Testimony presented by Ann Purchase, MS, RN to the Assembly Committees on Health and Corrections, November 14, 2003.
Good morning. My name is Ann Purchase. I am a Masters prepared registered nurse and an Associate Director in the Practice and Governmental Affairs Program of the New York State Nurses Association. On behalf of the Association, I appreciate the opportunity to testify about correctional healthcare services and the role of the registered professional nurse. NYSNA is the union for registered nurses in several jail health services, in New York City and upstate. In some instances, we represent the county public health nurses who provide services directly to county jails. We also represent nurses at hospitals throughout the state where prisoners receive health care services upon arrest, during incarceration and after release. NYSNA has had an ongoing interest in correctional health issues. In 1980, NYSNA created one of the first professional standards in the nation for nursing care in correctional health with the input of nursing experts throughout the state. That professional standard was the precursor for the American Nurses Association’s Scope and Standards of Nursing Practice in Correctional Facilities.
Your hearing notice depicts multiple failures in state prison facilities, including the “failure to have sufficient numbers of adequately trained health professionals who have the expertise to care for inmates with chronic diseases.” Reviewing the other deficiencies listed, NYSNA contends that staffing is the pre-eminent issue. Lack of sufficient staffing is a key contributing factor to disruptions in care, lack of quality chronic care disease management and lack of adequate discharge planning. NYSNA agrees that there are insufficient healthcare professionals in state prison facilities. We urge you to promote adequate staffing in local jail health services as well, particularly since more people pass through local jails than any other part of the correctional system.
The National Commission on Correctional Health Care (NCCHC) includes as an important standard having sufficient numbers and types of health staff to care for the inmate population. Compliance with this standard is judged by outcomes. “The adequacy and effectiveness of the staffing plan is assessed by the facility’s ability to meet the health needs of the inmate population.” NCCHC includes staff orientation and healthcare provider continuing education as important criteria. NCCHC provides a “general numerical expectation for physician time on-site: 3.5 hours a week per 100 inmates.”1
The February 2000 report of the Correctional Association of New York’s Prison Visiting Committee refers to inadequacy of medical staffing, noting that following a Department of Health audit, staffing increases were requested. In fiscal year 1994-1995 a 40% increase in nursing staff was needed, but was not reflected in the Executive Budget. The report identifies the need to recruit expert medical staff to meet prisoners’ healthcare needs and notes the disparity of pay between correctional health services and other health sector jobs in the same communities as one factor contributing to staff recruitment and retention issues.
According to the Human Rights Watch’s interview with correction officials and mental health experts, “the single most important requirement for good mental health services is adequate staffing levels.” They refer to experts in the field who advocate one mental health nurse per 100 patients in addition to one mental health professional (including RNs, nurse practitioners, social workers, psychologists and psychiatrists) for every 75 patients with serious mental illness. The study identifies understaffing as a crippling problem in attaining the mental health services sorely needed by this population. The study identifies New York as a state that has not kept up with mental health staffing needs.2
The nursing standard for practice in a correctional health setting is to ensure that inmates receive care that is comparable to the standard of health care in the community in which the correctional facility is located. The nursing standard is a direct parallel to the Supreme Court’s ruling in Estell v. Gamble, 1976. The standards for nursing care of patients with HIV, AIDS, tuberculosis, sexually transmitted diseases, hepatitis C, substance abuse, mental illness, hypertension, diabetes and other diseases prevalent among incarcerated patients are labor intensive. Nursing’s staffing standards for hospital and outpatient care will serve as a worthwhile comparison to the staffing needs in the correctional system. NYSNA would be pleased to work with the Assembly Committees, other unions, and the advocacy community to establish acceptable RN to patient staffing ratios in correctional health.
NYS regulations do establish nurse staffing standards for prisoners in need of skilled nursing services (NYCRR Title 9 Section 7651.9) These include a minimum of 1 hour of nursing care for a self-care patient, 2 hours for a partial care patient and a minimum of 4 hours for a total care patient. The regulations do not establish staffing standards for the many roles that the nurse in correctional health settings must perform beyond those prescribed as “skilled nursing care”. Regulations require a health assessment within the first 24 hours of reception, a complete written medical history within 14 days following reception, including a chemical dependency assessment and an assessment of risk behavior for HIV, and a complete physical within 14 days. The registered nurse is providing much of this care and primarily coordinating for each newly incarcerated person while addressing the health needs of the existing prison population as well as staff occupational health and safety issues.
To highlight the staffing situation, let me share with you a day in the life of a county correctional health nurse, as told to me by one of our members. This particular county in New York requires a minimum staffing standard of a 4-4-2 nursing ratio in a 24-hour period. This means that the staffing plan is for 4 nurses on the day and evening shifts and 2 that staff the night shift. It should be noted that although these are all licensed nurses, not all are registered nurses and only a registered nurse is qualified to complete the initial health assessment. Maintaining the minimum staffing has been strained recently due to difficulties in recruiting nurses. The county is not paying a prevailing wage and the working conditions are difficult at any time. As a result, the orientation period for newly hired nurses has been shortened, making their jobs even more difficult to handle.
An initial intake assessment or “booking” on all new inmates must be completed by a registered nurse within the first 24 hours. This intake consists of a 100 question instrument including a general health history, mental health history, past history inclusive of exposure to communicable diseases including HIV/AIDS and TB, a substance abuse history, completion of release forms, review of any available health records and a review of their currently prescribed medications. The average number of bookings per day is 20 and only 1 registered nurse is assigned to do these intake assessments. At this volume, less than one half an hour is allotted per assessment.
This is an inadequate amount of time to devote to an assessment, particularly given the complex healthcare needs of this population that has rarely received primary care in the community. The county correctional department provides healthcare services to both non-sentenced and sentenced inmates, many of whom are transferred from the county to state prisons. Nurses at county jails are responsible for providing the initial healthcare screening for many who will be transferred to New York State prisons.
At the same time, other correctional nurses are attending to the healthcare needs of other prisoners. They are coordinating transportation and appointments outside of the facility. They are administering medications or directly observing patient self-administration. They are staffing sick call. They are responding to emergencies including acts of violence that result in injury to both prisoners and correctional officers. They are providing health counseling and teaching disease prevention and urging compliance with established medical regimens. They are documenting all of this care and they are planning discharges and transfers.
National and state statistics indicate that correctional health is much more than a microcosm of society. “Inmates represent an extremely large population that is disproportionately burdened with problems of physical and mental illness and substance abuse.”3 The prevalence of HIV/AIDS, sexually transmitted diseases, Hepatitis C, mental illness, substance abuse and asthma, is much higher among inmates than the total US population. The Bureau of Justice Statistics (BJS) provides detailed analysis of health data in prisons and jails, with some information available by state. At year-end 1999, NY had 7000 prison inmates known to be HIV positive; New York City held 1165 jail inmates (7% of its total population) known to be HIV positive. The January 2001 BJS Special Report reveals medical problems of inmates from a 1997 survey. National statistics reveal that 19% of inmates in state prisons reported common illnesses such as a cold, a virus or the flu; more than ¼ of the inmates in state prisons reported injuries during confinement; 21% of inmates in state prisons said they had a non-injury related medical problem, 7% of which required surgery. Areas of medical problems reported include heart problems, diabetes, HIV/AIDS, kidney/liver problems, respiratory problems, cancer, skeletal and neurological problems.
Certainly correctional health staff are challenged to meet patients’ health care needs; these challenges are even greater in local jails than in state prisons. “A vast majority of inmates are in city and county jails, where short stays and rapid turnover pose serious challenges for implementing interventions.”4
With sufficient expert staff, the state’s correctional system could demonstrate excellence. There are some successful models of care here in NYS and elsewhere that do improve prisoner’s health status, teach patients to reduce risk behavior, manage chronic diseases and provide community-based coordination to promote post release compliance with medication regimens. These programs are time and staff intensive. They include five elements of care based on a public health model.
An outcome driven health focus should include all five of these elements. With the current staffing situation, however, the emphasis of health care is on the first two elements, that of early detection and assessment and treatment. The other three elements, those of prevention, health education and discharge planning for continuity of care are essential. Additional qualified staff are needed to provide these essential services. A model that has been well examined is a joint effort of the Massachusetts Public Health Association and the Hampden County Sheriff’s Department. They have produced a manual that is readily available and serves as a model for replication.5 Another effective model has been the Health Link service directed at incarcerated women with substance abuse treatment needs at the Montefiore/Rikers Island Health Service.
In August 1998, the American Journal of Public Health (AJPH) recognized these programs as public health models that connect correctional health care with communities. They noted, “Correctional institutions are reservoirs of physical illness and psychosocial problems, which constantly spill back into the community. If these diseases are to be properly treated, transmission interrupted, and the health of the general public optimized, then effective treatment and education must be provided within the jail system.” In addition to protecting the public’s health, investment in correctional health is an imperative. AJPH stated, “Effective health care during incarceration and continuity of care following discharge are associated with lower recidivism.” More recently, and closer to home, “Lack of aftercare has been identified as a significant predictor of recidivism to drug use and criminal activity for ex-offenders.”6 Models of collaboration between correctional health staff and community based providers that integrate discharge planning with follow-up care may even “result in downstream savings to taxpayers in the form of reduced long-term treatment costs, costs of avoided disease, and costs of re incarceration of repeat offenders.”7
The health care needs of prisoners should be addressed while they are incarcerated. In the interest of the public’s health, the state Department of Health should oversee and monitor the care provided in our prison healthcare systems. Since the standard of care in correctional health is expected to be equivalent to that available in the community, they should be subject to the same regulations. As such, NYSNA can support the intent of Assembly bill 3692. We wonder if the bill language would impose the Certificate of Need process on the correctional health service, or require the correctional health service to file for a license with the Department.
It may be more appropriate to create a separate section of the public health law to address the Department’s new authority.
NYSNA can also support the intent of Assembly bill 4204. Additional responsibility for the Department of Health will require additional staff. NYSNA would prefer to include a mandate to hire staff in the legislation rather than leave it to the state budget process. Additionally, we recommend that the provisions of the bill be changed so that notice is not given prior to conducting a review. An invitation to the public to provide the Commissioner with relevant information is to be encouraged, but not at such time that any visit to the facility is scheduled. The Joint Commission on Accreditation of Healthcare Organizations is moving away from announced visits, recognizing that the true picture of compliance with standards is revealed in unannounced visits.
NYSNA can also support the intent of Assembly bill 3940-A. We suggest that a priority be placed on staff development education, rather than on opportunities to use non-department personnel. In this way, the expertise will be developed among the correctional health staff. The American Nurses Association’s Position on HIV Disease and Correctional Inmates stresses that education be provided to all staff and inmates. All inmates should receive counseling regarding behavioral changes necessary to prevent transmission of the HIV disease. This is also a standard of the National Commission on Correctional Health Care.8
NYSNA recommends that the state urge correctional health facilities to become accredited by NCCHC. In so doing, correctional health services would be held to peer-reviewed accreditation standards that include:
The opportunity exists for healthcare professionals in correctional health to identify and control disease through screening, treatment and education. The issue of limited correctional health staff in New York’s prisons and jails must be addressed in order for other legislative solutions to be successful. We urge you to adopt A5591 and S3255 establishing the parameters for safe staffing in correctional and other community-based health care services. We further urge you to promote salary parity for correctional health staff with other regional health employers and fund loan forgiveness programs for nurses willing to enter correctional health care.
Thank you for the opportunity to provide this testimony. I would be pleased to be a resource to the Committees as you continue your deliberations and am available to answer any questions you may have.
1. “2003 standards: A summary guide to the revisions”, 2003
2. “Ill-Equipped: U.S. prisons and offenders with mental illness,”2003
3. Hammett, 2002
4. Hammett, 2002
5. Ashe Jr., Hager, Conklin, & Wilson, 2003
6. Richie, Freudenberg, & Page, 2001
7. Hammett, 2002
8. “2003 standards: A summary guide to the revisions,” 2003
“2003 standards: A summary guide to the revisions.” (2003). Retrieved November 12, 2003, from http://www.ncchc.org/resources/stds_summary/prison/a.html
Ashe Jr., M., Hager, C., Conklin, T., & Wilson, R. (2003). “A public health model for correctional health care.” Retrieved November 12, 2003, from http://www.mphaweb.org/hccc.html
Hammett, T. (2002, July). Health-related issues in prisoner reentry. “Crime and Delinquency.”
Ill-Equipped: U.S. prisons and offenders with mental illness. (2003). “Human Rights Watch,” 96.
Richie, B., Freudenberg, N., & Page, J. (2001). Reintegrating women leaving jail into urban communities: A description of a model program. “Journal of Urban Health: Bulletin of the NY Academy of Medicine,” 78(2), 290-303.
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