In the nurses’ station of the 39-bed med-surg unit I double-checked my patient’s 2:00 PM medications against the pharmacy sheet and then started down the hall to his room. Roger (not his real name) was from the local prison. A man of about 36, he was recovering without complications from a cholecystectomy. His surgeon had been in earlier and told him he’d be discharged back to the prison’s medical unit the next day. As I neared the room, the prison’s security guard glanced up from his chair just outside the door and pleasantly nodded at me in recognition. I went inside to find my patient in his bed, with his back toward the doorway. “Roger, I have your medications,” I said. He didn’t turn toward my voice, and as I came around to his bedside table I saw that his face was flushed and diaphoretic and he was grimacing as if in pain. “What’s wrong, Roger?”Alarmed, I put the meds down and automatically reached for his wrist to check his pulse, mentally beginning to assess this change from just an hour ago. Then I noticed that his nails and fingers were spotted with blood, and simultaneously saw smeared stains on the linen. What was going on, I wondered. After telling him I needed to look at his incision, I pulled back the sheet. The incision line was partly separated at the first layer, slowly oozing sero-sanguineous fluid. In a low voice, so the guard wouldn’t hear, he whispered angrily, “I can’t go back. I can’t.” Then I realized he had opened up the incision himself. This was in the mid 1980s. Roger was my first incarcerated patient, but not my last. I didn’t know what he was in prison for, and I can only think of one patient over my next 34 years of nursing that I knew the reason why she would be going to prison even before she arrived on our unit. Arrested at the airport, she was a “mule,” suspected of having swallowed condoms filled with narcotics and bringing them into the United States. The filled condoms were confirmed by x-ray in the emergency department. We waited for her to excrete them while she did her best not to, obviously becoming increasingly more uncomfortable as the hours wore on. The next night I learned she had undergone surgery to remove them.
Challenge of caring for incarcerated patients
Both these situations were disturbing, but it never occurred to me to refuse to accept the assignment. I did what was needed, practicing according to the American Nurses Association (ANA) standards, to bring a patient to their highest level of autonomy. I don’t believe I ever acted judgmentally, even in Roger’s case, when inwardly I was appalled at his determination to delay re-internment by opening his incision. However, with the April 2013, Boston Marathon terrorist event and the nationally televised search for both suspects ending in the eventual capture and hospitalization of Dzhokhar Tsarnaev, I began to wonder if I would have been unbiased in my nursing obligation to care for this prisoner, knowing that so many were maimed or killed through this person’s callous actions. How did the nurses feel who were assigned to his care? If someone was not comfortable to accept the assignment, what was the policy of this hospital? There is the ethical task of care, but on the other hand we are supposed to have, as Lachman writes, “a commitment to attending to and becoming enthusiastically involved in the patient’s needs.” The ANA Code of Ethics addresses in provision 2.2; Conflict of interest for nurses: “Nurses must examine the conflicts arising between their own personal and professional values…as well as those of patients. Nurses strive to resolve such conflicts in ways that ensure patient safety, guard the patient’s interests and preserve the professional integrity of the nurse.” The nurses assigned to care for Dzhokhar Tsarnaev at Beth Israel Deaconess Medical Center in Boston, Massachusetts, were given the option to refuse this particular assignment if not comfortable. All nine nurses accepted. In a Boston Globe article by staff reporter Liz Kowalczyk, some expressed worry that their decision would be thought to be insensitive to the feelings of the injured patients and their families. But, as the Code of Ethics notes, the professional nurse’s first obligation and responsibility is to the patient: “The nurse respects the worth, dignity and rights of all human beings irrespective of the nature of the health problem.” More guidance comes from the National Commission on Correctional Health Care, which cites six ethical principles that arise when nurses care for incarcerated patients: 1. Respect for persons (autonomy and self-determination) 2. Beneficence (doing good) 3. Nonmaleficence (avoiding harm) 4. Justice (fairness, equitability, truthfulness) 5. Veracity (telling the truth) 6. Fidelity (remaining faithful to one’s commitment) Nurses often do the little extras; for example the small joke to brighten up the patient’s day, or making sure the newspaper gets to the patient, or just briefly acknowledging a personal comment about themselves. However, when responsible for a prisoner’s medical needs, these additional gestures go beyond the professional standard of care and are inappropriate to the situation and may be misinterpreted. We don’t need to take on Nurse Ratchets’ austere personality as in the movie, “One Flew Over the Cuckoo’s Nest,” but we do need to maintain a professional and emotional distance.
Meeting the challenge
The challenges of Beth Israel’s staff during the hospitalization of the suspected terrorist were daunting, but met with management’s understanding and the established ethical policy of this medical center. Many of the community responded with support to the nurses’ commitment as caregivers. Again and again throughout our careers, professional nurses demonstrate that we can put aside personal bias and prejudices in or
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American Nursing Association. Code of Ethics for Nurses with Interpretive Statements. 2001. http://nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics-For-Nurses.html. Accessed June 24, 2013.
Kowalczyk L. For bombing suspect’s nurses, angst gave way to duty. Boston Globe. May 19, 2013.
Lachman VD. Applying the ethics of care to your nursing practice. MedSurg Nursing. 2012;21(2):112-4, 116.
Muse MV. Correctional nursing practice: what you need to know (Part 5). CorrectCare. 2011;25(1):16-7.