Prison nurses are viewed as either “brave or stupid” by staff in other sectors, according to a senior nurse who has called for more work to bust myths and promote the many positive aspects of this challenging yet rewarding role.
Stephanie Smith, clinical team lead at HMP Hewell, told Nursing Times she believed many more students and newly qualifieds would consider working in prisons if they had the chance to experience what the sector was really like.
“You don’t need to be brave to work in a prison – you just need to be non-judgemental”
She also maintained there was a strong case for prison nursing to be made a speciality in its own right, with specific undergraduate training to prepare nurses for the sheer diversity of the work.
Ms Smith began working at HMP Hewell in Worcestershire seven years ago as a band 5 and has worked her way up to her current band 7 role within the service, which is run by independent provider Care UK.
She now manages a team of more than 30 nurses, plus some bank and agency staff, at the 1,200 capacity all-male prison, which has its own inpatient unit and provides a wide range of other healthcare services to inmates.
“It is never predictable and no day is the same,” she said in an interview with Nursing Times. “You can be sitting eating your lunch one minute and the next you’re ‘resusing’ someone on a landing somewhere.
“Nurses may be responding to emergencies from drug overdoses to assaults and then from a primary care perspective we do a phenomenal amount and some really good work,” she noted.
“When they leave, you know you have contributed to transforming their life.”
However, she said most student nurses and nurses who worked outside prison had little idea of the reality of prison nursing and there were lots of misconceptions.
“People think we’re either brave or stupid,” she said. “I’m not going to say it is all singing and dancing on a daily basis, because it is not and we see things quite often that would make your toes curl.
“But we’re all dedicated and we need to get more students in so they know what it is like,” she said. “You don’t need to be brave to work in a prison – you just need to be non-judgemental.”
HMP Hewell welcomes student nurses on placement and has just started taking student paramedics.
Ms Smith said she was also keen to promote prison open days as a way to “dispel myths and show people what we actually offer and the services provided here”.
“People have a preconceived idea of what it is going to be like and all the students say the same: ‘It’s not what I thought it was going to be’,” said Ms Smith. “We have had some students who don’t like it, but I would say about 98% do love it and come back.
“I think it is about how you engage with the men and it is a respect thing”
Regarding the prison inmates, she added: “I think you have to remember that sometimes people make stupid mistakes to get in here and that doesn’t make them evil or a bad person – they have just made some poor life choices.”
Widespread problems with the use of psychoactive substances, staffing shortages and management issues in some areas have led to safety fears for prison nursing staff across the UK.
Ms Smith admitted prison nursing was challenging but was adamant that she felt safe at work.
“Staff safety is paramount and that comes first and foremost,” she said. “I can honestly say that in all my time here – yes, there have been confrontational situations but never directly involving me. I have been verbally abused but I have never been physically assaulted.
“I think it is about how you engage with the men and it is a respect thing,” she said. “On the whole, I have very few problems here.”
However, she acknowledged that psychoactive substances – such as spice, a form of synthetic cannabis – were a big challenge for prison healthcare teams and managers.
“Our most challenging issue at the moment is psychoactive substance use, when we’re going into cells and taking men out who have had an episode and are under the influence. We get it daily and it can be fatal,” said Ms Smith.
“You don’t know what it has been cut with and you just don’t know how they are going to present because everyone presents differently,” she said. “We have had a couple of deaths in custody. It is a horrific death to witness and be a part of. They don’t train you for this and it can be quite disturbing.”
“The problem is that when they get released the continuity of care isn’t that great”
Ms Smith said there was a need for more multi-disciplinary training for nurses, paramedics and others on how to identify and treat psychoactive substance users.
Meanwhile, some of the unique challenges of prison nursing – including dealing with substance misuse and mental health issues in custody – meant she would be all in favour of a specialist nursing degree.
“There should be a national qualification because it so diverse,” she said. “We do primary and acute care and have the inpatient unit, which is a lot of mental health – there are so many areas that we cover,” she said. “For example, a lot of our nurses are skilled to a high standard in suturing to prevent the men needing to go to external hospitals.
“They don’t like doing to the local hospital, because they’re in escort chains and their perception is that they are judged by the nursing teams,” said Ms Smith.
Meanwhile, an ageing prison population meant prison nurses were dealing with more long-term chronic conditions, dementia and sometimes palliative care needs.
A recent development at HMP Hewell has been the introduction of a high tech “telemed” service that means prisoners have access to a wide range of specialist expertise and care – including in cardiology, dermatology, neurology, urology, gastroenterology, general surgery, tissue viability, and diabetic and palliative medication.
“We have a lot of issues with substance misuse and alcohol dependency”
Ms Smith, who is a clinical nurse specialist in blood-borne viruses (BBVs) and sexual health, said she was also particularly proud of work to diagnose and treat BBVs and cut waiting times.
Together with healthcare assistant Christine Hawkswood, she has overseen a reduction in the prison’s turnaround time from hepatitis C diagnosis to treatment to just seven weeks.
The prison was the first in the region to roll out dry blood spot testing for all BBVs and the pair has built up a comprehensive screening and treatment programme.
“We do wing-based screening, health promotion events throughout the year and try and target high risk patients like intravenous drug users and sex workers,” she said. “It encourages the men to engage.
A lot of them just want to bury their head in the sand about their diagnosis and there are a lot of stereotypical views on hep C – that it is a death sentence. But we’re seeing around a 97% cure rate at the moment,” she said. “They see us regularly every week and I think it gives them a chance to own their condition.”
Much prison healthcare is now provided by the independent sector and Ms Smith admitted she had been concerned when services at HMP Hewell transferred across, especially when it came to accessing training and career development.
However, she said her fears were unfounded and she had actively been encouraged to gain qualifications and explore special interests, thanks to the “unlimited” support and continuing professional development available from Care UK.
She said that, overall, she thoroughly enjoyed her job, which is why she was passionate about encouraging more nurses to consider prison nursing as a career. “I get a massive sense of job satisfaction. I can hold my head up high and know that I have positively impacted my patients,” she said.
“For the people we diagnose with HIV, we make sure their CD4 count is stable, they’re on treatment and in a good medication regime – they’re under a consultant and have a follow-up care plan in place,” she said.
Prison staff at HMP Hewell
“We have a lot of issues with substance misuse and alcohol dependency and I can’t even put it into words what it is like when you get a patient that does a detox and looks the picture of health when they leave – there is something really rewarding about that,” she noted.
For some inmates, this progress could be the start of a new life but Ms Smith said a lack of support when people left prison contributed to high re-offending rates.
“The problem is that when they get released the continuity of care isn’t that great and the whole cycle starts again so we do see the same faces all the time,” she added. Nevertheless, she noted there were success stories.
“The condition that some people are in when they arrive in prison – especially if they have nowhere to live – can be terrible,” she said. “When we meet and greet them in reception they smell, some are covered in lice and wounds and they haven’t had a hot meal for god knows how long.
”When they leave and get weighed again on the way out, you know you have contributed to transforming their life,” she told Nursing Times.