdf).

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43 Cooney, Teresa, Christine Proulx, Linley Snyder Ambiguity Among Women Providing Care for Ex Journal of Wom en & Aging 26(1):84 104. Creswell, John. 2013. Qualitative Inquiry and Research Design: Choosing Among Five Approaches 3rd ed. Thousand Oaks, CA: SAGE Publications. Dahlkea, Sherry, Maureen O'Connor, Teresa Hannessonb, and Karleen Cheethamb. 2016. Nurse Education in Practice 17:145 52. Dodd, Agnes, Jeanette Lawrence and Jaan Val he Social: Mead's Theory of T Theory & Psychology 7( 4 ):483 503 ruelty, Prison Conditions, and T New York University Law Review 84( 4 ):881 Journal of Community Health Nursing 11(4): 201 210. Finney, C BMC Public Health 13(1): 82. Role, Journal of Correctional Health Care 8( 1 ): 67 85. Flanagan, Nancy and Ti J ob Satisfaction and Job Stress in Correctional N Resea rch in Nursing and Health 25 (4): 282 294. Nursing Research 55 ( 5 ): 316 327. Garland Brett and William McCarty ences: Criminal Justice Policy Review 20( 2 ): 188 208. Gulotta, Kleanthe. 1986. are S Journal of Prison and Jail Health 6(1): 3 22.

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44 Giorgi, Amedeo. Descriptive Phenomenological Journal of Phenomenological Psychology 43( 1 ):3 12. Glaser, Barney and Anselm Strauss. 1967. The Discovery of Grounded Theory : Strategies for Qualitative Research Chicago, IL: Aldine Publish ing Co. Goffman, Erving. 1961. Asylums: Essays on The Social Situation of Mental Patients and O ther I nmates Garden City, N.Y.: Anchor Books. Gerber, Lois. 2012 Look at Correctional Health N Nursing 42( 4 ):52 56. Greenberg, Elizabeth, U.S. Department of Education Retrieved August 5, 2016 ( http://nces.ed.gov/pubs2007/2007473.pdf ). Greer, Tomika and Review of Role Salience Literature 11(4) : 463 49. Griffin, Marie et al. 2010. Criminal Justice and Behavior 37( 2 ): 239 255. Halter, Margaret. 2008 racteristics of P sychiatric N urses: Stigma by A Archives of Psychiatric Nursing 22 (1): 20 26. Hardesty, Katherine, Janice Champion Perceptions, Stigmatization, and Working Styles in Correctional Health Jour nal of Correctional Health Care 13 (3 ): 196 205. Social Service Review 54( 1 ): 31 44. Taking, Role Commitment, and American Sociological Review 59( 3 ): 365 390.

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45 Hepburn, John and E mpirical Examination of the Treatment Custody Dilemma Amo ng Correctional Criminology 17( 4 ): 445 460. James, Doris and Lauren Glaze. 2006. eport: Mental Health Problems of Prisons and Jails Bureau of Justice Statistics Retrieved Auguest 5, 2016 (http://purl.acc ess.gpo.gov/GPO/LPS75138). Kaeble, Danielle, Lauren Glaze, Anastoasios Ts outis and Todd Minton. 2014. Bureau of Justice Statistics. Retrieved August 5, 2016 (http://www.bjs.gov/content/pub/pdf/cpus1 4.pdf). Kahn, Robert, Donald Wolfe, Robert Quinn, and J. Dedriek Snoek. 1964. Studies in Role Conflict and Ambiguity New York, New York: John Wiley & Sons. Lobato, Mark, Jessica Disparity: Tubercu losis Among Correctional Inmates, 1993 Through American Journal of Public Health 95(10): 1800 1805. urnout Journal of Occupational Behavior 2(2): 99 113. Maroney, Mary. Journal of Correctional Health Care 11( 2 ): 157 169. Journal of Mixed Method s Research 9(1): 91 107. to Be National Commission on Correctional Health Care Retrieved August 5, 2016 (http://www.ncchc.org/filebin/Health_Status_vol_1.pdf). NCCHP. 200 2. The Health Status of soon to be released Inmates: A Report to Congress National Commission on Correctional Health Care. Retrieved August 5, 2016 (http://www.ncchc.org/filebin/Health_Status_vol_1.pdf). NCCHP. 2010. Certification for Registered Nurs es in the Correctional Setting National Commission on Correctional Health Care. Chicago, Illinois. Retrieved August 5, 1016 (http://www.ncchc.org/CCHPRN/index.html).

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46 The Academy of Management Review 6( 4 ): 665 674. Prison Policy Initiative. 2016. Mass Incarceration: The Whole Pie 2016 Prison Policy Initiative. Retrieved August 5, 2016 (http://www.prisonpolicy.org/reports/pie2016.html). Schoenly, Lorry and Catherine M. Knox. 201 3 Essentials of Correction Nursing New York NY : Springer Publishing Company, LCC. Essentials of Correction Nursing, edited by Lorry Schoenly and Catherine M. Knox. New York: Springer Publishi ng Company, LCC. Social Research 12( 1 ): 77 97 Sercu a nfluence Mental H ealt h Nursing Identities? An Ethnographic Study of the Mea ning of S tigma for Nursing Role Identities in T International Journal of Nursing Studies 52( 1 ):307 316 lth Care Nurses' Attitudes Journal of Correctional Health Care 4( 1 ): 37 59. Correctional Nu Corrections Today 67( 1 ): 54. Stryker, Sheldon. 1968. "Iden tity Salience and Role Performance : The Relevance of Symbolic Interaction Theory for Family Research ." Journal of Marriage and the Family 30(4) :558 64. Annual Review of Sociology 4 (1): 57 90. Sung, Hung Occurring Mental Health and Journal of Offender Rehabilitation 49 (2) :126 145.

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47 The Pew Center On the States 2008 1 in 100: Behind Bars in America. 2008 The Pew Center on the States. Retrieve d August 5, 2016 (http://www.pewtrusts.org/~/media/legacy/uploadedfiles/pcs_assets/2008/one20in201 00pdf.pdf). Turner, Jonathan, Leonard Beeghley, and Charles Powers. 20 07. The Emergence of Sociological Theory 7th ed. Belmont, CA: Thomson Wadsworth. Turner Taking, Role Standpoint, and Reference American Journal of Sociology 61( 4 ): 316 328. Turner, Ralph. 1974. Life as Theater: A Dr amaturgical Sourcebook edited by D. Brissett and C. Edgley. Chicago, IL: Aldine Publishing Co. American Journal of Sociology 84( 1 ): 1 23. e P Journal of Advanced Nursing 49 (4): 336 343. Journal of Correctional Health Care 18(1) : 70 76.

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48 APPE NDIX A I NTERVIEW SCHEDULE AND VOLUNTARY CONSENT Thank you for volunteering to be a part of this project. As former and current correctional nurses, you know better than most that giving care in a correctional environment has many challenges. The reason for this project is to learn more about the fascinating field of correctional nursing and attempt to learn specifics about the profession that have yet to be challenged in their roles compared to nursing environments outside of corrections. Your participation is strictly confidential and any names, locations, or specific details regarding people or places will be altered or given pseudonyms to further insure confidentialit y. Since your participation is voluntary you have the right to withdraw from the project at any time. My personal information along with my department project chair for this project is listed at the bottom. The following document asks several questions r egarding your experiences as a correctional nurse. Please answer all questions completely and feel free to add as much detail as you like. The longer your response, the more richness in data I will have, which gives me more to work with during my analysis. If you are unsure exactly what a question is asking, just answer to the best of your knowledge or feel free to contact me for clarification. With that said, feel free to add more space between questions if you feel you need more room to type. This should take around 30 minutes to complete. Again, thank you for your assistance with my project. If you have questions or concerns, you may contact: Brandon.Kilgore@UCDenver.edu or Candan.Duran Aydintug@UCDenver.edu The following questions relate to how correctional nurses feel about the role they play while in terpretation. Please answer the questions and explain why you answered in that way. Correctional Nursing Roles Did you ever feel like your role as a nurse was challenged while working at the jail? Did you ever feel pressure between the caring for and cu stody of the inmates? job, or that made your job more challenging? Do you feel there is stigma being a correctional nurse compared to another medical setting? If you answer yes, please explain why you feel that way.

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49 Did you ever receive stigma from people outside the jail setting? If so, describe what they said? While a nurse at the jail, did you actively pursue other nursing positions outside of corrections? Did your nursing education prepare you specifically for the correctional nursing environment? When you started at the jail, do you feel you were not given the proper training? Do you believe the care received by inmates is at an acceptable level? Pl ease give your thoughts on the following areas. Feel free to explain how each area has or has not affected your nursing experience or your ability to give care. Guards Have you had good relations with correctional officer staff? How would you describe their interactions with inmates? Describe a positive experience, or a time an officer assisted you while at work. Describe a negative experience, or a time an officer has impeded your work. Inmates Have you ever had any trust issues with patients, or have you ever been manipulated by inmates? What is your opinion on giving education to the inmates who have problems with drug and alcohol addiction? What is your opinion on giving education to the inmates who have infectious or debilitating diseases?

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50 Have you ever felt challenged in giving an inmate medical care due to their reason for incarceration? Describe an experience where you had an incident with an inmate that impeded their care. Setting What about the jail setting do you like the least? Explain how you would feel working in a conventional hospital setting compared to working in corrections. Give me your thoughts on the rules and policies that existed while working at the jail. What worked? What did not work? Resources Have you experien ced staffing issues or felt overworked at the jail? Do you feel there are enough nurses on site to care for the inmate population? Please give an explanation for your answer. Is the proper type, amount, and quality of medical equipment and other resour ces available? As a professional nurse, do you feel your pay was appropriate while working at the jail? Management In your opinion, did management ever impede your ability to make professional judgment calls? Was management more focused on security m easures or medical care of inmates? Has management offered realistic goals for correctional nurses to complete? Demographic Questions Age: Level of education: Years of nursing experience: Years worked as correctional nurse: Type of work currently in: