key: cord-0054860-3xik2nt6
authors: Brooks, Katherine C.; Makam, Anil N.; Haber, Lawrence A.
title: Caring for Hospitalized Incarcerated Patients: Physician and Nurse Experience
date: 2021-01-06
journal: J Gen Intern Med
DOI: 10.1007/s11606-020-06510-w
sha: 947cb5101e9f297b34249753450af87a2f91a616
doc_id: 54860
cord_uid: 3xik2nt6

nan

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.

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 openended question on respondents' perceptions of differences in care was independently coded by two authors for thematic analysis.

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).

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.

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. "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 "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 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.

Katherine C. Brooks, MD 1 Anil N. Makam, MD, MAS 1,2 Lawrence A. Haber, MD 1

Correctional populations in the United States

Acute Care for Patients Who Are Incarcerated: A Review

Mass incarceration, public health, and widening inequality in the USA

Prisoners in general hospitals: doctors' attitudes and practice

Nurses' experiences caring for incarcerated patients in a perinatal unit

Perinatal care for incarcerated patients: a 25-yearold woman pregnant in jail