Corrections Works March 2014 (special prisoner health edition)

From our Chief Executive

Chief Executive Ray Smith. Welcome to this special Prisoner Health Edition of Corrections Works.

Prisoner health is important to me because until someone has their immediate health needs met we’re not going to be able to address their rehabilitation needs.

The state of your health affects your overall well being. This is something you know from your own experience; the better you feel physically and mentally, the better you’re able to lead a full life and cope with the everyday stresses that come along.

This is especially true of those in prison. If a prisoner has their physical and mental health needs met, they are better able to focus on their rehabilitation.

A criminal lifestyle is not conducive to good health. Many offenders enter prison with serious health issues that are the result of a lifetime of lack of care, violence, alcohol and drug abuse and poverty-related illness. Prisoners tend to have much higher healthcare needs than the general population, e.g. a 50 year old prisoner often suffers similar health problems to someone 10 years older.

At Corrections, we provide much-needed, quality primary healthcare to prisoners. Our nurses are caring people who do a great job in what can be trying circumstances. They not only address the immediate health needs of prisoners, they look at wider health issues too, delivering innovative projects such as an asthma management initiative, and, in conjunction with our community partners, a diabetic retinal screening program.

We don’t do this alone. We work closely with the Ministry of Health, medical experts, local District Health Boards and Primary Health Organisations to provide the most appropriate care; and to ensure that care continues in the community following someone’s release from prison.

Our prisons provide excellent healthcare for prisoners and I’m proud to say that most people in New Zealand prisons leave in better health than when they came in.

Let us know if you have any ideas about stories that you’d like to see in upcoming issues. You can email commdesk@corrections.govt.nz.  

Ray Smith
Chief Executive

Nursing careers at Corrections

Graduate nurse follows prison path

Nurse Geoff RuaineGeoff Ruaine’s fellow nursing students were surprised when he decided to work in a prison rather than following the traditional graduates’ path of working in a hospital. But he has no regrets and is thriving in the busy environment.

Geoff, of Te Arawa, Tainui and Cook Islands heritage, has worked at Spring Hill Corrections Facility (SHCF) for the past five months.

He spent four weeks at the prison during his Wintec Bachelor of Nursing study and then asked to come back for the final three-month clinical placement.

“I was already curious about healthcare in prison and asked if I could do a placement at SHCF,” says Geoff. “I wanted to work with marginalised groups, and with my own people – Maori and Pasefika – to get experience in this area as well.”

His first six weeks of orientation were spent working alongside colleagues, and now he’s “flying solo” and enjoying the learning within this unique primary healthcare setting.

“As a new graduate registered nurse I take ownership of my decision making,” he says, “although I am supported and guided in the right direction.”

This means keeping in close communication with his team and observing as much as he can of colleagues’ work and practice.

“The Spring Hill health team is really diverse. We have a wide range of experience, knowledge and cultural backgrounds. There’s a lot to learn and I feel connected as part of the team.”

One difference between working in a prison and in a hospital is the emphasis on safety and security, and the need to consider his own safety. Geoff feels he has adjusted well and understands the need to work closely with custodial staff.

“It’s about having a clear understanding of what Corrections does. As a nurse I have a key role to play in building a therapeutic relationship with my patient to promote good education, health and well-being.”

Some of the prisoners, he says, know how to work the system, but that “keeps us on our toes” and ensures that every interaction with patients is recorded to “ensure we are doing the right thing”.

And how did he find coming to prison at first? “I felt very comfortable from the get go,” Geoff says. “Nine times out of ten we don’t need to know what the prisoners are in for. As long as we treat our patient and environment with respect, then that is usually what we get in return.”

He’s also pleased with the education opportunities he’s had, which so far include pre-hospital emergency care training, and alcohol and drug withdrawal training.

Geoff is keen to stay with Corrections and gain more experience. In the long term he would like to go back to his hometown of Rotorua and work in a Maori/Pacific health service.

Corrections is very supportive of further education and personal development. The expertise of registered nurses working in prisons was recognised mid-2013 with the launch of a new professional development programme. The Professional Development and Recognition Programme (PDRP) provides a pathway for nurses who deliver primary healthcare to a prison population. It recognises nurses’ expertise in the prison setting, values clinical practice, and identifies expert nurses and role models.

Experienced nurse leads team

Nurse Paula MacDonald. Experienced nurse Paula MacDonald has worked at Rimutaka Prison for the past six years and is one of two health team leaders.

After working briefly in a hospital, she came to the prison because she had always wanted to practise in primary care nursing. She finds it similar to working in primary health in the community, with the addition of emergency care, which can cover anything from chest pain, stroke and asthma to assaults and burns.

How does she feel working with prisoners? Day to day, Paula says she feels comfortable. “I don’t find working with our patients any different to working with anyone else. We must ensure the service we offer is safe, respectful and dignified, no matter where we work or who we are dealing with.”

She enjoys the fact that every day is different. “We never know what to expect. You can prioritise jobs, but you never know what may happen to make you completely re-think your priority list.”

The job requires the ability to work autonomously, she says, but there is also the need for “real teamwork”. There is also a high level of collaboration with custodial staff.

She describes starting work at the prison as a “fast learning curve”, with a lot to learn.

“The most essential skill you have to develop and be confident with is physical and mental health assessment. You need to be a real people person and be able to form a rapport quickly. Getting to know your population is really important to help you understand issues and behaviours. We also work hard to improve links with our external partners and help them to understand our unique environment as this leads to better health outcomes for our patients.”

Working as a team leader, it is Paula’s job to promote a culture that enables the registered nurses to progress and develop their practice.

“At Rimutaka we encourage nurses to act as role models and adopt good practice standards. I have been in the role now for about three years and it has been challenging at times but also very rewarding.”

Paula was heavily involved in setting up the High Dependency Unit. She has a vital leadership role particularly in supporting the implementation of the new healthcare assistant role developed for the HDU.

She enjoys the diversity of the work and the focus on quality. “There’s always something to learn and I have to use my initiative every day. I also love the fact that there’s so much opportunity to champion change, hopefully changes that will be taken home into the community and so affect a wider group.”

“We work with patients who often haven’t accessed healthcare in the community. Because of this, many of our patients present with a health age ten years older than they are, and have often made poor lifestyle choices prior to coming to prison.”

“Unfortunately, there are a disproportionate number of Maori incarcerated. We have to work closely across the department to ensure we are responsive to their needs.”

What would she advise other nurses who are considering working at a prison? They are likely to find it a very rewarding job with many opportunities, she says. “It’s such a challenging and diverse role where you need to wear many hats, and where consistency is the key.” 

Healthcare in prisons offering primary health++ 

Auckland Region Women’s Corrections Facility Health Centre Manager Kirstin Harrison with a patient.

Marie*, 27, was seen by a nurse when she arrived at Auckland Region Women’s Corrections Facility. Marie is a chronic methamphetamine addict and was starting to suffer from withdrawal symptoms. She was thin, with skin lesions, and a possible sexually transmitted disease.

The nurse gave Marie some medication to help her deal with the withdrawal symptoms, and placed her on segregation for health oversight. Marie was distressed and angry, seeing and hearing things, and so needed a lot of “TLC and patience” in the words of Health Centre Manager Kirstin Harrison. “We monitored her constantly to ensure her condition was stable; if it had deteriorated we would have transferred her to hospital for specialist de-tox support.”

Ryan*, 23, a prisoner at Waikeria Prison, was seen and assessed by Registered Nurse Kay Smith within an hour of coming to prison. She completed the Reception Health Screen, which checks health basics such as blood pressure and temperature, and some initial questions on mental health and drug and alcohol use. Ryan told Kay he’d been under mental health services in the community for self-harming, but didn’t like the medication so had stopped taking it. Since Ryan has a history of self-harming, he was put in the At Risk Unit, so custodial and health staff could check on him regularly. Ryan is a smoker, and since all our prisons are smoke-free, Kay gave him a pack of lozenges and a single nicotine replacement patch to see him through the night. The next day Ryan was referred to the Forensic Service from the local District Health Board. He was also referred for a short rehabilitation course to address his occasional drug use.

Marie and Ryan clearly need a lot of help, and yet, says Corrections Director Offender Health Bronwyn Donaldson, it’s common for prisoners to have multiple health needs that need extra management by healthcare staff.

“Many prisoners live chaotic lives before they come to prison. A large proportion are addicted to drugs and alcohol and don’t look after themselves well."

Photos of health care in prison. “Prisoners, as a group, have higher health needs than the average person. And it’s especially important for us to help prisoners sort out their health issues so they can engage properly in rehabilitation opportunities such as programmes, education and work training,” she says.

Every prison has a health centre staffed by registered nurses who are employed by Corrections. Doctors and dentists are contracted to provide their services, and local District Health Boards provide secondary and tertiary healthcare services. The health centre staff provide primary healthcare services to the same standard offered in the community.

“In many cases, such as with Marie and Ryan, we need to offer more, so it’s really primary healthcare plus, plus!  But while alcohol and drug management and mental health screening are a big ‘extra’ part of what our nurses do – the story certainly doesn’t end there. There’s huge variety in healthcare in prison,” says Bronwyn (see primary health ++ text box above).

“Our health centres run nurse-led clinics in a wide variety of areas. For example, one of our most popular programmes is cervical smear screening for female prisoners. Last year we carried out about 270, and for many women it’s their first time, even though they’re in a high risk group. We know we’ve saved lives through this programme.”

* Names and some details have been changed to protect privacy.

Primary health ++

All prison health centres offer the same standard of care as that available in the community, and because of the high health needs of prisoners, many prison health centres offer additional support, including:

  • mental health screening
  • drug and alcohol use screening
  • hearing loss screening
  • cardio-vascular risk assessments
  • support for women’s health, including a cervical smear screening programme, mammograms and Mothers with Babies Units in our three women’s prisons
  • health education for prisoners
  • response to medical emergencies
  • retinal screening for diabetes and hepatitis C fibroscanning (offered in conjunction with District Health Boards).

 

Mental illness more common in prison

Research shows that mental illness is up to five times more common among prisoners than in the general population, so our nurses screen for mental health issues, including whether a prisoner is a risk to themselves or others. If the prisoner has a mild to moderate mental health need they can be referred to the prison doctor or an external health provider. All prisoners with serious mental health needs are managed in partnership with Regional Forensic Mental Health Services. In acute cases prisoners may be transferred to a secure forensic mental health facility, managed by a District Health Board.

Prison Health Centres: Part of the Community

Partnerships key to care: Forensic Nurse Tracey Turner visits a prisoner at Spring Hill Corrections Facility. Tracey is part of the Forensic Team at the Waikato District Health Board and comes to the prison at least three times a week with other members of her team, including a forensic psychiatrist and psychologist. The Forensic Team has weekly meetings with the prison Health Services Team to discuss patient care, including discharge planning. 
Health services in prisons are part of the wider community, functioning alongside local hospitals and other providers to form healthy communities.

Corrections contracts registered medical practitioners, who work as general practitioners (GPs) in the community, to provide medical advice in each prison and complement the work of nurses who provide the day-to-day care. The number of GPs and hours worked depends on the size of each prison and the number of prisoners.

“In essence the prisoners’ primary healthcare service is led by nurses,” says Manager Regional Health (Lower North) Derek Perkins. “It’s very important that the GPs appreciate the extent of the nurses’ scope of practice and support the nursing teams to manage health conditions.”

GPs who work in prisons need to be skilled in communicating with patients, as they can be tested at times – for example, it can create tension if prisoners are not prescribed the medication they want.

Health services in prison also have relationships with GPs working in the community. Less than half of all prisoners have a current enrolment with a GP. For those who are enrolled, it’s vital that the health service in prison is able to access patients’ medical records.

“When a prisoner is released we try to provide their GP with as much information as possible about their health treatment in prison,” says Derek. “For those not enrolled, there is a big push to have social supports in place prior to release, including GP enrolment.”

Manager Regional Health (Southern) Deb Alleyne is leading a 12-month pilot that has based mental health clinicians in Christchurch Men’s Prison, Spring Hill Corrections Facility and Auckland Region Women’s Corrections Facility.

The clinicians (all mental health nurses) support prisoners with mild to moderate mental health needs. They provide a range of options, from teaching coping strategies to referral to forensic services.

They work with prisoners who have spent extended periods in an At Risk Unit or inpatient psychiatric care to support their return to the mainstream prison, and they work with case managers and probation staff to support reintegration.

The clinicians are all contracted (from a Public Health Organisation, a District Health Board and an external provider) and continue to engage with the wider mental health community for supervision and peer support.

A significant aspect of their role is to assist Corrections staff to improve their ability and confidence in working with this group. “It’s about up-skilling our staff,” say Deb. “The idea is for the mental health clinicians to work alongside our staff, not do it for them.”

The pilot will be evaluated this year and if it is shown to make a difference we will then consider how we can embed this across all sites.

“We know that if mental health issues are addressed, individuals are more likely to succeed following release and less likely to re-offend,” says Deb.

An initiative at Northland Region Corrections Facility (NRCF) near Kaikohe involves the use of audio visual links (AVL) with the Mason Clinic in Auckland. Due to its remote location, the prison has been trialling the use of AVL for consultations between psychiatrists and prisoners under their care. Initial face-to-face consultations are followed up by AVL as appropriate. NRCF has a close relationship with Waitemata DHB’s community mental health and forensic team.

“There is excellent collaboration and communication with the forensic service,” says Regional Health Manager North Pam Lightbown, who meets monthly with Mason Clinic managers.

The clinicians (all mental health nurses) support prisoners with mild to moderate mental health needs. They provide a range of options, from teaching coping strategies to referral to forensic services.

They work with prisoners who have spent extended periods in an At Risk Unit or inpatient psychiatric care to support their return to the mainstream prison, and they work with case managers and probation staff to support reintegration.

The clinicians are all contracted (from a Public Health Organisation, a District Health Board and an external provider) and continue to engage with the wider mental health community for supervision and peer support.

A significant aspect of their role is to assist Corrections staff to improve their ability and confidence in working with this group. “It’s about up-skilling our staff,” say Deb. “The idea is for the mental health clinicians to work alongside our staff, not do it for them.”

The pilot will be evaluated this year and if it is shown to make a difference we will then consider how we can embed this across all sites.

“We know that if mental health issues are addressed, individuals are more likely to succeed following release and less likely to re-offend,” says Deb.

An initiative at Northland Region Corrections Facility (NRCF) near Kaikohe involves the use of audio visual links (AVL) with the Mason Clinic in Auckland. Due to its remote location, the prison has been trialling the use of AVL for consultations between psychiatrists and prisoners under their care. Initial face-to-face consultations are followed up by AVL as appropriate. NRCF has a close relationship with Waitemata DHB’s community mental health and forensic team.

“There is excellent collaboration and communication with the forensic service,” says Regional Health Manager North Pam Lightbown, who meets monthly with Mason Clinic managers.

The truth about prison healthcare

Most prisoners are simply grateful to receive help with their health issues.

Prisoners often continue taking the same medicine

In New Zealand, we don’t automatically ‘stop’ prisoners’ medicines when they enter prison. Prisoners continue on the same medication until the medical officer (the doctor) has assessed their health and reviewed their medicines. Often, the same medication is continued, though some changes may be made depending on the doctor’s assessment of the prisoner’s needs. One of our registered nurses checks all medicines brought into prison to ensure they are safe – for example, to check it hasn’t expired and that it belongs to that person.

We prescribe any necessary drugs

Prison doctors can prescribe any medication that the patient needs. We treat prisoners in a holistic way to find alternatives to addictive drugs, thus supporting their rehabilitation and reintegration. Prisoners who are addicted to drugs, alcohol, or cigarettes are never forced to withdraw suddenly without help. For example, we follow best practice clinical guidelines for alcohol and drug withdrawal, and for smokers we provide smoking cessation support, including access to counselling and nicotine replacement therapy.

Prisoners access specialist health services

Prisoners who are referred for specialist services, including hospital care, are treated like anyone in the country; they have to meet the same criteria and wait the same length of time.

Nursing in prisons is innovative

Our nurses receive on-going training and are highly skilled across a wide range of areas, including primary healthcare, managing trauma, health promotion activities, and care and treatment of mental illness, and alcohol and drug addiction. Our prison health centres run many innovative projects, making prisons interesting places to be a nurse. Examples of nurse-led projects are a diabetic retinopathy clinic at Auckland Prison, and a nurse distributing health promotion information for prison visitors (who, like the prison population, often have high health needs) at Otago Corrections Facility.

Nurses working in prisons are as safe as any nurse

Prisons are a special environment, and we have processes and supports in place to keep all staff, including healthcare staff, safe. Custodial staff work alongside healthcare staff to give close support. Most prisoners, like most patients anywhere, are simply grateful to receive help with their health issues.

Myths abound about the healthcare offered in prison

Often these myths are learned from books or movies. It makes a more dramatic story to depict a hard-hearted prison nurse or to have your prisoner ‘hero’ forced to go cold turkey. But these stories are just that: stories. The truth about healthcare in New Zealand’s prisons is a lot less dramatic – and a lot more compassionate, clinically excellent and innovative.

High Dependency Unit to expand

 Healthcare Assistant Neil Escarda with an older prisoner.

Corrections will expand the 20-bed High Dependency Unit (HDU) at Rimutaka Prison in Upper Hutt by a further ten beds by the end of 2014. The HDU opened at the end of 2012 to house prisoners with health issues that make it difficult for them to function independently. Most residents are in their seventies or eighties, but the unit also houses younger prisoners with significant disabilities or health conditions.

The HDU has been full since mid 2013, with some turnover as a few prisoners have been released or returned to other prisons as their conditions have stabilised or improved.

Manager Regional Health (Lower North) Derek Perkins says the expansion will ensure Corrections can continue to deliver quality healthcare to high needs prisoners.

“The expansion will mean we can meet the need for this level of care for the next three to five years. We’re also planning other strategies to manage care for the aging population across our prisons.”

Prisoners in the HDU have single cells, each containing a shower, toilet and hospital-type bed. A disabled accessible shower room is also available, along with a health office, medication administration facilities and a treatment room. Healthcare assistants provide 24-hour care, helping prisoners with the activities of daily living such as eating, showering and toileting.

“The expanded unit will have the same specifications, though there are a couple of things we’ve learned from the original, such as painting the cell doors different colours so those who are confused can get back to their own bed more easily,” says Derek.

The ten additional high dependency beds will be in an existing, adjacent 20-bed unit. The remaining ten beds are already allocated to low-security prisoners who look after the grounds and clean the unit.
In line with the rest of the country, the prison population is getting older. Currently there are more than a hundred prisoners over 70.

From our Minister

Hon Anne TolleyI’ve visited every prison in New Zealand, and I’ve seen first hand the dedication of Corrections staff. This doesn’t apply only to safety and security.

Our staff are well aware of their duty of care to prisoners, and prisoner health.

We know that if prisoners are healthy, they are more likely to engage in education and training programmes that can help their rehabilitation and ultimately reduce re-offending.

And I’m very pleased to say that the Government has ensured that prisoner health, and particularly mental health, is addressed, and that it is dealt with appropriately.

Offenders can often be volatile and unpredictable. Some are determined to harm themselves.

We introduced a mental health screening tool in 2012 to identify prisoners’ mental health needs, so they can be referred for appropriate care.

In the last five years there has been a dramatic reduction in self-harm threat to life incidents, down from 33 in 2008/9 to 7 in 2012/13.

By 2017, Auckland Prison’s maximum security wing will be completely rebuilt, and will house a mental health unit for prisoners with severe to moderate needs, providing care to offenders who currently have to be transferred off site.

We recognise issues with our ageing prison population, and in 2012 I opened New Zealand’s first High Dependency Unit, at Rimutaka Prison.

The unit has been successful in catering for prisoners who can no longer look after themselves and who have high health needs.

And let’s not forget the revolutionary smoking ban, which proved a lot of people wrong by providing healthier working conditions for staff, and for prisoners, in a well-managed transition.

So, we are making a difference for prisoner health. And we will continue to focus on this issue as we strive towards our goal of a 25 percent reduction in re-offending by 2017.

Hon Anne Tolley 

Regional Highlights

Read about Corrections' health activities around the country

Nurse-led health service recognised in law

NZNO Industrial Advisor Chris Wilson.

Last year, changes to how Corrections operates and manages prisoners were made law in the Corrections Amendment Act 2013.

One of the changes highlights the importance of the role of the health centre manager by making it a legal requirement that every prison has one, and that this person must be either a registered nurse or medical practitioner.

The New Zealand Nurses Organisation (NZNO) was one of the organisations that supported the change to the law, and appeared at Select Committee to talk about their support.

“The role of nurses is central to the delivery of healthcare to prisoners, and the law change acknowledges just how vital the role of a health centre manager is. The NZNO works closely with Corrections on innovations to achieve best practice in healthcare, and we were pleased to support them to have these important changes recognised in law,” says NZNO Industrial Advisor Chris Wilson.

Corrections Director Offender Health Bronwyn Donaldson says Corrections has been employing health centre managers, all of whom are registered nurses, for years and the law change endorses the role.

“Health centre managers are responsible for managing and maintaining the overall physical and mental healthcare of prisoners. They work closely with custodial staff to make important decisions about the management of prisoners, for example, they may decide if a prisoner should be segregated, and whether a prisoner should be transferred to hospital.” 

Quality health care

Clinical Director of Health Debbie Gell (left) and Clinical Quality Advisers Kay Sloan and Kirsty Fraser.

Over the past few years Corrections has put a substantial quality programme in place to support good clinical care to prisoners.

Clinical Director of Health Debbie Gell says Corrections has a fantastic opportunity to make a difference to patients who very rarely access healthcare. “We take this obligation incredibly seriously, and try to use their time with us to support and improve health outcomes.”

Focusing on quality supports Corrections’ commitment to ensure our health services meet, or exceed, health sector standards. We have introduced an extensive range of quality initiatives to achieve and maintain those standards.

Each health centre has been working towards Cornerstone accreditation, the standards set by the Royal New Zealand College of General Practitioners for general practice. Thirteen of our 16 health services have attained this accreditation and the remaining three are on track for it.

Nationally, a clinical governance committee has been set up to oversee clinical services. Each health centre has its own clinical governance committee (which includes the health centre manager, medical officer, a custodial representative, dentist and other members of the multi-disciplinary team). These committees examine incidents and complaints, and develop services to meet patients’ needs. Additionally, all health staff take part in monthly health quality forums.

Debbie leads a team of three staff in the regions dedicated to quality assurance. Each year they develop a quality plan, which identifies any improvement projects needed. The team investigates new initiatives, taking into account developments in primary health care, and supports and educates staff about the new systems.

A dedicated reporting system (HSIR) has been introduced to record and monitor all incidents related to health service delivery and support the development of improvements.

Patient satisfaction surveys started in 2011 and the results are important for quality improvement, says Debbie.
Prisoner feedback, from patient satisfaction surveys, includes:

  • “My mental health has improved.”
  • “My diet control is getting better and my blood sugar levels are starting to look better too.”
  • “I have been in prison for over a decade and in this unit the nurses seem to prioritise and make appointments ASAP and are very helpful.”
  • “Very professional and helpful.”

A new complaints management policy aims to resolve issues at the lowest possible level. “Quality is a top priority and we are proud of the breadth of our quality activities,” says Debbie.