NurseWeek News

Hard Times
Faced with short staffing and slim budgets, prison nurses clear up misconceptions about working behind bars

By Cathryn Domrose
June 21, 2004

You didn’t even say hi,” Fe Au, RN, teased a patient arriving for dialysis at the California Medical Facility in Vacaville.

The man gave her a shy smile. “You were busy,” he replied, politely. He has been receiving dialysis treatments since 1984. Au, the shift leader of the unit, knows him well.

She joked with another patient already in the dialysis chair. “Smile for me, Gomez,” she said, and Jose Ramon Gomez, a soft-spoken, baby-faced man, obliged with a wide grin as a photographer snapped a picture.

The banter between nurse and patients is typical of any dialysis unit, in any medical center. In this one, however, the patients wear blue jeans and chambray shirts when they are not wearing gowns. They come in through a locked door, escorted by uniformed medical technical assistants, or MTAs, who are trained as correctional peace officers.

Some patients, including Gomez, have been convicted of homicide.

On the inside

Nurses who work at the Northern California facility, the state’s main medical and psychiatric institution for convicted adult male felons, say they face many of the same challenges as nurses who work in hospitals outside the prison: They have a severe nursing shortage that forces them to use registry nurses and mandatory overtime. They’re working with an increasingly older and sicker population. They would like to have had more time to spend talking to patients and educating them about improving their health.

Nurses who work in the prison — both RNs and the MTAs, who are mostly LVNs — have other challenges as well. They work in an enclosed facility with elevators that require keys, gates that clang shut, and corridors marked with yellow lines that their patients may not cross. They must be alert for patients who may try to take advantage of them and must take care in addressing or touching patients. Appointments and schedules must be flexible to allow for lockdowns and sudden court dates.

But the nurses say the rewards of their job — bringing health care to people who need it, the gratitude of their patients, and job security combined with great benefits — more than make up for the difficulties of nursing behind bars.

From the outside, the California Medical Facility, built in 1955, looks more like a prison than a medical facility. Guard towers and double chain-link fences topped with rolls of barbed wire surround a field of clipped dry grass and somber wheat-colored buildings pockmarked with tiny windows.

But after passing through a round of security checks, a metal detector, and an automatically locking door, visitors pass through a small landscaped area with flowers and sculptures. A caduceus — the medical insignia of two snakes entwined with a staff — marks the entrance to the building that is both a medical center and a prison.

Inside, the two concepts seem to shift constantly. At a clinic for HIV patients, inmates sit in chairs waiting for a nurse to call their names. Some grumble or argue about their appointments. It could be a clinic waiting room in almost any hospital, except the patients are all men dressed in the same blue uniform.

Double Agents

As a medical technical assistant, Ogbanedi Abu, LVN, delivers medicines to inmate patients at the California Medical Facility. The trickiest part of the job, he said, is when an inmate tries to hide the medication to sell it to someone else, or crush it so he can snort it later.

That’s when Abu must switch roles: from nurse to custody officer.

“If I catch them, I take the medicine and throw it away,” he said. Or he might write up the patient and let the physician know what’s going on.

Sometimes his patients, many of whom are mentally ill, get upset. They might protest, saying they’re not babies and deny hiding or crushing the medicine. They might scream and yell at him. They might throw a bag of bodily fluids at him, a practice called gassing.

MTAs, who are employed throughout the California prison system, have the most dangerous job of the medical staff, physicians and nurses who work at the California Medical Facility say. They are on the frontlines, dealing directly with inmates in the cells. They pass medications, take blood for testing, escort inmates to clinics and the hospital, and provide security for physicians and nurses who treat the inmates. When an inmate is sick at 2 AM or needs to see a dentist for an emergency toothache, the MTA gets the call.

Most MTAs are LVNs, although a few are RNs, prison officials said. Many have military backgrounds. MTAs go through two weeks of training as correctional peace officers and are members of the correctional officers union.

“They’re nurses with badges,” said Constance Gibbs, RN, nurse supervisor at the California Medical Facility, California’s main prison medical center in Vacaville in Northern California.

Despite the potential dangers, Tom Donahue, MTA, LVN, a senior MTA supervisor, said workers still are safer in the prison than they are on the street, and the salary and benefits make an MTA position an attractive job. “For LVNs, it’s probably the best thing they’ve ever seen in their lives,” he said. “If I were an LVN, I’d be jumping on this in a heartbeat.”

The system has its benefits and challenges, said Joseph Bick, MD, chief medical officer at the prison. MTAs can take medications to inmates or escort them to appointments, freeing clinical staff for other duties. The prison’s main outpatient clinic is run by MTAs, who work mostly with physicians contracted from outside the prison. MTAs assist the physicians — taking vital signs, processing paperwork — but they also can intervene if a patient starts to get out of control.

But some inmate patients have a hard time distinguishing between MTAs and correctional officers, Bick said. Sometimes, MTAs find it difficult to balance their custodial and medical roles, he said.

“That makes things challenging for the patients. It makes it challenging for the staff,” he said. “Everything they do is in the gray zone.”

MTAs in other prisons have been accused of punishing inmates by denying access to clinics and physicians or ignoring complaints of pain or illness.

No matter how conscientious someone tries to be, the two roles — custodial and medical — “sometimes can raise conflicting interests,” said Rebecca Craig, RN, MPA, board member of the American Correctional Health Services Association and manager of the correctional health care program for the California Medical Association’s Institute of Medical Quality.

For instance, she said, if a medical provider discovers an inmate sequestering drugs, he or she could remove the drugs for safety reasons. But putting them in handcuffs or punishing them in some way should not be the role of a medical provider who is working to gain patient trust, she said. In the California jail system, she said, most of the time nurses dispense medications and guards accompany them. The roles of each are clear, she said.

Dennis Kearney, an MTA and LVN at the California Medical Facility, said he thinks medical training and an LVN license give MTAs a more compassionate attitude toward inmate patients than that of many regular correctional officers. Kearney recently returned from Iraq, where he worked as a flight nurse caring for wounded soldiers.

“We understand that inmates came here as a punishment, not for punishment,” he said. Some correctional officers, especially those who worked 15 or 20 years ago when inmates were treated more harshly, seem to have a difficult time understanding that, he said. Some still treat them disrespectfully.

“It gives a bad name to the rest of us,” he said.

Three-quarters of MTA duties are supposed to be medical and one-quarter custodial, but some MTAs said that in recent years they have had to take on more custodial duties as more medical duties went to RNs or CNAs.

“Now, you feel like you’re doing more custodial work because there’s no medical work to do,” said Richard Nichols, MTA, LVN. The situation does not please him. “I’m here for the people,” he said. “I’m here to take care of people and they’re making it harder and harder to take care of people.”

-Cathryn Domrose

In another clinic, a patient consults with a physician behind a screen while an MTA sits at a desk outside. She is filling out documents, but also listening for any changes in either the physician’s or the inmate’s tone that might suggest trouble and the need for her to switch roles, from medical worker to custody officer.

Inside the surgery area, a recovery room nurse talks about common procedures the hospital performs, including hernia operations, orthopedic surgery, and colonoscopies, while outside, an MTA in scrubs and booties pats down inmate patients before they leave the area.

A few other prisons in California have on-site hospitals, but almost all of the inmates in the Vacaville facility need some sort of medical or psychiatric treatment. The facility includes a general acute care hospital, outpatient clinics, inpatient and outpatient psychiatric facilities, a hospice unit, treatment for inmates identified with AIDS/HIV, and inmate housing. The California Department of Mental Health operates a licensed acute care psychiatric hospital within the prison.

The prison, which holds more than 3,000 inmates, has its own dialysis, med/surg, surgery, emergency room, and pharmacy. It contracts out major surgeries to a nearby hospital. But most medical conditions are treated within prison walls.

Nationally, between 30% and 40% of inmates have hepatitis C, estimated Joseph Bick, MD, the prison’s chief medical officer and director of HIV treatment services. About one in four are infected with tuberculosis. About 1% to 2% are infected with HIV. “At the California Medical Facility, we house between 480 and 540 inmates who are known to be HIV-infected,” Bick said.

Other conditions include chronic diabetes, hypertension, asthma and heart disease. About three-quarters of them have some form of alcohol or other substance abuse, Bick said. An increasing number are elderly with chronic conditions.

Most developed these conditions before they entered the prison, Bick said. For many inmates, the treatment they receive in prison is their first encounter with any sort of health care. He sees medical care in prison as an extension of public health. “Whether you care about inmates or not, you should care that they are healthy,” he said, “because most of them will be released.”

Bar none

The approach of Bick and other health care workers, including nurses, to correctional health care reflects a change in thinking during the last 20 years, said Rebecca Craig, RN, MPA, board member of the American Correctional Health Services Association and manager of the correctional health care program for the Institute of Medical Quality in California.

“I have seen it continually improve,” she said. When she first started working in jails and prisons, she said she would hear inmates express concern about symptoms and see nothing written on their charts. Now, she said, “the nurses are really doing good clinical assessment. Overall, the nursing staff that I see are much more professional.”

They wear lab coats instead of casual street clothes. They show respect for their inmate patients. She also sees more teamwork between nurses and correctional officers to provide inmates with treatment and medicines.

“It’s catching up very rapidly with health care in the rest of the community,” she said.

Craig has not visited the California Medical Facility for many years, she said, but has heard positive things about its recent care, especially its hospice and HIV programs. “There were some problems a few years ago,” she said, referring to protests by HIV/AIDS activists in the late 1980s about the poor treatment of AIDS patients, and the deaths of three mentally ill patients from heatstroke in 1991.

Since then, she said, the prison has taken “aggressive and proper steps to improve care,” she said. “They have some very good physicians now. Their reputation has improved.”

Inmate patients interviewed during an escorted tour of the facility said they were happy with the care they received. “I like it here, it’s good,” said Gomez, the dialysis patient. In another prison, he had received his dialysis under guard at a community hospital. “I feel like it’s the same here as it would be anywhere,” he said.

Wanted: RNs

Like other medical facilities in the state, the California Medical Facility is battling a severe nursing shortage. The greatest shortage is of MTAs, Sherman Champen, RN, MSN, FNP, said.

The facility has openings for more than 40 MTAs, Constance Gibbs, RN, a nursing supervisor, said. The prison’s 60 RN positions are almost filled, but it needs to hire 30 more nurses to comply with recently enacted state-mandated nurse-patient ratios, she said. The ratios require a registered nurse for every six patients in noncritical areas.

Because of the ratios and the MTA shortage, “we’re all doing a lot of overtime right now,” Gibbs said. The prison also is using registry nurses to comply with the ratios, Champen said. “We’ve used registries a whole lot and then we’re killing our budget,” he said.

Last year, the prison shut down one unit of its 63-bed hospital, but has reopened the unit when the inmates need it, Champen said. The alternative to treating an inmate in the prison, Champen said, is to take him to a community hospital under guard, which costs more than reopening the unit.

The surgery unit, which used to do some major surgeries many years ago, now is in its second year of limited operation for minor surgeries, said Noel McGarter, RN, a post-anesthesia care unit nurse. “We wish we could do it every week,” she said, “but there’s such a shortage of nursing staff, we can only open every other week.”

Au, the dialysis nurse, said her unit is growing and needs to expand. But she’s short of space and nurses. “We have the same problems they do on the outside,” she said. “We’re short-staffed. There are not enough dialysis-trained nurses.”

On a particularly busy week, Au may work six shifts, she said. The nursing department is trying to find alternatives, she said, and is considering offering 12-hour shifts as an alternative to the eight-hour shifts that prison nurses now work.

Hiring new nurses and MTAs is not easy, Champen said, especially when hospitals around the state are competing for RNs and medical staff. Although state employee benefits are among the best in the industry, RN salaries are lower than what nurses can make at many other hospitals, he said. Nurses at the California Medical Facility make a maximum salary of about $4,800 a month, he said, plus an $800-per-month recruitment and retention bonus.

It also takes time for new prison employees to obtain required clearance. Red tape and paperwork are particular obstacles in hiring MTAs, he said. Because MTAs are considered correctional peace officers, they must go through training and a security process that used to take a year and now takes about nine months. Few people are willing to wait that long to start a job, Champen said. “We lose them in the interim.”

Security issue

Many nurses — or their families — also feel uneasy about working in a prison, Champen said. “This is not for everybody,” he said, although he added that most nurses are pleasantly surprised after they actually visit the prison and see its services. “Very few people end up saying, ‘I don’t want to work here, I’m scared.’ ”

The prison clinical staff is about as safe, or safer, than the staffs of any inner-city emergency department, Bick said. The greatest risks are for MTAs who escort inmates and deliver medications. MTAs sometimes get gassed — hit with a bag of bodily fluids from infected patients — or stuck with needles or scalpels that an inmate has stolen from a sharps bucket.

Charles Humphries, RN, BSN, a public health nurse for infection control at the prison, said he did not know of any incidents of inmates passing infections to staff in the 10 years he’s worked at the prison.

“I don’t know why, but I’ve never felt scared,” said McGarter, the recovery room nurse who has worked in the prison for 14 years. “These guys are human and they need the care.”

Au, the dialysis nurse, said she never feels frightened because so many correctional officers are around. “You have to remember where you are at all times,” she said. “You have to always think custody. Safety, safety, custody.”

But she has never felt conflicted by the need for security vs. the need for medical care, she said. From the time she arrived at the prison, she knew her first priority was care. “That goes for everybody who works here,” she said. “I was hired to administer medical nursing care and that’s all I do.”

Au said she was apprehensive about working in the prison at first. “But once I got here, my perspective changed because they deserve the same kind of care as anyone else. The inmates are really nice people.” When she hears about their crimes, often she is shocked. “But here they are in a controlled environment, so their whole demeanor changes.”

Bick said one of his goals is to create “zero tolerance” for disrespect, whether from patients to staff or from staff to patients. Many problem patients have horrendous stories of abuse and mental trauma, he said. They’ve grown up in a world with different rules, different ways of dealing with anger and pain. “You have to set very clear expectations and show them another way,” he said.

McGarter said she has always treated her patients with respect and has received nothing but respect from them in return. “I have a good rapport with them,” she said.

Recently, as she was picking up a chart, an inmate she had never seen before approached her. “I have a problem,” he said, “and I think you can help me.” He was trying to get a lower bunk and needed to show proof that he needed it for medical reasons. McGarter was hesitant. It didn’t sound like her area of duty, and she knew inmates could be manipulative. But the man was so nice, she decided to see what she could do.

She did some research, but when the answer came back, “it wasn’t the result he wanted to hear,” she said. He was denied the bunk. “But he was still very polite to me,” she said. He thanked her for her help, and she felt glad she had helped him.

“These guys know me,” she said. “They tell me I’m a good nurse. They feel comfortable to know I will be here when they wake up after surgery.”

That relationship is the reason she doesn’t want to work anywhere else. “I love this,” she said. “I really love it.”

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