Nursing care of prisoners: staff views and experiences

Authors


J. Powell: e-mail jane.powell@uwe.ac.uk

Abstract

powell j., harris f., condon l. & kemple t. (2010) Nursing care of prisoners: staff views and experiences. Journal of Advanced Nursing66(6), 1257–1265.

Abstract

Title. Nursing care of prisoners: staff views and experiences.

Aim.  This paper is a report of a study of the views and experiences of nurses and other prison healthcare staff about their roles and the nursing care they provide to prisoners.

Background.  Nurses have become the key providers of healthcare in prison settings in England, replacing the previous prison service-run system. However, there is very little evidence about the health services they provide to meet the health needs of prisoners.

Method.  A ethnographic study was conducted. Participants were 80 healthcare staff working in 12 prisons of all security categories in England. Twelve individual interviews with general healthcare managers and 12 key informant focus group discussions with healthcare staff were undertaken in 2005 using a semi-structured interview schedule. Issues investigated included participants’ thoughts and experiences of nursing roles and delivery of primary healthcare. The group discussions and interviews were analysed to identify emerging themes.

Findings.  Participants gave accounts of day-to-day processes and the healthcare routine. They saw their work as identifying and meeting the health needs of prisoners and maintaining their health, and identified major influences that shaped their daily work, including new ways of working in primary care. They identified how policy and organizational changes were affecting their roles, and acknowledged the conflict between the custody regime and healthcare delivery.

Conclusion.  The move towards a NHS-led primary healthcare service within prisons, predominantly delivered by nurses, has made positive changes to healthcare. Healthcare managers have benefited from the involvement of the local NHS in improving the health of prisoners.

What is already known about this topic

  •  Nurses have become the key providers of healthcare in prison settings in England, but there is very little evidence about the health services they provide to meet the health needs of prisoners.
  •  Under the new arrangements for a National Health Service-led primary care services within prison settings, nurses have taken on greater responsibilities and new roles.
  •  Prison settings are a challenging environment in which to manage and deliver healthcare.

What this paper adds

  •  All healthcare managers had developed working relationships with their local National Health Service organisations, and most expressed enthusiasm for the modernizing changes.
  •  The infrastructure of prisons and their security categories have a direct impact on healthcare delivery in that nurses often undertake security duties in order to fulfil their healthcare remits.

Implications for practice and/or policy

  •  New ways of working by nurses within the prison setting have started to create better services for prisoners, including prescribing, diagnosing, running specialist clinics, receiving and making referrals.
  •  Recent policy and organizational changes towards National Health Service – led healthcare delivery should continue to improve the health of prisoners.
  •  The recruitment and retention of nurses to deliver healthcare within the prison setting may continue to be an issue of concern.

Introduction

International reformers have long suggested that, for healthcare provision for prisoners to truly improve, it should be part of the general health services of the country rather than a specialist service (Coyle 2007). The integration of prisoner healthcare between custody and the community is moving fast in England, but has long been an aspiration for other countries. In 1990, the United Nations’‘Basic Principles of the Treatment of Prisoners’ declared:

Prisoners shall have access to the health services available in the country without discrimination on the grounds of their legal situation (p. 3).

Recently, the WHO Europe went further than this in calling for:

(acceptance of) internationally recommended standards for prison health; providing professional care with the same adherence to professional ethics as in other health services, and… promoting a whole-prison approach to the care and promoting the health and wellbeing of those in custody. (Moller et al. 2007, p. ii)

Background

The responsibility for healthcare in English prisons transferred to the National Health Service in 2002, with the aim of providing a service equivalent to that available to the general population (Joint Prison Service/NHS Executive Working Group 1999). This followed similar moves in other countries. Norway completed the process of giving local health authorities responsibility for healthcare of prisoners in the 1980s. In 1994, France introduced legislation that put prison healthcare under the General Health Directorate for public health in the Ministry of Health (Coyle 2007).

Before 2000, nurses working in prisons in England and Wales were employed by the prison service and had few links with the National Health Service (NHS) (Health Services Management Centre 2004). Few had the opportunity to develop their primary care role at the same level as the NHS workforce outside of prisons (UKCC 1999). Nurses were recruited without assessment of their skills and knowledge regarding the specific needs of prisoners (Joint Prison Service and National Health Service Executive Working Group 1999). Calls for further educational development for nurses working in the prison environment have been made in the light of the increasing scope of the nursing role (Norman & Parrish 2002).

In 2000, a national programme started in England and Wales to support the modernization of the prison health service. The reforms introduced a better skill mix among staff, more effective management and the implementation of a health needs-driven service with greater patient empowerment (HM Inspector of Prisons 2004).

Prison is a challenging environment in which to deliver equitable healthcare. Both the infrastructure of a prison and its security category have a direct impact on how healthcare services can be delivered to prisoners. Table 1 presents a description of the different categories of prisons in England and Wales. The rigidity of the security regime required in most prisons makes it a particularly stressful and challenging setting in which to deliver healthcare. A literature review of prison health exploring the health needs of prisoners and the provision of nursing care in prisons has identified more evidence of the health needs of prisoners than of services provided to meet those needs (Hek et al. 2006, Condon et al. 2007a).

Table 1.   Prison categories in England and Wales
  1. Adapted from Norman and Parrish (2002).

Category A: Highest level of security. For prisoners who have committed serious criminal offences
Category B: Very high levels of security. Un-sentenced prisoners are automatically categorized B, unless they are provisionally placed in Category A. Category B prisons are often referred to as local prisons, and are characterized by high levels of prisoner movement to and from law courts or transferring to other prisons
Category C: For prisoners who cannot be placed in open conditions but who are deemed unable to make an escape. Primarily used as training prisons where rehabilitation can take place
Category D: For prisoners nearing the end of their prison sentences and who can be reasonably trusted not to attempt escape. Healthcare services in these prisons can operate in similar ways to a health centre in the outside community
Women’s prison: Characterized by the same environment as a male prison
Young offenders’ institution: A secure setting for those between 15 and 21 years of age

Despite national policy focusing on the need for a primary care model of healthcare delivery in prisons (Department of Health 2000b), there has been little research exploring healthcare practice in the prison setting (Hek 2006).

The study

Aim

The aim of the study was to describe the views and experiences of nurses and other prison healthcare staff about their roles and the nursing care they provide to prisoners.

Design

A qualitative study was carried out in 2005, using ethnographic techniques. This study formed part of a broader Department of Health-funded research project exploring primary care nursing in prisons (Hek et al. 2007). In addition to the views of healthcare staff, 111 prisoners were interviewed. The findings of the prisoner data have been reported elsewhere (Condon et al. 2007b). These showed that users’ perceptions of imprisonment were that it improved their access to both mental and physical health services. Confidentiality, being seen as a ‘legitimate’ patient and living with a chronic condition were issues identified by prisoners as problematic within the prison healthcare system.

Participants

Twelve prisons were purposively selected to cover four diverse regions in England and capture all categories of prison. Eighty nurses and other healthcare staff working in the prisons on the day of the research team’s visit were interviewed as key informants in 12 focus groups (n = 68), and 12 individual interviews were carried out with nurse managers. The recruitment of nurses for interview was aimed at those working in primary care; however, where there were small teams, or teams where nursing tasks were shared or where nurses were keen to be involved in the interviews, then this was accommodated by the research team. This meant that some of the focus groups included community psychiatric nurses/mental health nurses, substance misuse nurses and in-patient nurses; this added breadth and richness to the discussions.

Data collection

Individual interviews

Healthcare leads and managers were interviewed separately following the first focus group discussion, in which a primary care lead was included. The focus group facilitators observed that participants in this group tended to defer to their manager. It was anticipated that participants in the remaining focus groups would feel more able to express their true feelings without a manager’s presence. Interviewing the healthcare leads separately gave a manager’s perspective, often generating information about strategic issues related to nursing care in prisons.

Focus groups

Recruitment for the focus groups was aimed at nurses as key informants working in primary healthcare, but other healthcare staff were included if they wished to be. Focus groups were the main method of data collection because we were interested in hearing the discussions generated by healthcare team members.

Conduct of interviews and focus groups

The focus group discussions with healthcare staff and individual interviews with primary care and healthcare managers were conducted using the semi-structured interview schedule in Table 2.

Table 2.   Semi-structured interview questions and prompts
  1. STI, sexually transmitted infections; TB, tuberculosis; HIV, human immunodeficiency virus.

 1. Background: Gender, Age, Ethnic group, Confirm qualifications, Job title
 2. Are you already taking part in a research project? (If participant already taking part in a research project, consider whether to proceed)
 3. Tell me about your role as a nurse working in this prison. What would you do in a typical day?
 4. What are the main health problems that you come across in this prison?
(Check frequency and extent of need for the following- e.g. does that come up a lot/is that common? Is that a big problem for people in this prison?)
Asthma, Diabetes, Coronary Heart Disease, Cancer, Epilepsy, Communicable disease, e.g. STI, hepatitis, HIV, TB. Minor ailments, Trauma and minor injury, Primary care mental health problems, e.g. anxiety, depression, bereavement. Self-harm, substance misuse (alcohol, smoking, drugs)
 5. Which prisoners do you think have the highest health needs? Why is that?
Older, Younger, Black and Asian, other minority ethnic group, Prisoners with disabilities, Substance misusers, any others?
 6. How do you and the rest of the primary care team try to meet the health needs of prisoners?
 7. How do you identify the need and what services do you provide? Reception, Primary/Secondary health needs assessment, Triage system, Request slip system, Prison officers, Treatment room, Anything offered on wing?, Drop in clinics for prisoners, Referral to health services outside prison
 8. What effect do you think prison has on prisoners’ health? Better/worse in prison? Physical health Mental health Better health care inside or outside? e.g. access to health services (including treatment, immunizations, detoxification/maintenance, health promotion, referral) Look after health differently Inside and outside? Health eating/diet Exercise Family relationships
 9. What are the frustrations of working as a nurse in prison?
10. What are the barriers to providing a good service?
11. What improvements could be made?
12. What is satisfying about working as a nurse in prison?
13. What works well?
14. What do you do well in this prison?

Focus group interviews lasted between one and one and a half hours, and most individual interviews with healthcare managers lasted just over an hour. These were audiotaped and transcribed verbatim. The four-person multidisciplinary research team worked in pairs to facilitate the focus groups and interview the nurse leads. The data were collected in the prison healthcare centres.

Ethical considerations

Ethics approval for the study was gained from the relevant research ethics committees.

Data analysis

Thematic analysis was undertaken using the analytical framework developed by Ritchie and Spencer (1994). Atlas.ti software (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany) was used to assist with coding and sorting of the data. Data analysis was conducted in four key stages: identifying initial concepts, coding the data, sorting the data by theme and developing a theoretical framework. Data from the focus groups and interviews were analysed the same way.

Rigour

Data collection with the large number of healthcare staff working in different categories of prisons ensured that the views of most grades of nurse and other healthcare staff working in prison healthcare were captured. However, the data do not represent the views of all prison healthcare staff. Rather, our purpose was to explore the views of nurses and healthcare staff and obtain thick and rich data.

The research project had a steering group which gave guidance throughout the process. The four researchers worked as a group rather than as four individuals to develop and test the codes and identify the emerging themes. This group researcher process enhanced the credibility of the themes generated, as individual interpretations were modified by a consensus process. The dependability of the resulting group interpretation was supported through discussion in steering group meetings.

Findings

Participant characteristics

The ages of the nurses ranged from 24 to 58 years, and the average age was 44·59 years. There were 21 male and 59 female participants. Most staff were aged either in their 40 s (n = 28) or 50 s (n = 24). The majority of those in the focus groups were Registered Nurses, mostly as general nurses or to a lesser extent as mental health nurses, and seven were dual- or triple-qualified with as general and mental health nurses, or as nurse for mentally handicapped people. However, there were 13 healthcare assistants/healthcare workers/nursing auxiliaries, three healthcare administrators, one nursing student and five agency nursing support staff (two of whom also had nursing qualifications) involved in the focus groups. Four of the nurses had first degrees, a small minority had certificates or diplomas, and two were nurse prescribers. Agency nurses were included in the study, and three participated in the focus groups. The individual interviews were with healthcare managers or primary care leads. The majority of managers interviewed were female, reflecting the general situation in the prison nursing workforce.

The nurses and other healthcare staff identified three core processes of their nursing role: identifying health needs, meeting health needs and maintaining the health of prisoners. These processes represented how they defined their day-to-day work with prisoners. A further three structural themes were identified: custody vs. care issues, new ways of working and organizational change. These structural themes described the influences that dictate how care is managed and provided within the diverse range of prison settings, and reflected the impact of recent policy changes within prison healthcare services.

Nursing processes

Identifying health needs

The reception process.  When prisoners enter a prison they undergo the reception interview, in which health screening is undertaken for communicable diseases, mental health problems and substance misuse. Referrals to other healthcare services can be made at this early stage of entering the prison setting or transferring from another prison. Changes in prison healthcare provision have meant that doctors no longer have to perform the reception interview. In most of the prisons in the study, nurses undertook the reception process. Several nurses described how being allowed certain prescribing rights (called Patient Group Directives) improved the reception process for prisoners who might previously have had to wait a considerable time for a doctor’s prescription. This was seen as useful when addressing detoxification needs and the effects of drug withdrawal for new prisoners. Where such provision was lacking in some prisons, nurses described the reception process as a cause of anxiety and distress:

We’ve just got to hope that none of them are having problems when they get off the bus, because we have no doctor until tomorrow morning. (Nurse, focus group participant, category C prison)

Application for healthcare.  An ‘application system’ to enable prisoners to access healthcare services was used across the prisons. Prisoners filled in a form requesting one or more healthcare services, including the general practitioner (GP), nurse, dentist, podiatrist and optician. Most participants suggested that the system worked well because it similar in every prison and so was familiar to prisoners. Not all participants expressed satisfaction with the application system; one primary care manager alluded to an inefficient paper-chase, where applications ‘half the time, go missing…’

Nurse-led triage.  Talk of the application system often led to discussion about the process of ‘triage’, which some participants referred to as ‘see and treat’. The triage process represented a significant change for many of the nurses:

Until recently, they all had to see a doctor within 24 hours of being here. That stopped. That was deemed completely unnecessary, and now we refer them on as we feel necessary. (Healthcare Manager, category C prison)

Participants’ perceptions about triage differed between prisons, and within the focus groups. The topic provoked debate and revealed uncertainty and confusion about this emerging nurse role within several of the focus groups. A large number of participants saw their triage role as one of gate-keeping to protect general practitioner (GP) time:

Sometimes they request to see the doctor for colds, but if everybody went to see their GP, the doctor wouldn’t be able to go home, would he? (Healthcare staff, focus group participant, category A prison)

Triage was described as a paper-sorting task where decisions were based on interpreting prisoners’ healthcare applications or as a face-to-face meeting between prisoner and nurse in their prison cells or in the health centre. Few of the participants had received any formal training in triage. Some nurses approached the concept of triage as a common-sense decision-making process that did not require any particular training, whilst others voiced their worries about acting beyond their levels of competence.

Meeting the needs of individuals

Medications, minor ailments and injuries.  Many participants expressed their frustration with the time-consuming task of ‘dishing out the meds’ and seeing to minor ailments and injuries. Some nurses thought that these responsibilities took them away from delivering a more preventive healthcare service. Nurses gave examples of a growing range of medications which they could dispense under Patient Group Directives to treat such things as spots, rashes, colds, earache, headache, sore throats, sports injuries, cuts and grazes. A small number had gained a nurse prescribing qualification. This meant that a prisoner could obtain from nurses ‘all the kind of things…you would go to the chemist for if you were on the outside…’ It was seen as an effective way of cutting down on the number of applications to see the doctor.

Nurse-led clinics.  The rationale for service, planning and implementation varied considerably across prisons. This variability was influenced by the category of prison and when prisoners were released from their cells, periods of time referred to as ‘movement’ or ‘free-flow’. Providing a specialist clinic in prison requires flexible and innovative practice. In a category A prison, where security measures are high, a diabetes nurse specialist had to conduct his clinic by visiting individuals in their cells because it was too complicated and time-consuming to take the prisoners to a centralized clinic.

Referral.  Taking a prisoner to an outside specialist healthcare appointment was described as a lengthy, frustrating process that could easily be sabotaged. Participants described many incidents of unsuccessful referrals. Attempts to take prisoners out to secondary healthcare services highlighted the complex issues that healthcare staff and prison officers face when trying to balance healthcare needs and security requirements. The impact of having to cancel a planned secondary care referral (usually as a result of lack of prison officers to escort the prisoner to the appointment) was described as hugely distressing. One nurse described her irritation at receiving letters from prisoners’ lawyers complaining that their clients had suffered medical neglect as a result of missed hospital appointments:

It really annoys me… I see why they’re doing it, but we get hundreds of letters a year…And it’s not neglect – if the officers aren’t there to do it, we can’t do it. (Healthcare Manager, category B prison)

Emergency referrals of prisoners to hospital appeared to be not as adversely affected. One healthcare manager suggested that ‘emergency care is probably the easiest, because the prison has to find staff – there’s no option.’

Mental health.  Participants talked about how they perceived their role in primary mental healthcare. Opinions varied as to how far they felt able to take on this responsibility, and some expressed a lack of confidence.

The majority of participants across all the prisons cited mental health problems as being a substantial issue among prisoners. In some of the prisons a few interviewees and focus group participants voiced concerns that they were not providing as comprehensive a mental health service as they would want. Several suggested that the problem stemmed from the old ways of dealing with mental health or over-reliance on forensic psychiatrists and psychologists that traditionally played dominant roles in delivery of mental health in prisons. The healthcare manager of a large Category B prison indicated that much could be managed by primary healthcare:

[GPs] just refer them straight to the mental health team…we need to stop this… a lot of the neurotic illnesses don’t really need a psychiatrist’s input. (Healthcare Manager, category B prison)

Some participants saw this as more of a management issue, with confusion about the constitution of primary and secondary mental healthcare. For others it was the under-development of primary care services that was to blame. Despite these concerns, there was recognition that for many prisoners, prison offered the only chance to access appropriate mental health services. In many prisons, this service was seen to be improving:

The demand for sleeping tablets is huge…and nursing staff are now explaining to people why they don’t need (diazepam) continually…[they are] encouraging exercise, relaxation techniques, warm drinks in the evening…it’s all part of the package offering alternatives to sleeping tablets… some GPs are starting to prescribe gym instead of anti-depressants… (Healthcare Manager, category A prison)

Maintaining health

Much discussion was generated about responsibility for maintaining the health of prisoners. There was a sense amongst some participants that prisoners should be given more responsibility for their own healthcare. This often provoked discussion about the fundamental problem of trying to give them more responsibility within a prison system. Prisoners’ responsibility for their own health was much more likely to happen in the two open prisons. Healthcare staff described the ways in which prisoners were encouraged to access the health centre in much the same way as outside prison. This was seen as important rehabilitation towards eventual release from prison.

Healthy living.  Tackling the lifestyle behaviour of prisoners was considered challenging in a population that was seen as having deep-rooted habits:

It’s the lifestyle in the past, yes. A lot of them are smokers, go down and have pie and chips everyday, don’t exercise. (Practice Nurse, category D prison)

Prison gymnastics instructors were described as being important health advisers. Many prisons offered gymnastics training programmes, planned with input from gymnastics instructors and healthcare staff and matched to the abilities of prisoners compromised by physical or mental ill health. Although seen predominantly as a means of maintaining prisoners’ physical health, there were examples in some prisons that gymnastics was increasingly being prescribed for their mental health benefits.

Custody vs. care

Participants gave more than simple accounts of their healthcare roles. They gave detailed descriptions about the barriers they encountered, the changes taking place in prison healthcare and the innovations they were making. Many thought that the ‘dinosaur culture’ of the prison regime was dying out, and that nurses were able to have a greater say in how healthcare services should be delivered. One nurse described how this change has happened relatively recently in the prison in which he worked:

Historically, healthcare was run and delivered by prison officers who were trained in healthcare. In the last 18 months it was very difficult to come into this environment when officers always thought that they knew better. That has subsequently changed now because it’s been taken over now by, err, nurses! (Nurse, focus group participant, category B prison)

Participants described many examples of the conflict between the aims of healthcare and the prison regime. A major constraint in providing appropriate healthcare services was the problem of nurses being required to undertake security duties:

And we’ve started a vaccination clinic which the nurse is working independently on her own, but she’s actually running and fetching the prisoners so that they can get their vaccinations. So it’s actually taking longer to do that job, and it’s taking them away from the job. It’s wasting our time. (Nurse, focus group participant, category B prison)

Despite these frustrations, many nurses spoke of not being able to do their job if it were not for the support and cooperation of prison officers, and several viewed them as an integral part of the interdisciplinary team. One nurse, describing her prison officer colleague, said: ‘His nickname is do-it-all, can-do-it-all!’ (Nurse, focus group participant, category B prison)

In general, nurses expressed job satisfaction in meeting prisoners’ very high levels of health needs in the new organizational environment:

The government decided that we were going to go into the local NHS organizations, best bit of bloody news I’ve heard for years, because it means that the people who control healthcare are people who understand what care is, as opposed to security. (Healthcare Manager, category B prison)

Policy and organizational change

Across the prisons, there was a sense that the policy changes were improving things, and some participants acknowledged that the prison culture was changing for the better:

It’s more prisoner-friendly. It’s not: throw away the key. Prison’s not seen as punishment now, it’s seen as rehab. (Nurse, focus group participant, category C prison)

For some participants, being managed and guided by local NHS organizations meant less professional isolation:

We’ve got all of (local NHS) policies and protocols now… the nurses …they know what’s going on and they attend other things that go on outside now, they have supervision with nurses from the local NHS. (Healthcare Manager, category B prison)

Not all changes were perceived in a positive light. A major concern across all prisons was the recruitment and retention of nurses in prison nursing. Some prisons relied on a staff bank system developed by local NHS organizations. However, this service was not working well in some regions:

At first we thought, ‘Well, that’s great, because we can use the local NHS bank of staff to help and not the agency’, so again costs would be cut, which would be good. So when we approached the local NHS about that, ‘Let’s have some staff, then’, they said that they don’t have enough for the hospitals! (Primary Care Lead, category B prison)

Discussion

Study limitations

The findings from this qualitative study illuminate the issues surrounding nursing care delivery in England and must be considered in the light of the Department of Health policy reforms occurring in England and Wales. Similar changes in policy and healthcare delivery prison settings in Scotland, Ireland and some European countries are taking place, and our findings may be relevant in these contexts. However, the findings should be translated internationally with care.

New ways of working

The new model of healthcare delivery in English prisons is that of primary care, with nurses being the key providers (Department of Health/HM Prison Service 2002). This change matches the increasingly primary care-led NHS, in which nurses are being given greater responsibilities and extended roles (Department of Health 2000a, 2002).

New ways of working for nurses include prescribing, diagnosing, running specialist clinics, receiving and making referrals, and managing care pathways. Participants described a variety of specialist health clinics run by nurses, including chronic diseases management for diabetes, asthma, chronic heart disease, sexual health and communicable diseases, mental health, substance abuse and smoking cessation. These developments were considered beneficial for prisoners and were seen to spring from the involvement of local NHS organizations in healthcare delivery as Sim (2002) also concluded.

Mental health needs and health promotion

The recent Bradley Report supports a recommendation that primary care provider organizations (PCTs) and the Criminal Justice System (CJS) work in partnership to commission a range of services to reduce re-offending and to take opportunities to deal with social and health inequalities in many more opportune settings than the custodial setting (Bradley 2009). Consequently, there is likely to be a new focus on mental healthcare delivery in all criminal justice settings in the near future, and this should be a focus for future research.

In the light of the Bradley Report, it may well be that commissioning mental healthcare in prisons will change, and that workforce development will be required for all healthcare professionals working in prisons and the criminal justice system (Birmingham 2003). Workforce development, clinical supervision and commissioning with regard to mental healthcare are topics for future researchers to explore in relation to the effectiveness and quality of delivery of healthcare in prisons.

Tension between custody and care

The ethos of healthcare for prisoners, first identified by Willmott (1997), needs to be further developed and should be the focus of future research. In describing the daily routines of healthcare and the tasks of nurses and prison officers, the content of focus groups and interviews revealed that participants thought that it was a daily challenge to meet prisoners’ health needs. Words such as ‘fire fighting’, ‘reactive’ and ‘crisis intervention’ were often used to describe their work. The overwhelming demands of prisoners, staff shortages, a perceived lack of time and the regime of prison itself were all seen to inhibit effective healthcare provision.

Nurses described time and time again how the provision of nurse-led clinics relied to a large extent on the availability of prisoners to attend at particular times, and the availability of prison officers to collect prisoners and return them to their cells after the consultation. Prison environments have a culture characterized by order, control and discipline, and this overrides the healthcare needs of prisoners and the caring perspectives of healthcare professionals. Healthcare staff felt this tension acutely and a major concern across all the prisons was recruitment and retention in prison nursing. Some prisons depended on agency nurses to fill the gaps left by unfilled positions or absent staff. This was perceived as a massive drain on resources.

Although many examples of new and innovative healthcare delivery were described in all the participating prisons, participants considered that they were often hampered in instigating and maintaining these services.

Despite these concerns, there was also a sense of anticipation that such problems would be ironed out over time. Participants clearly described their role as one of primary care. Individuals who had specialized and trained in a particular area of healthcare spoke confidently of their contribution to improving prisoner’s health and the satisfaction in doing so. All healthcare managers in the study had developed working relationships with their local NHS organizations and most expressed enthusiasm for the modernising changes.

Conclusion

The implications of a move towards a NHS-led primary healthcare delivery predominantly delivered by nurses within custodial prison settings raises some issues regarding recruitment, retention and security duties that must be addressed if the full benefit of these changes is to be felt. We recommend that local NHS organizations continue to develop a full range of nurse-led primary healthcare services in prison settings that achieve equivalence and finally integration with those provided in all communities.

Conflict of interest

No conflict of interest has been declared by the authors.

Author contributions

JP, FH, LC, TK and GH were responsible for the study conception and design. JP, FH, LC, TK and GH performed the data collection. JP, FH, LC and GH performed the data analysis. JP and FH were responsible for the drafting of the manuscript. JP and TK made critical revisions to the paper for important intellectual content. GH obtained funding. FH and LC provided administrative, technical or material support. JP and GH supervised the study

Acknowledgements

The Department of Health funded this research as part of its Policy Research Programme and had a presence on the project steering group. The arguments in this paper are owned by the authors and may not necessarily reflect those of the DH. Gill Hek, who inspired and led this research, died unexpectedly in November 2006, leading to some delay in the publication of papers based on the research. The authors and project team would like this paper to be dedicated to her, in recognition of her passion for nursing research and her commitment to using research to improve the nursing care of those with the greatest health needs. Professor Moira Plant and Sally Price were also part of the research team.

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