CA Forensic Nurses’ Practices & Views With Inmates with Serious Mental Illness: Medication Compliance

Phyllis M. Connolly, PhD, APRN, BC, CNSProfessor, San Jose State University

Chia-Chen Lee, MS, RN, FNPSanta Clara County Custody Facilities &

NP Crestwood

The Problem

Estimated 283, 800 mentally ill inmates is US (Sniffen, 1999)

547,800 mentally ill offenders on probation every year (Sniffen, 1999)

Non compliance with psychiatric medications most significant predictor of arrest (McFarland, 1989)

1/3 discharged from psychiatric hospitals lose contact with services within a year (Barr, 2000)

Costs California, $40,000,000 annually (MIOCRG, 2002)

Solutions

Increasing compliance with psychotropic medications

Improving compliance

￬ relapse, ￬ hospital

readmission and ￬criminal transgression (Dubyna & Quinn,1996)

Research Questions

What do forensic nurses believe about medication compliance?

What information do forensic nurses collect during their assessment of inmates’ medication compliance?

What barriers do forensic nurses identify related to medication compliance after inmates are released?

What are the self care behaviors? Do they have concerns for their safety?

Methodology

Exploratory mail survey Questionnaire developed based on

literature review and Scope and Standards of Forensic Nursing Practice (IAFN & ANA, 1997)

Experts utilized to develop and pilot tool

Human Subjects Protected by meeting IRB requirements, SJSU

31 jails or prisons with population over 500 in CA were targeted

Final Instrument

Survey design expert formatted the final 60 questions in a 4 page questionnaire

Piloted by 10 forensic nurses not part of the final study

Procedure

Phone call made to medical directors/or directors of nursing stratified nonrandom sample of 31 CA jails or prisons with populations over 500

3 facilities could not obtain administrative approval

Surveys were mailed to 28 sites in CA Forensic nurses: RNs, NPs, & CNSs Each nurse was supplied pre-stamped,

pre-addressed envelope A follow up phone call was made 1

week after mailing

Response & Data Analysis

14 facilities participated (50%) 55 Forensic nurses returned

questionnaires Question #50 asked for the exact number

of forensic nurses & based on self-report there were 86 potential participants

64% response (55/86) SPSS was used to compute frequencies

and percentages

Institutional Characteristics N = 14

Average inmate population

Ranged from

500 – 6,000

Separate units for inmates with MI

66%

Located in urban areas 46%

Located in suburban areas

33%

Located in rural areas 20%

Demographic Characteristics: Gender, Age, Education N = 55

0 5 10 15 20 25 30 35 40 45 50

Males

Females

Age 25 -45

Age 45 - over 50

EDU AA

EDU Dip

BS Nurs

BS other

MS Nurs

MS other

Doctorate

Other

Other2%

African Am9% Chinese

5%Filipino

9%

White75%

Ethnicity N = 55

Nursing Experience N = 55

Less than 5 yrs. 3 (6%)

5 -10 yrs. 8 (15%)

11 – 15 yrs. 9 (16%)

16 – 20 yrs. 7 (13%)

More than 20 yrs. 28 (51%)

Nursing Experience as Forensic Nurse N = 55

Less than 5 yrs. 16 (29%)

5 – 10 yrs. 18 (33%)

11 – 15 yrs. 12 (22%)

16 - 20 yrs. 7 (13%)

More than 20 yrs. 2 (4%)

Experience With Inmates With Mental Illness N = 55

Less than 5 yrs. 14 (26%)

5 – 10 yrs. 16 (29%)

11 – 15 yrs. 8 (15%)

16 - 20 yrs. 11 (20%)

More than 20 yrs. 6 (11%)

Medication Compliance Views (N = 55)Very important to Important

Importance ￬ recidivism

51 (99%) n = 52

Follow up after release 53 (96%) n = 55

Educating inmates SE psychotropic meds

51 (93%) n = 55

Teaching disease mgt 51 (93%) n = 55

Therapeutic relationship ex-inmates

45 (88%) n = 45

Assessment of Medication Compliance

Name of Med 44 (80%)

Last dose 39 (71%)

Explored issues related to noncompliance 38 (69%)

Financial issues 16 (29%)

Side effects 43 (78%)

Memory impairment 24 (44%)

Inmate doesn’t believe s/he needs 38 (69%)

Doesn’t like to take along with street drugs/alcohol

23 ( 42%)

Lack of support system 25 (46%)

Lack of money for medication 26 (47%)

Medication Compliance Nurse Behaviors N = 55

How often review SE of psych meds with inmates

Always 8 (16%)

Frequently 14 (28%)

Occasionally 24 (42%) n = 51

Most important nursing skill

Communicating with patient 45

( 88%)

Teaching 3 (6%)

Administration meds. 3 (6%) n = 51

Greatest influence over pts

Nurses in jail 19 (42%)

Family 10 (22%)

Peers 7 (16%)

Psychiatrist 6 (13%)

MFCC 3 (7%) n = 45

Perceived Barriers Referrals to Outside Agencies N = 55

Lack of resources 24 (44%)

Lack of time 21 (38%)

Length of custody 11 (20%)

Stigma criminal record 11 (20%)

Out of judicial area 10 (18%)

Budget limit 9 (16%)

Confidentiality 9(16%)

HIPPA regulations 9(16%)

Barriers Providing Discharge Summaries to Outside Psychiatrist and/or Medical Clinic

Lack policy & procedure

19 (35%)

Lack of Time 17 (31%)

HIPPA Regulations

16 (29%)

Fee 6 (10%)

Fee charge to ex-inmate

2 (4%)

Barriers When Providing Medications at Discharge

Lack policy & procedure

25 (46%)

Budget 14 (26%)

Suicide risk 10 (18%)

Lack of time 8 (15%)

Lack of psychiatrist

7 (13%)

Inmates don’t feel they need it

6 (10%)

Barriers When Providing Prescription Prior to Release

Lack policy & procedure

33 (60%)

Lack of psychiatrist

10 (18%)

Lack of time 6 (11%)

Inmates feel they do not need it

6 (11%)

Self Care Practices N = 55

Engaged in support groups Never 35 (70%)

Sometimes 12 (24%)

Most of time 2 (4 %)

Always 1 (2%) (n = 50)

Get Adequate rest Never 13 (25%)

Sometimes 14 (16%)

Most of time 23 (44%)

Always 3 (6%)

Engage in leisure activities Never 13 (25%)

Sometimes 21 (41%)

Most of time 15 (29%)

Always 3 (6%)

Personal Safety N = 55“While on duty, I am concerned about my personal safety”

Strongly agree 9 (16%)

Agree 23 (42%)

Disagree 14 (26%)

Strongly disagree 9 (16%)

“Debriefing services are important for nurses after critical incidents (death, violence, suicide, riots, hostages)”

Strongly agree 37 (67%)

Agree 15 (27%)

Disagree 1 (2%)

Strongly disagree 2 (4%)

Limitations

Nonrandom sample Survey tool lacked established

reliability & validity Study population in California

only Participants well educated &

experienced and may not be representative of all forensic nurses

Self-report and may not match actual practice or behaviors

Conclusions

55 well educated, experienced, caucasian forensic nurses in 14 jails & prisons in CA believe that medication compliance is very important in reducing recidivism & crime

Believed that forensic nurses had the most influence over inmate’s medication compliance

Believed that the therapeutic relationship was very important to medication compliance

Identified many barriers to medication compliance after release

58% were concerned about their personal safety Self care behaviors are not engaged in frequently 94% believed that debriefing services were important

Recommendations Repeat study with larger random sample in

multiple states Maintain high percentage of baccalaureate

and advanced practice nurses employed in jails and prisons

Increase self care practices Increase ethnic diversity of nurses CA specific recommendations:

Add regulation to Title 15 California Code of Regulations to include discharge plans, follow up care, medications or prescriptions upon release, visits by forensic nurses after release

A Vision

Mandating discharge medications and ensuring follow up treatment, along with well-educated, experienced, compassionate, and dedicated forensic nurses practicing in CA jails and prisons may lower rates of crime, recidivism and reduce costs. Furthermore, ex-inmates with serious mental illness may have an opportunity for improved quality of life and increased tenure in the community