The Mentally Ill in Jail: Contemporary Clinical and Practice Perspectives for
Psychiatric-Mental Health Nursing

Horace Ellis, Vinette Alexander

PII: S0883-9417(16)30261-8
DOI: doi: 10.1016/j.apnu.2016.09.013
Reference: YAPNU 50908

To appear in: Archives of Psychiatric Nursing

Received date: 15 May 2016

Revised date: 13 September 2016
Accepted date: 20 September 2016

Please cite this article as: Ellis, H. & Alexander, V., The Mentally Ill in Jail: Contempo-
rary Clinical and Practice Perspectives for Psychiatric-Mental Health Nursing, Archives
of Psychiatric Nursing (2016), doi: 10.1016/j.apnu.2016.09.013

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May 15, 2016

Title: The Mentally Ill in Jail:

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Contemporary Clinical and Practice Perspectives for Psychiatric-Mental Health Nursing

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The following authors participated equally in preparing this manuscript:

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Horace Ellis, DNP, ARNP, PMHNP-BC

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10246 SW 24 Court,
Miramar FL 33025:
Cell: 954-303-2906:

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Work PH: 305-355-7228:
Email: hellis@jhsmiami.org
Affiliation: Jackson Medical Center
1611 NW 12 Ave, Miami, FL 33136
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Vinette Alexander, DNP, ARNP - Corresponding author
12335 NW 51St,
Coral Springs, FL 33076
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Tel: 954-709-6545
Email: va213@nova.edu
Affiliation – Nova Southeastern University
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3200 S. University Drive, Davie, FL 33328

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The Mentally Ill in Jail:

Contemporary Clinical and Practice Perspectives for Psychiatric-Mental Health
Nursing
ABSTRACT
Individuals with serious mental illnesses (SMI) who are incarcerated pose major

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treatment challenges for both correctional personnel and healthcare providers, yet

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deserve the same high standards of care as those in traditional mental health
facilities. The literature references these challenges as types of mental health

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treatment disparities, and calls for improvement measures from clinicians,
researchers, policy-makers, and advocates. From the standpoint of psychiatric-mental

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health (PMH) nursing, this paper explores, examines, and offers some contemporary
clinical and practice perspectives for providing best-practice psychiatric care for SMI
individuals who are in jails. The diverse roles of PMH nursing can contribute

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meaningfully to tackling quality improvement initiatives on mental health treatment
agendas for SMI inmates. MA
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INTRODUCTION AND BACKGROUND

The overrepresentation of people with severe mental illness (SMI) in correctional
systems has received unwavering clinical, legal, and political attention as an important
global public health matter (Treatment Advocacy Center, 2015). Determining effective
treatment models is the first step to improving the quality of care needed for this
vulnerable population in such a challenging environment (Prins et al., 2012; Prins, 2014;
Steadman et al., 2009). Despite established legal rights for inmates, evidence
consistently indicates major gaps in providing mental health treatment throughout
correctional facilities (Prins et al., 2012; Steadman et al., 2009).
The purpose of this paper is to explore and examine the roles of psychiatric-
mental health (PMH) nursing within jail environments, while offering some
contemporary clinical and practice perspectives to help develop interdisciplinary
alliances aimed at achieving best practice standards for quality mental health care to
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SMI inmates. The authors choose to focus specifically on jails in order to avoid
conflation with prison due to their discrete functionalities (Prins, 2014). As opposed to
prisons, jails are short-term facilities where inmates await trial and/or sentencing
(James & Glaze, 2006; Minton & Zeng, 2015); hence the importance of prompt
psychiatric intervention is of time-sensitive nature. Throughout this paper, the term

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“inmate-patient” is being used to denote jailed individuals who receive direct nursing
care. Notwithstanding the focus on nursing, this paper could have pedagogical and

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epistemological applicability to any correctional health professional.

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There are more mentally-ill persons in U.S. jails and prisons than in psychiatric
facilities (Aufderheide & Brown, 2005; Treatment Advocacy Center, 2015). Additionally,

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upward of 29 percent of American jails are housing SMI individuals with no charges
against them, but instead are holding them while the individual awaits either

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psychiatric evaluation, availability of hospital beds, transportation to a psychiatric
facility, or all of the above (James & Glaze, 2006; Minton & Zeng, 2015; Treatment
Advocacy Center, 2015). Studies have also found that while a large proportion of SMI
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jailing is being done as emergency detentions, these individuals frequently do not
receive timely, adequate, or in some instances, any mental health treatment (James &
Glaze, 2006; Minton & Zeng, 2015; Treatment Advocacy Center, 2015). There is therefore
an urgent need to bridge these critical service-disparity gaps in mental health care for
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jailed SMI individuals.

Significance of the Issue
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Nowhere is the deinstitutionalization model for mental health care and services
failures more evident than in the criminal justice system (Treatment Advocacy Center,
2015). The closure of many community mental health facilities has contributed to jails,
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which were not designed nor equipped to manage the strata of challenges associated
with mental health conditions, becoming de facto psychiatric facilities and thus creating
layers of complex health, legal, and human rights challenges (Appelbaum et al., 2001;
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Rekrut-Lapa & Lapa, 2014; Torrey et al., 2010; Treatment Advocacy Center, 2015).
Multisource data suggested that the psycho-social disparities of indigence is strongly
linked to alcohol/drug abuse and poor adherence to treatment (Greenberg &
Rosenheck, 2008; Primm et al., 2005; Prins et al., 2012; Prins, 2014; Torrey et al., 2010).
The accruals of these health and social disparities have led to systematic health, social,
and economic burdens, fashioning the narrative of “criminalizing the mentally ill”
(Primm et al., 2005).
National organizations such as the American Psychological Association (APA)
and the National Commission on Correctional Health Care (NCCHC), along with
various court rulings, have mandated inmates’ entitlement to access of the same high
quality mental health care and services as their non-jailed counterparts (Rekrut-Lapa &
Lapa, 2014; Whitehead, 2006). As frontline providers, PMH nurses possess the breadth
of knowledge, skill, and expertise across levels of education, practice, research,
education, and administration that put them in unique positions to work collaboratively
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with correctional professionals to develop and advocate for these mandated best-
practice guidelines for the incarcerated mentally ill.
STATE OF THE LITERATURE
Appelbaum et al., (2001) and Weiskopf (2005) acknowledged that providing

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health care to inmates must be carefully balanced against multilayered factors including
security measures, correctional staff values, organizational practices, staff education,

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and nursing management. A review of the literature from 2005 to present reveals that,

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despite their formidable presence, little improvement has been made regarding the role
of nurses in caring for the mentally ill in jails. These findings correlate with Maruca &

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Shelton (2016) and Whitehead (2006), who observed that there is a paucity of scholarly
literature directly relating to the roles and function of correctional PMH nursing. For
example, there are instances where the contribution of nurses is omitted from the

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discussion among those professionals viewed as special mental health management
team (e.g. physicians, social workers, therapists; Powell et al., 2010). New to the
literature is the finding that nurses are actively engaged in providing therapeutic,
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evidence-based health care interventions such as cognitive behavioral therapy,
labyrinth walking, and yoga aimed to improve coping and adaptation of incarcerated
persons (Maruca & Shelton, 2016). From pedagogical, epistemological, and
transformative perspectives, there is a critical urgency for PMH nursing to address
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improvements in providing care/treatment, services, and advocacy for jailed inmates

with SMI.
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SERIOUS MENTAL ILLNESS AMONG JAILED INMATES

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Within the context of SMI, the salience of jails is an overrepresented

phenomenon (Prins et al., 2012). The charges, characteristics, and needs of inmates with
SMI differ significantly from those who are not mentally ill (Primm et al., 2005).
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Contextually, psychiatric conditions among jailed inmates are thought to be influenced

by multilayered, complex, interactive and cumulative psychobiological, sociocultural,
and environmental factors that attribute to and often precipitate multiple incarcerations
(Pearson et al., 2014). Prins et al., (2012), Prins (2014) and Steadman et al., (2009)
observed that, due to varying methodological approaches, attempting to obtain valid
and reliable estimates on the prevalence of mental illness in U.S. jails has been
challenging and renders current data inconclusive.
Jails have become homes for thousands of SMI individuals representing
approximately 10 to 15 percent of the total inmate population (Appelbaum et al., 2001).
According to the U.S. Department of Justice report, roughly 3 million (64%) of jailed
inmates have mental health diagnoses, and rates 3 to 12 times higher than comparable
community samples (Prins et al., 2012; Prins, 2014). Schizophrenia/psychotic disorders,
major depressive or bipolar affective disorders, anxiety disorder, and posttraumatic
stress disorder (PTSD) are four to eight times as prevalent among inmates as in the
general population (Prims, 2014; Steadman et al., 2009), yet only about 7% receive
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adequate mental health treatment (Rich et al., 2011). Other frequent psychological
symptoms/conditions reported by inmates include: acute panic attacks, insomnia,
substance withdrawal, acute/complicated bereavement-related issues, and adverse
childhood experiences (Steadman et al., 2009).
The relationship between mental illness and criminal activities has been a

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phenomenon of collective interest among scholars, practitioners, lawmakers,

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administrators, and advocates (Prins et al., 2012; Prins, 2014). A large number of SMI

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individuals are being arrested due to nonviolent offences, misdemeanors, or felonies
associated with their illnesses: loitering/trespassing, panhandling/petty theft, public
disturbances, and assault/battery (Primm et al., 2005). In response to these alarming

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disparity indicators, some local governments have implemented specialized mental
health training and screenings combined with jail diversion and jail initiative programs

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in an attempt to accurately identify and divert SMI individuals from jail to community-
based treatments (Eleventh Judicial Circuit Criminal Mental Health Project, 2012; Ellis,
2011; Prins et al., 2012; Prins, 2014). Despite these contemporary and transformative
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initiatives, the prevalence of SMI among jail inmates remains a growing phenomenon
with no simple resolution in sight (Prins et al., 2012; Prins, 2014).
Contextualizing the Issue
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For the SMI population, contacts with the criminal justice system can be
additionally stressful, leading to exacerbation of symptoms, disruption in established
services, or can present a first-time opportunity for treatment (Prins, 2014). Reports of
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adverse life experiences (including trauma) are common among inmates and have been
cited as strong predictors of subsequent major medical and psychiatric/psychological
disorders , conflating factors predisposing to and and precipitating from criminal
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behaviors (Felitti & Anda, 2010; Reavis et al., 2013). Reports surrounding these life-long
negative sequelae often involve physical, emotional, and/or sexual abuse; exposure to
violence; unresolved grief; and issues of neglect or abandonment (Carlson & Shafer,
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2010; Reavis et al., 2013). Substance abuse and psychiatric manifestations (e.g.,
psychosis, unstable moods including suicide, aggression, and violence; and anxiety-
related insomnia and nightmares) are thought of as common, interrelated consequences
of trauma exposure (Carlson & Shafer, 2010; Reavis et al., 2013). Maladaptive
psychopathology characteristic of poor emotional/mood regulations, dissociative rages,
self-destructive behaviors and criminality are sequelae of trauma (Wolff & Shi, 2012).
These descriptive emotional challenges fit Torrey et al., (2010) description that is
consistent with correctional clinical observations and anecdotal reports by inmate-
patients frequently engaging in unhealthy activities in lieu of treatment (e.g., substance
use and other antisocial behaviors) as a means of distraction, coping, and/or escaping
unpleasant symptoms associated with their mental illnesses. However, stressors
associated with incarceration often diminish the individual’s ego-syntonic buffering,
making them vulnerable to additional psychosis, mania, depression, or panic/anxiety-
symptom breakthrough (Wolff & Shi, 2012).
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PSYCHIATRIC-MENTAL HEALTH NURSING IN JAILS

PMH nursing is a specialty that has been evolving and advancing to meet
societal changing needs. Broad-based educational preparations in the socio-
biological sciences have expanded contemporary roles and scopes, allowing PMH
nurses to care for individuals with diverse psychobiological/psychosocial, socio-

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behavioral, socio-demographic, and cultural conditions across the lifespan in wider

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ranges of settings (Gournay, 2005; Pearson et al., 2014). At the same time experts have
noted that the evolvements and advancements of PMH nursing have simultaneously

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created interdisciplinary confusion due to interchangeable definitions (Lyons, 2009).
For example, Kent-Wilkinson (2011) listed correctional, psychiatric, forensic, jail and

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prison as prefixes denoting nursing within correctional settings. Additionally,
Weiskopf (2005) points to autonomy as well as conflicts between custody and caring
as ongoing struggles for correctional nursing.

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Correctional nursing has been an evolving sub-specialty of PMH nursing
(American Nurses Association [ANA], 2014); Kent-Wilkinson, 2011), as outlined in
the ANA scope and standards of practice (see ANA, 2014). Advanced practice PMH
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nurses provide psychiatric, psychological and psychosocial services to inmates
including assessment, diagnosis, and psychopharmacological and psycho-behavioral
interventions (Gournay, 2005). Undeniably, the roles of PMH nurses within jail
systems constitute the same level of prominence as in traditional mental health
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settings. Whether in correctional or traditional settings, the roles of PMH nurses are
grounded in theoretical constructs such as self and expanding consciousness,
authentic engagements, the purposeful use of self, empathy and altruism, and
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holistic humanism. These constructs are in accordance with caring philosophies of

respecting individuals’ social values within the context of attending to the health
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needs of diverse inmate-patient population regardless of charges (Pearson et al.,

2014).
Kent-Wilkinson (2011) identified correctional nursing practice as having layers
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of complex organizational and socio-professional structures, where nurses have to

maintain the caring environment by navigating multiple systems, including mental
health systems, criminal justice systems, protective service systems, and the forensics
(medical examiner/coroner) systems, all falling within some aspects of nursing’s
scope and standards of practice (Kent-Wilkinson, 2011). It is well-established that
these constructs are not without professional, ethical, occupational and sometimes
legal challenges especially from theoretical standpoints of balancing self-awareness,
authentic presence, altruism, and ethics with the institutional philosophy of custody,
control, and punishment in correctional settings; Weiskopf (2005) refers to this as
“double-barreled conflicts”.
Both Gournay (2005) and Holmes (2005) identified correctional nursing’s
paradoxical roles and powers, where the caring principles are fused with
surveillance, discipline, order, coercion, and sometimes punishment that complicates
the philosophies of therapeutic engagements. For PMH nurses, regardless of clinical
settings, maintaining professionalism requires honing the necessary knowledge,
skills, and competency required to be authentically mindful and effective in the
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management of powerful interpersonal nurse-patient phenomena. Contemporary

PMH nurses in correctional facilities must be able to unobtrusively meld and balance
these subjective powers with providing SMI inmate-patients’ care.
ISSUES IMPACTING THE INMATE-PATIENT
Incarceration-induced stressors among SMI individuals have been well-

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documented as potentially exacerbating existing or triggering new psychiatric

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conditions that could precipitate behavioral challenges, resulting in infractions of
correctional rules (Adams & Ferrandino, 2008; Appelbaum et al., 2001; Appelbaum et

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al., 2011; Dvoskin & Spiers, 2004). Separation from social support systems (e.g.
families, caregivers), and fears or threats of intimidation and assault are cited as

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significant stressors for SMI inmate-patient, and pose equal challenges for both PMH
nurses and correctional officers who are expected to respond in accordance with
professional and procedural guidelines (Adams & Ferrandino, 2008; Appelbaum et

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al., 2001; Appelbaum et al., 2011). Inmate-patients’ stress-related behavioral responses
may include suicide threats or attempts; self-mutilating behaviors; or violence to
themselves or others. These clinical emergencies require higher levels of inmate-
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patient care that can be prescribed by the credentialed advanced practice PMH and
carried out by the sufficiently trained officer (e.g., 1:1 constant observation) (Adams
& Ferrandino, 2008; Appelbaum et al., 2011; Appelbaum et al., 2001; Dvoskin &
Spiers, 2004).
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COMPARATIVE ROLES AND INFLUENCES

Psychiatric-Mental Health Nurses
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Within correctional systems (including jails), PMH nursing represents a blended

model of interdisciplinary and inter-professional, integrative structures to deliver the
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highest quality, evidence-based, and comprehensive best practice healthcare services to

SMI inmate-patients (Staten et al., 2005). Indubitably, correctional officers’ and PMH
nurses’ roles are intrinsically weaved together, creating a service-delivery structure that
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supports a dynamic health paradigm and which fosters a culture of interactive

cooperativeness serving to benefit inmate-patients and their service providers.
Successful role-blending relies on both disciplines forming respectful, trusting, collegial
relationships where the inmate-patient is centrally represented. It is therefore
imperative that PMH nursing recognize, appreciate, and nurture the valuable clinical
contribution of correctional officers in order to sidestep territorial conflicts, reduce
stress, and ultimately improves the quality of service rendered to inmate-patients under
their joint care (Dvoskin & Spiers, 2004).
PMH nursing practice within the forensic environment must separate the
existing paradoxes between social control and nursing care by appreciating that legal
punishment does not exclude medical treatment. Empirically speaking, the primary
socio-professional objective role-power of contemporary PMH nursing in
correctional settings should be on assessment, planning, intervention, and re-
assessment of care provided. Holmes (2005); Lyons (2009) and Weiskopf (2005)
observed that correctional PMH nursing duties are not limited to
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psychiatric/psychological treatment alone, but are rather complimentary across

professional lines to ensure the safe balancing of inmates’ correctional custody and
medical treatment: including surveillance, coercion, punishment, and social
rehabilitation. Effective collaboration and communication between disciplines are
vital to preventing morbidity/mortality occurrences among inmate-patients’

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population.
However, the literature observed that, because the delivery of healthcare

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varied between countries and levels of clinically-qualified professionals, no

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universally, integrated mental health service model exists to serve as a benchmark for
the treatment of jailed SMI individuals (Bowring-Lossock, 2006; Holmes, 2005;

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Lyons, 2009; Rekrut-Lapa & Lapa, 2014). These service fragmentations offer
opportunities for PMH nurses at all levels to function at their fullest capacity
according to training by improving systems, thus maximizing health outcomes

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through research, education, practice, education, administration, policy, and
advocacy.
Correctional Officers
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In the recent decades, there has been a growing body of literature identifying the
emerging and evolving roles of correctional officers as a significantly important aspect
of the integrative multidisciplinary health care treatment team (Adams & Ferrandino,
2008; Appelbaum et al., 2001). The diversity of health services in correctional settings
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such as jails are similar to that of conventional healthcare settings where nurses,
physicians, social workers, therapists, and other allied healthcare professionals
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collaborate in caring for inmate-patients, with one exception: in correctional settings

(including jails), officers play a central role in the overall care of SMI inmate-patients
through their constant observation and maintenance of order, custody and control
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(Adams & Ferrandino, 2008; Appelbaum et al., 2001).

Correctional officers are typically the first to observe clinically significant mental,
physical, or behavior changes in an inmate and report such information to the nurse
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(e.g., the inmate-patient who is increasingly depressed/manic, suicidal/psychotic, or

noncompliant with treatment; Appelbaum et al., (2001); Appelbaum et al., (2011) and
Dvoskin & Spiers (2004), and which necessitate immediate psychiatric/medical
intervention (Appelbaum et al., 2001; Appelbaum et al., 2011). While these interventions
are generally within the roles and scopes of the credentialed advanced practice PMN
nurse, experts advise that correctional officers receive the necessary education and
training that would enhance this very important team collaboration (Adams &
Ferrandino, 2008; Appelbaum et al., 2001). Dvoskin & Spiers, (2004) observed that many
roles and duties traditionally assigned to clinical personnel can, and in some cases
should, be performed by correctional officers who are in 24-hour contact with inmates.
Another key difference about the correctional care-service model is that custody,
security, and medical care are of equal importance (Appelbaum et al., 2001; Appelbaum
et al., 2011). While PMH nurses and correctional officers must work collaboratively to
maintain safe custody while being therapeutic, they each have distinct professional
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characteristics that must be recognized, appreciated, nurtured, and translated within

the context of inter-professionally shared constructs (Adams & Ferrandino, 2008;
Appelbaum et al., 2001). Correctional officers can effectively assist mental health teams
to make important, constructive contributions to the overall care and wellbeing of the
SMI inmate-patient in jails (Appelbaum et al., 2001).

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Despite such contemporary and transformative proposals, the literature

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consistently shows correctional nurses’ continuous struggle to provide interpersonal

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and relationship-centered care alongside correctional systems’ philosophy of
authoritative custody and control (Adams & Ferrandino, 2008; Appelbaum et al., 2001).
Effective behavioral health and custody management of the SMI inmate-patient

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depends on successful partner-relationships between these two disciplines that
understand and respect each other’s uniquely important philosophies, roles, boundaries

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and overall contribution to such uniquely structured care delivery system (Adams &
Ferrandino, 2008; Appelbaum et al., 2011; Appelbaum et al., 2001).
Perceptions and Attitudes
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Foremost among the proposed working frameworks is the question of whether

correctional officers and PMH nurses are able to value and respect each other’s
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professional roles, expertise, and core philosophies to authentically care for the SMI
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inmate-patient (Appelbaum et al., 2011; Appelbaum et al., 2001). Studies indicate that,
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while correctional professionals’ perceptions and attitudes toward SMI inmates have

been shifting positively over time, SMI inmates continue to be viewed unfavorably
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relative to non-psychiatrically disordered and non-incarcerated groups (Appelbaum et

al., 2001; Callahan, 2004; Ellis, 2014; Lavoie, Connolly & Roesch, 2006). Common themes

identified in these studies were that SMI inmates are viewed as: having character flaws,

irrational, difficult to understand/manage, time-consuming to care for, dangerous and

harmful to themselves and others, attention-seeking, and unable to be rehabilitated

compared to non-SMI inmates (Appelbaum et al., 2001; Callahan et al., 2004; Ellis, 2014).

These assumptions may be related to opposing philosophical and professional

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orientations/conditionings such as the holistic, caring philosophy of nursing versus the

punitive philosophy of the correctional culture.

These differences can also be seen in cross-disciplinary prejudices, such as

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narratives among correctional professionals perceiving mental health problems as

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character flaws and mental health professionals as being excessively soft, gullible, and

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coddling (Appelbaum et al., 2001; Callahan, 2004). These authors also noted that some

correctional professionals view mental health services to SMI inmates as underserving

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or unneeded; resent the idea of inmates having access to mental health care; and
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perceive treatment as protecting inmates from consequences of their offences. These

skewed perceptions have led many mental health professionals to call into question the
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ethics of some correctional professionals (Appelbaum et al., 2011; Appelbaum et al.,

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2001; Callahan, 2004). Since correctional officers and PMH nurses are the two primary

professional fixtures in jails, there are opportunities for PMH nurses to capitalize on
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their teaching and coaching roles to positively influence correctional officers’

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perceptions and attitudes toward SMI inmates thereby enhancing their working

relationships.

Education and Training

Working with the SMI inmate-patient can be particularly stressful, attributing to
vicarious burnout among correctional officers, particularly those without the emotional
or educational preparedness for working with the mentally ill population. Providing
basic mental illness and symptomatology education is of vital, synergistic importance to
both nursing and correctional professionals for the benefit of their mutual, all-
encompassing caring roles. Honed therapeutic communication skills and techniques,
such as de-escalation, could benefit officers during routine interactions or when
intervening in psychiatric emergencies such as the acutely unstable SMI inmates-patient
(Ellis, 2011; Ellis, 2014). For example, officers with basic knowledge of psychiatric
disease symptomatology could assist a functionally impaired inmate-patient using
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supportive coaching/prompting, thereby helping that inmate-patient achieve both

treatment and correctional compliance (Appelbaum et al., 2001). Dvoskin & Spiers
(2004) referred to this idea as “functional professionals”. For example, the correctional
officer who lacks formal mental health credentials performs some functions usually
reserved for credentialed mental health professionals. Similarly, although they are not

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therapists, correctional officers can affect therapeutic outcomes by redirecting
disruptive behaviors and setting clear and firm, but simple limits that include positive

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enforcement choices with resulting consequences. This highly specialized technique

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could be challenging for officers who are trained disciplinarians, not psychiatrically
trained, and yet expected to therapeutically intervene with psychotic, manic, depressed,

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or anxious SMI inmates-patients (Appelbaum et al., 2001). However, a seminal yet
salient study by Torrey et al., (1998) revealed correctional officers often voiced concerns
about inadequate training in how to best work with SMI inmates. This same study

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showed that approximately 84% of correctional facilities provide officers with less than
three hours of mental health training or even none at all. These conclusions warrant
further investigation as to today’s saliency.
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Conversely, another study indicates that correctional officers who participated in
basic mental health training were better able to associate brain chemistry imbalances
with psychiatric and substance abuse disorders; identify symptoms pertaining to
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schizophrenia, bipolar and major depressive disorders; have a more favorable attitude
toward inmates with SMI; and achieve balance between firmness and sensitivity during
interventions (Appelbaum et al., 2001). The Crisis Intervention Team (CIT) is a
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contemporary evidenced-based training model that could have useful applications

within the dynamic roles of correctional officers and nurses working collaboratively in
serving SMI individuals (Ellis, 2011; Ellis, 2014). The premise of CIT to train police
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officers how to recognized and intervene safely when someone is experiencing a mental
health crisis, and to use de-escalation principles and techniques to get the individual to
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a treatment facility instead of jail (Ellis & Alexander, 2016). Interprofessionally, there are
pedagogical and epistemological values to the concept of CIT between law enforcement,
the criminal justice system, and PMH nursing.
PMH nurses have clinical, educational, leadership and research skills that can be
used in coaching, mentoring, and supporting correctional professionals, achieving
assessment and treatment that meet best practice standards. It is therefore imperative
that correctional PMH nurses continue to achieve, promote, and preserve their skills
through advanced education/specialization, and certification (Whitehead, 2006). As
practitioners working with patients along the spectrum of SMI, PMH nurses have
legitimate praxis that can be implemented as part of correctional professional and
cultural learning. In essence, they both can expand their repertoire of important tools to
enhance the care experience of the SMI individuals in jail (Browning & Waite, 2010).
CLINICAL ISSUES AND CHALLENGES
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Providing mental health care in correctional settings presents multilayered

complexities that must be simultaneously addressed, including illness severity, physical
setting, and the intersection of ethical, legal and medical concerns (Rekrut-Lapa & Lapa,
2014). As previously mentioned, SMI offenders entering the criminal justice system
bring with them many health and social challenges that are inextricably linked to SMI:

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homelessness, alcohol/drug abuse, physical/emotional/sexual abuse, and chronic
medical problems (Binswanger et al., 2010). Correctional facilities were never designed

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or intended to provide mental health care/services but for those who are incarcerated,

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legal charges do not invalidate their need for proper psychiatric care/services (White &
Gillespie, 2005).

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Even with a growing body of literature highlighting the prevalence of SMI and
substance abuse, and the importance of adequate mental health services for inmates

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(James & Glaze, 2006; and Rekrut-Lapa & Lapa, 2014), evidence suggests that gaps
remain with regards to adequate assessment, diagnosing and treatment (Kaba et al.,
2015; Reingle Gonzalez & Connell, 2014). This is despite data supporting
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multidimensional and cumulative adverse events that contextually exist among
incarcerated individuals (Carlson and Shafer, 2010). Scholars however, argue as to
whether increased community access to services would reduce the prevalence of mental
illness and co-occurring disorders (e.g. substance abuse) entering correctional facilities
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(Prins, 2014).
On a global scale, PMH nurses have the educational, clinical, and leadership
skills to navigate and negotiate the boundaries between the cultures of correctional
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custody and community treatment for SMI individuals (Pearson et al., 2014; Weiskopf,
2005). Evidence shows that PMH nurses and correctional officers have become more
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cognizant that the authoritatively-controlled jail environment can negatively impact the
wellbeing and treatment outcomes of SMI individuals, and are collaboratively
addressing the issue (Appelbaum et al., 2001).
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CLINICAL AND PRACTICE IMPLICATIONS

Working with SMI individuals in correctional settings requires the mindful use
of engagement praxes to purposefully, intentionally, authentically, and rationally
develop and manage the nurse/inmate-patient relationship; a central tenet to
professional nursing (Alexander, Ellis, & Barrett, 2015; Scheick, 2011). In-depth
knowledge with evidence-based skills in PMH nursing coupled with basic
understanding of the criminal justice system are relevant combinations to competently
care for SMI jailed inmate-patients, care that includes evidence-based, broad assessment
and a wide range of structured clinical judgments and recommendations to other
clinicians and the criminal justice system (Lyons, 2009). Based on educational
preparation and expertise in clinical, research, and legislative policies, PMH nurses at
various levels and roles are in unique positions to help actualize the treatment goals for
thousands of vulnerable SMI inmates in jails across communities (Pearson et al., 2014).
Empirical evidence exists supporting assumptions that nursing is, and will continue to
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be, central to the future of global health service delivery by virtue of consistently
achieving outcomes across multiple quality indicators – emphasizing the protecting,
and promoting the health, safety, and rights of patients (Ellis & Alexander, 2016).
PMH nursing is steadily gaining recognition as having the ability to bridge gaps
between systems; including the criminal justice and mental health systems (Holmes,

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2005), and as a result opens up new horizons for optimal utilization of roles. As part of

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professional, clinical, and practice mandates, correctional PMH nurses must assume

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functions of social and psychiatric care in a hybrid clinical environment where the
concept of jail and hospital merges into newly innovative and transformative care-
delivery models and systems (Holmes, 2005). While working with the SMI in jail, the

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PMH nurse must be cognizant of the many disparity-variables that impact effective
mental health assessment, diagnosing, treatment and prognosis of this population as a

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group: cultural and demographic variables, insight and judgment variations, poor
reasoning abilities, and inability to learn from past mistakes (Holmes, 2005).
Contemporary theories, backed by evidence, support new nursing-focused approaches
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to person-centered socio-rehabilitative care and recovery models capable of addressing
disease process, symptom management, adherence, and relapse prevention and
recovery of clinically diverse SMI groups, including those caught up in the criminal
justice system (Ellis, 2011; Ellis & Alexander, 2016). Effective and sustainable
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operational strategies for these conceptual models should include:

 Collective commitment and dedication to achieve and maintain targeted
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benchmarks and outcomes for SMI inmate-patients.

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 Developing effective policies to expand the concept of jail diversion/initiative and

involuntary outpatient treatment programs to a wider-targeted SMI inmate-patient

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population.

 Developing jail-to-community re-entry based programs for the SMI inmate-patient

population.

 Using skillstreaming-type psychoeducation appraisals to facilitate SMI inmate-

patients in appreciating jail environments while demonstrating how to maintain

suitable post-release wellness behaviors.

Evidence consistently suggests that concepts such as jail initiative and jail diversion
(pre- and post-arrest) of SMI individuals from criminal justice to mental health systems
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is an initiative that is implementable, achievable, outcome-driven, and could aid in

eliminating treatment barriers to SMI inmate-patients (Schneider, 2010; Verhaaff, &
Scott, 2015). While remaining front-line providers in traditional health care settings,
PMH nurses could serve to advocate, coordinate, and assist in smooth un-interrupted
transition of SMI inmate-patients from jail back into the community; for example, a

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nurse-run wrap-around bridge and outreach program where the SMI individual leaving
jail is directly connected to and followed-up by community-based mental health and

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social service benefits.

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CONCLUSION

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The call is out for PMH nursing to address gaps in mental health needs of at-risk,
underserved, and disenfranchised populations; such as those who are incarcerated
(Pearson

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et al., 2014). This paper highlights the fact that circumstances surrounding SMI
individuals in jail are multidimensional and complex, and outlines collaborative roles
and processes of PMH nursing practice and correctional professionals for improving the
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health services of SMI inmate-patients. This paper also contributes to the existing
literature by showing the risks of those circumstances as well as the benefits of
integrative caring roles and processes. It is well documented that nursing is the largest
and most dominant discipline within the health service delivery system serving all
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aspects of society across the lifespan (Frenk et al., 2010). Effective management of
psychiatrically unstable inmate-patients are equally the responsibilities of PMH nurses
and correctional officers, and requires an integrated care-service paradigm where the
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goal of care and control are equally achieved using person-centered evidence-based best
practice standards (Adams & Ferrandino, 2008; Appelbaum et al., 2001; Appelbaum et
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al., 2011; Dvoskin & Spiers, 2004).

With diverse levels of education and evidence-based skills and techniques, PMH
nurses are well-positioned as change catalysts, influencing new and innovative health,
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social, legislative, and policy paradigms benefiting healthcare delivery strategies and
outcomes measures for SMI individuals throughout jail systems. It is the hope that this
paper can serve to promote new insights and interest into a disparity phenomenon that
has long been acknowledged among practitioners, researchers, policy makers,
administrators and advocates – that the prevalence of SMI among incarcerated
populations are higher than non-incarcerated populations (Prins, 2014). In our
contemporary environment where the delivery of healthcare is constantly being
reviewed and revised to meet parity and best practice standards, PMH nurses are
clinically prepared and ready to influence new and transformative mental health care
for jailed inmate-patients with SMI.
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