Caring for Hospitalized Incarcerated Patients: Physician and Nurse Experience.

INTRODUCTION

There are 2.1 million incarcerated individuals in the USA,[1] yet established best practices for the care of hospitalized incarcerated individuals are lacking.[2] Given that people of color are overrepresented in jails and prisons,[3] improving care for this patient population can mitigate racial health disparities.

Limited evidence suggests hospitalized incarcerated patients face challenges to health privacy, comfort, and discharge planning.[2] These studies were confined to a small group of British physicians[4] or narrative descriptions of providers caring for incarcerated pregnant women.[5, 6] We investigated providers’ knowledge, attitudes, and practices caring for hospitalized incarcerated individuals, with the goals of guiding education and standardizing institutional policy. We examined physicians’ and nurses’ responses given their distinct roles and expertise.

METHODS

The study was conducted at a 284-bed safety-net hospital, the primary referral hospital for the county jail system. We disseminated an online survey by email (Qualtrics, Provo, UT) to internal medicine residents, attending physicians, and nurses who had cared for an incarcerated patient within the past 5 years. Questions on knowledge, attitudes, and practices included Likert scale and true-false response choices. Knowledge questions focused on documented legal rights and hospital policies. A single open-ended question on respondents’ perceptions of differences in care was independently coded by two authors for thematic analysis.

RESULTS

We obtained 76 unique responses–26 attending physicians (response rate 44%), 26 resident physicians (response rate 19%), and 24 registered nurses (unknown response rate due to method of recruitment). Respondents were predominantly female (64%) and self-described as white (45%), Asian (19%), Hispanic (13%), and Black (5%). Attending and resident responses were combined.

Respondents demonstrated knowledge deficits around legal surrogate decision makers (48% physicians vs. 22% nurses correct, p = 0.04), in-hospital shackling rights (66% physicians vs. 70% nurses correct, p = 0.27), and mandatory bedside presence of custody officers (84% physicians vs. 48% nurses correct, p < 0.01).

Physicians and nurses felt safe caring for incarcerated patients and interacting with officers and believed that incarcerated patients should receive a full range of medical care, including organ transplantation (Table 1). Physicians believed that incarcerated hospitalized patients received fewer medical interventions (39% physicians vs. 5% nurses, p < 0.01) and non-medical interventions (80% physicians vs. 25% nurses, p < 0.01).

Table 1

Provider Practices and Attitudes

Question	All providers	Physician	Nurse	p value
Attitudes	% (n) strongly agree or agree
I feel safe when obtaining a history and physical exam from an incarcerated patient.	90% (64)	94% (47)	81% (17)	0.18
I feel safe when interacting with custody officers.	89% (63)	92% (46)	81% (17)	0.22
A patient should receive acute medical care (including hospitalization) while incarcerated.	100% (70)	100% (50)	100% (20)	1.0
A patient should receive elective surgeries (for example, hip or knee replacements) while incarcerated.	96% (67)	100% (50)	85% (17)	0.02
A patient should receive organ transplantation (for example, liver or kidney) while incarcerated.	91% (63)	94% (46)	85% (17)	0.35
Hospitalized patients who are incarcerated receive fewer diagnostic tests than patients who are not incarcerated.	29% (20)	35% (17)	15% (3)	0.14
Hospitalized patients who are incarcerated receive fewer medical interventions than patients who are not incarcerated.	29% (20)	39% (19)	5% (1)	< 0.01
Hospitalized patients who are incarcerated receive fewer non-medical interventions (social work support, physical therapy visits, nutrition consults) than patients who are not incarcerated.	63% (43)	79% (38)	25% (5)	< 0.01
I feel uncomfortable discharging hospitalized incarcerated patients to jail since the onset of the COVID-19 pandemic.	53% (28)	74% (35)	13% (3)	< 0.01
Practices	% (n) always or sometimes
I ask incarcerated patients why they are incarcerated.	2.6% (2)	3.8% (2)	0% (0)	1.0
I ask custody officers why a patient is incarcerated.	14.5% (11)	9.6% (5)	25% (6)	0.09
I ask custody officers if the patient is a safety risk.	32% (24)	19% (10)	58% (14)	< 0.01
I spend less time interacting with a hospitalized incarcerated patient compared with a non-incarcerated hospitalized patient.	25% (19)	19% (10)	38% (9)	0.09
I ask custody officers to leave the room when obtaining a history or physical exam.	51% (39)	65% (34)	21% (5)	< 0.01
I ask custody officers to remove shackles when obtaining a history or physical exam.	36% (27)	37% (19)	33% (8)	1.0
I inform incarcerated patients of their plan of care while in the hospital (for example, plans for tests, procedures, consultants).	99% (73)	98% (49)	100% (24)	1.0
I inform custody officers of a patient’s plan of care while in the hospital (for example, plans for tests, procedures, consultants).	42% (31)	32% (16)	63% (15)	0.02
I inform incarcerated patients of their pending discharge.	30% (22)	36% (18)	17% (4)	0.11
I inform custody officers of a patient’s pending discharge.	30% (22)	70% (30)	79% (19)	0.58
When I discharge incarcerated patients, I discuss their care plans with the patient’s family members.	18% (13)	26% (13)	0% (0)	< 0.01
When I discharge incarcerated patients, I discuss their care plans with the healthcare provider at the receiving correctional facility.	76% (56)	80% (40)	67% (16)	0.25

Nurse and physician responses were compared using Fisher exact tests

Neither nurses nor doctors commonly requested shackles be removed (Table 1). Nurses were more likely to ask the officer whether the patient posed a safety risk (19% physicians vs. 58% nurses, p < 0.01), and less likely to request the officer leave the room (65% physicians vs. 21% nurses, p < 0.01).

Providers infrequently informed patients of their pending discharge (36% physicians vs. 17% nurses, p = 0.11). Transitional care plans were commonly discussed with the healthcare provider at the receiving correctional facility (80% physicians vs. 67% nurses, p = 0.25), but rarely discussed with a patients’ family member (26% physicians vs. 0% nurses, p < 0.01).

On thematic analysis of 41 narrative responses (Table 2), providers expressed concern about differential care pertaining to privacy, shackling, and patient informed discharge counseling, in addition to fears around personal safety and the influence of incarceration on the patient-provider relationship.

Table 2

Differences in care between incarcerated and non-incarcerated patients

Parent theme	Subthemes	Representative quote	n
In-hospital care	No difference	“No difference. A person is a person.” -RN	4 (MD), 6 (RN)
	Privacy	“Harder to build rapport because of the trust issues that arise.” -MD	6 (MD)
	Shackling	“I would strongly prefer that all my patients be unshackled when safe to do so, but I am not sure whose call that is to make.” -MD	3 (MD)
	Contact with family	“I recognize they have less contact with loved ones since incarcerated patients in my experience have no visitors.” -MD	4 (MD), 1 (RN)
	Ancillary services	“I don't think they often get as thorough of care in terms of ancillary services.” -MD	4 (MD)
	Policy confusion	“I am unsure of the policies regarding incarcerated patients and never received training in this during residency or from my employer.“ -MD	2 (MD), 3 (RN)
	Correctional officer presence	“(Lack of policy) makes it difficult for staff to challenge the behaviors of correctional officers who interfere with care.” -RN	2 (MD), 2 (RN)
Transition of care	Discharge counseling	“My understanding is that we cannot inform them of hospital discharge which makes it more difficult to engage patients.” -MD	7 (MD), 3 (RN)
	Follow-up care	“I worry about discharge more, as I think we often think the jail MDs will pick up where we leave off but usually this is not the case.”-MD	8 (MD)
	Communication (family, provider)	“I don't know all the rules on whether they can call family while there, and often don't think to call family myself unfortunately.” -MD	4 (MD)
Safety	Aggression/assault	“I personally was physically assaulted by a patient in custody who was shackled to the bed.” -MD	3 (MD), 4 (RN)
	Gender	“If I have a patient who is a violent criminal, especially toward women, I am more insistent about officer presence during care and also more cautious in my care of the patient.” -RN	1 (MD), 4 (RN)
Patient-provider relationship	Non-judgment/empathy	“I try to be kinder to them and make them extra comfortable, so they have bit of a break of the hardships of jail.” -RN	3 (MD), 1 (RN)
	Bias	“I have found myself sometimes second guessing a patient's chief complaint if I am told by correctional officers that the patient was just arrested and then complained of something like chest pain.” -MD	1 (MD), 1 (RN)
	Autonomy/decision making	“I try my best to provide the same care to incarcerated patients… but the reality is the doctor-patient relationship is severely affected by their captivity. There is no true autonomy, which should be the foundation of the relationship.” -MD	3 (MD)

Authors (KCB, LAH) independently reviewed and coded responses for thematic analysis, and resolved discrepancies using negotiated consensus

DISCUSSION

Despite beliefs that incarcerated individuals should receive a full range of medical care, reported day-to-day care deviated from standards for non-incarcerated patients. Clinicians were unsure as to best practices regarding correctional officer presence, shackling during examination, and informed transitions of care—areas where guidelines are lacking and common practices do not always protect patient rights or align with medical or nursing society guidelines.[2]

Nurse respondents were more likely than physicians to ask officers about safety risk of a patient and less likely to request officers leave the bedside during encounters. Higher perception of safety risk among nurses could be related to greater time spent on and proximity of care tasks. These differences should be targeted in education and policy efforts.

Our survey was conducted at a single institution; responses may not be nationally representative and may be impacted by local laws. Respondents care for patients from our county jail system, where duration of incarceration and predictability of release differ from prisons. The study assessed self-reported practice, which may not reflect actual practice.

Our findings may be used to inform institutional policy, tailor education to knowledge deficits and practice variations by provider type, and inform future clinical guidelines that protect patient rights, while ensuring security.