Ethical conflicts in nursing care in the prison context.

OBJECTIVE: The general objective of the study is to gather the corresponding evidence with the ethical conflicts that may affect penitentiary nurses.
METHODS: The methodology used consists methodology used consists in a systematic review of narrative analysis in the mayor data-bases by means of an applied search strategy and critical appraisal skills programme español (CASPe).
RESULTS: A total of 167 studies published between 1998 and 2017 were identified, of which 60 met the inclusion criteria.
CONCLUSION: The main conclusion is the need for research on the ethical problems related to the treatment of prisoners and on the search for the benefits of the inmates. In addition to the need for a training in ethics for the prison professionals, the identification of the real health-care needs of the prison population, and the collaboration between the prison assistance and the health system.

Introduction

Understanding the sensitivity and the humanistic training needed for providing healthcare in the prison context is part of the professional improvement that will influence the quality of life of the imprisoned population and the moral certainty of the actions developed by professional prison nurses.

Prisons are a space for communication, actions and regulations that determine the relationships established between those who live there (inmates) and those who work (the staff) there. It is worth considering the importance and influence that this environment plays on all involved agents, and more specifically, on nurses.

The deprivation of liberty and the legal influence within prisons are factors conditioning the provision of care by healthcare professionals. On the other hand, prison healthcare includes a series of specific nursing care. Therefore, prison nurses should be trained in specific areas such as mental health, drug abuse, emergencies, primary healthcare and public health, as well as in legal and regulatory aspects.

Nursing care represents the will to negotiate the frontiers between the cultures of custody-demanding and that of care-benevolent. This particular situation entails complex challenges and includes a series of limitations regarding the therapeutic relationship between the patient and the nurse.

The comprehensive approach of care is certainly present in our healthcare institutions, yet this does not keep certain degree of dehumanization out. Several studies point out the need for a major shift of the biomedical model of health-. Dehumanizing aspects associated to working conditions, lead to miscare and therefore to the individual’s depersonalization, the lack of privacy and information, among others. Health research should address these aspects, raising awareness on the ethical social and politic implications for nursing professional activity regarding the humanization of care.

In view of this situation it is worth considering whether prison nurses face ethical conflicts regarding the provision of care to inmates. To answer this question we intend to review the available bibliography to determine the typology of these conflicts.

Objectives

The main endpoint of the study is to gather the available evidence on ethical conflicts that are likely to affect prison nurses.

We also intend to describe the features of the analyzed publications and identify the main topics addressed in those studies.

MATERIAL AND METHODS

Systematic review of literature to describe the features of the publications addressing the ethical conflicts that prison nurses face during the period between January 1998 and May 2017 and to identify the main topics of such conflicts.

Inclusion criteria

The documents subject to analysis included the following criteria:

- Design: for our review, we accepted quantitative, qualitative and mixed methodologies, including narrative, experimental, quasi-experimental and descriptive designs

- Type of study: we included all types of studies, from the evaluation of programs, the assessment of treatments - whether pharmacological or not- to studies addressing the effectivity of an intervention, among others.

- Participants: We included studies with nurse participants preferably, although we also included other types of prison healthcare providers.

- Outcome measures: We accepted all types of measures (scales, performance tests, self-reports, general remarks, etc.)

- Language: We admitted studies in Spanish, English, French and Italian.

- Time range: We included studies from 1998, when the International Council of Nurses (ICN) was first established to take a reference for humanized care in prisons.

We excluded publications not focused on prisons despite addressing ethical consideration of healthcare provision and publications that while focused on prisons did not address ethical considerations but physiopathological aspects.

Literature search

We searched the main bibliographic healthcare databases: MedLine, Cuidatge, CUIDEN, LILACS, SCOPUS, CINAHL, SAGE, ProQuest Health, the library Dialnet and the Virtual Health Library. We also performed a manual search of the Spanish Journal of Prison Health (Revista Española de Sanidad Penitenciaria, RESP) and took into consideration informal sources such as conference proceedings with the aim to reduce publication bias.

For the literaturesearch we used DeCS and MeSH descriptors under three main headings: nurse, prison and ethical conflict.

- Nurse: we included terms referred to the profession, the activity and the provision of nurse care.

- Prison: we included terms regarding correctional institutions and social adaptation centers.

- Ethical conflicts: we considered terms referred to ethics in healthcare professions and institutions (Table 1).

Table 1

DeCS and MeSH thesaurus terms used for the search equation

keywords	Nursing/health care	Prision	Ethical conflicts
Descriptors in Spanish	Enfermeras	Prisiones	Conflictos éticos
	Enfermera	Instituciones penales	Ética basada en principios
	Relaciones enfermera-paciente	Centros de readaptación	Ética en las instituciones
	Atención sanitaria	Social	De salud
	Atención de enfermería	Centros penales	Ética en enfermería
	Cuidados de enfermería	Cárceles	Ética médica
	Evaluación de las necesidades	Presidios
	Prestación de atención de salud
	Atención al paciente
Descriptors in English	Nurses	Prison	Ethics
	Nurse-patient relations	Dilemma prisoner	Ethics, nursing
	Community health services	Prisoners dilemma	Ethics, professional
	Delivery of health care		Ethics committees
	Health services		Principle-based ethics
	Nursing care
	Outcome and process assessment (Health care)
	Patients care team
	Quality indicators health care
	Needs assessment
	American nurses associations
	Care, nursing
	Management, nursing care

With the aforementioned terms and descriptors. we constructed several equations according to the search strategy (nurse) AND (prison) AND (ethics). We gathered all studies, whether published or not, in English, French, Italian and Spanish between January 1998 and May 2017.

Variables examined

The year of publication, the geographic scope of the study, the presence of nurses, the relevance of information sources, contact with experts, the use of unpublished documents, the language of sources, the explicit presentation of results, the presence of discussion, the applicability of results; the categorization of results and of the ethical topic of the study.

Selection process of the articles

The articles gathered with the previous search strategy were further subject to a selection process on the basis of their title and abstract. We used the CASPe system to filter and analyze documents since it enhances the effectiveness of reading.

The first stage of this process was aimed at cleaning up the results and therefore, only articles with a clearly focused and appropriately designed question were included. Consequently, the resulting articles were put to the CASPe checklist with questions addressing the study variables (Figure 1).

Figure 1

Revision process and obtained results flowchart.

The primary search started in September 2016. 167 studies were found, out of which 105 complied with the selection criteria. The reasons to rule out the remaining 62 documents were mainly that the title was not in line with the study topic or that the abstract was incomplete, although eight other studies were also discarded because they were out of time range and 22 that had been doubled.

The 105 articles selected were submitted to a thorough revision based on their abstract to detect whether they offered a clear definition of the problem, the intervention, if results were explicitly provided and we assessed if the design properly matched the raised issue. When this information could not be obtained from the abstract, the whole text was reviewed. 50 studies were eliminated with this selection process: only 55 remained.

A second complementary literature search was performed manually in the Spanish Journal of Prison Health and in conference proceedings. 42 studies were obtained out of which 23 were considered non-eligible due to non-compliance with criteria or duplication.

The final 74 documents (55 from the first search and 19 from the second) were subject to complete text analysis based on the CASPe checklist and therefore, 14 were ruled out since they failed to fulfil the analysis criteria. Finally, 60 articles remained for the revision.

Results

Results were provided as a narrative summary since studies with different types of design, measurement tools and focused on different population sub-groups.

Descriptive analysis of the studies’ features

The study period includes twenty years and we can see how, in this time, the production fluctuates with a maximum production rate of 10% in 2007 and 2013 and the lack of publications in 2011. The descriptive analysis shows an average od three publications per year.

With regard to the geographic scope, we can see how 41.7% of them are focused on the United States; 26% on Spain, 16.7% on European countries such as France, Italy and Germany; 5% on Canada and only 3.3% on Australia. 5% of the studies did not specify where it took place.

An important aspect of the analysis has to do with the presence of nurses in the reviewed studies. Over half of the studies (more specifically 51.7%) considered this presence, compared to 45% which did not specify that healthcare providers were nurses or clearly referred to other types of providers and 3.3% of studies which did not clarify this aspect.

To analyze the included bibliography, we have focused on aspects such as the relevance of sources, the language, expert consultation, the use of unpublished documents and the methodological approach of the studies (Table 2).

Tabela 2

Main features of selected studies

Variable	Present (+)	Absent (-)	Unspecified
Relevance of sources	56.7%	36.7%	6.6%
Language of sources, other than English	26.7%	66.7%	6.6%
Unpublished documents	10%	68%	22%
Specifies expert consultation	36.6%	50%	13.4%
Methodological rigour	53.4%	11.6%	35%

The analysis of result presentation shows how more commonly these are presented narratively (66.7%), according to the study’s main endpoints, which is a correct approach. Numerical data were used to a lesser extent.

We found statistics and graphs (6.7%), theoretical descriptions, classifications in categories and tables (3.3% for each of these presentations), percentages or arguments of a line of research (1.7% for each modality) and last in some studies, we were unable to know this fact (13.3%).

For the analysis of results accuracy, we took confidence intervals and saw that only 6.7% used them while 65% did not whereas 28.3% of studies did not need them. The use of qualitative methodology in some articles is the reason for the lack of confidence intervals. We must also consider that 50.1% of these studies provided a discussion on the basis of results obtained while 49.9% did not.

An important critical point of our analysis refers to the applicability of results. We must ask ourselves whether the results can be incorporated to our everyday activity to improve the quality of care that we provide. Therefore, we take into account whether the individuals in our study are different or similar to those in our area.

In this sense, we saw that 56.7% of the studies were similar and for 3.3% of them we concluded that although the study population had differences regarding the subjects or the environment, they did not lead to different results and therefore results can be extrapolated.

As far as the categorization of results is concerned, 58.3% of the cases show them jointly while 30% did so partially and in 11.7% of cases this could not be assessed.

In 30% of studies only some partial results were considered: in this context we saw that 13.3% of them focused on assistance-related aspects; 6.7% considered ethical issues, 5% research aspects; 3.3% training results and 1.7% only considered legislative results.

Categorization of ethical issues considered in the studies

The analysis of the results from the selected studies show great variability (see Table 3).

Table 3

Result categories according to the study’s ethics main theme

Result categories	N of studies
Need for ethical training among professionals	10
Need for further research on increased chronic diseases	8
Palliative care in prison	5
Prisoner mental health	5
Nursing care and needs of inmates	4
Prison health prevention for cost reduction	3
Refusal to treatment and attitude towards death	3
Improved operating rooms in prison	2
Prevention of sexual assault in prison	2
Need for teamwork and cooperation	2
Rational prescription and evidence-based medicine	2
Ideological freedom of prisoners and professionals	2
Clinical record available for patients	2
Death and suicide in prison. Administrative responsibility	2
Prison regulations on healthcare	2
Ethical vulnerability and autonomy	2
Prison nursing ethics and citizen’s perception	1
Teenage female prisoners and pregnancy as an attempt to improve quality of life	1
Psychological disorders in prison officers	1
Organ trasplantation in prisoners	1

The ethical considerations show that a high proportion (65.1%) focus on research as a need, that should provide a response mainly to the conflicts of ethical treatment in prison or the inmate’s benefits.

To a lesser extent (13.3%) studies mainly focus on the negative of inmates/patients to receive treatment or the conflicts leading to hunger strike among them (11.7%).

With regard to other ethical considerations, such as the refusal of inmates to undergo diagnostic tests, voluntary discharge or approaching the topic of organ transplantation, the analysis shows prevalence rates of 3.3% for each of these categories.

For the approach of articles to the concept of gender, we found that only 13.3% of studies did so while 81.7% did not and in 5% of the studies this could not be assessed.

On the immigration of inmates, just 3.3% of studies consider this aspect while 91.7% do not and in 5% this was not considered.

Discussion

This revision shows ongoing interest throughout time on the issue although with low production rates, with a special emphasis on English and Spanish publications.

The explicit presence of nurses together with other healthcare providers shows their active role before the exposed situations, with rigorous actions and the aim to avoid conflict by preserving the right to life and providing physical and psychological care to inmates. Likewise, nurses take part in a system whose main objective is to rehabilitate individuals and ensure maximum protection of health during imprisonment.

With regard to unpublished studies or expert consultation, not including these would lead to an overestimation of the relationship between the study element and the resulting event and most probably, this relates to the fact of not having consulted experts that could have recommended some unpublished studies to minimize this bias and improve the rigor of the project. Therefore, Szklo and Nieto state the need to gather unpublished studies to avoid the publication bias.

Frequently studies only include bibliography in English and their native language 19, yet it is worth considering that language restrictions can lead to a result bias since some relevant studies could be excluded.

The presentation of results could improve by using numerical data. Therefore, the vast majority of authors recommend a numerical presentation due to its accuracy. Another significant element is the lack of comparison with other studies or a discussion of findings.

IT is true that experience and analysis skills are needed to make pertinent comments and relate our own results to those of other studies. The studies lacking this can not explain the differences between primary studies, neither critically nor descriptively, and do not provide the necessary arguments to convince the reader. It is wise to remember that the discussion is especially useful to answer uncertain clinical practice issues, to explore new situations and provide potential lines of investigation. Therefore, we believe that there is a great need for discussion in all the studies.

The results of studies play a prominent role in decision-taking. However, not only evidence should be considered but it also the experience of stakeholders, the circumstances surrounding the patient or the specific situation and overall, the applicability of results. Accordingly, over half of the results can be extrapolated to our field of study.

On the other hand, the inclusion of research in everyday practice should provide benefits for users, professionals and institutions in the form of optimized resources and an improved efficiency-. According to these premises, and taking into account that all healthcare providers are critical consumers of research, the benefits of most studies have been considered positive.

Years ago, Brontons stated that in the search for benefits the implementations of results should not be automatic. He advised on being cautious and acting only after assessing the internal validity of the study. Thus, once completing the analysis of the studies’ features we can see the relevant concerns of methodology.

The category of results on ethical issues shows the need for a specific training of providers in line with the proposal of the European Union which recommends that all professionals in this system be trained on ethical competences. IT also shows the need for more thorough research in the prison context, even though there are few nurses dedicated to research and mostly lack the appropriate support.

It is true that the identified categories are not exclusive of specific situations of the imprisoned population, yet we must admit that this is a population who generally speaking, is especially vulnerable and therefore nurses must pay special attention to their rights in situations which implicitly are highly complex. Consequently, social and healthcare aspects of the imprisoned population lead to specific and unique needs.

In conclusion, the imprisoned population has the right to a quality care but also to appropriate and complete information, to confidentiality and last, to self-determination .

Conclusions

After the analysis of scientific literature on ethical issues faced by prison nurses, we can conclude that there is a need for more research. We also recommend to consider expert consultation to draft studies as well as including unpublished studies in the bibliography.

Besides, we must ensure the use of comparable results to improve internal validity and the presentation of results in the studies.

We observed a significant correlation between the issues of the studies and their results. It is worth considering the need for further research on the ethical issues that the treatment of inmates entail and on the search for benefits for inmates. These needs relate to some results of the studies we analyzed such as a specific ethical training for prison healthcare providers, the identification of real needs in the imprisoned population or the cooperation between the prison healthcare system and the national health system.