CA Forensic Nurses’ Practices
& Views With Inmates with
Serious Mental Illness:
Medication Compliance
Phyllis M. Connolly, PhD, APRN, BC, CNS
Professor, San Jose State University
Chia-Chen Lee, MS, RN, FNP
Santa 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
66%
Separate units for
inmates with MI
Located in urban areas 46%
Located in suburban
areas
Located in rural areas
33%
20%
Demographic Characteristics:
Gender, Age, Education N = 55
Other
Doctorate
MS other
MS Nurs
BS other
BS Nurs
EDU Dip
EDU AA
Age 45 - over 50
Age 25 -45
Females
Males
0
5
10
15
20
25
30
35
40
45
50
Ethnicity N = 55
Other
2%
White
75%
African Am
9%
Chinese
5%
Filipino
9%
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
Teaching disease mgt
51 (93%) n = 55
51 (93%) n = 55
Therapeutic relationship 45 (88%) n = 45
ex-inmates
Assessment of Medication Compliance
Name of Med
44 (80%)
Last dose
Explored issues related to noncompliance
Financial issues
39 (71%)
38 (69%)
16 (29%)
Side effects
Memory impairment
Inmate doesn’t believe s/he needs
Doesn’t like to take along with street
drugs/alcohol
43 (78%)
24 (44%)
38 (69%)
23 ( 42%)
Lack of support system
Lack of money for medication
25 (46%)
26 (47%)
Medication Compliance Nurse
Behaviors N = 55
How often review SE of
psych meds with inmates
Most important nursing
skill
Greatest influence over
pts
Always 8 (16%)
Frequently 14 (28%)
Occasionally 24 (42%) n = 51
Communicating with patient 45
( 88%)
Teaching 3 (6%)
Administration meds. 3 (6%) n = 51
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
Lack of time
Length of custody
Stigma criminal record
Out of judicial area
Budget limit
Confidentiality
HIPPA regulations
24 (44%)
21 (38%)
11 (20%)
11 (20%)
10 (18%)
9 (16%)
9(16%)
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
Budget
25 (46%)
Suicide risk
10 (18%)
Lack of time
8 (15%)
Lack of
psychiatrist
7 (13%)
Inmates don’t feel
they need it
6 (10%)
14 (26%)
Barriers When Providing Prescription
Prior to Release
Lack policy &
procedure
Lack of
psychiatrist
33 (60%)
Lack of time
6 (11%)
Inmates feel they
do not need it
6 (11%)
10 (18%)
Self Care Practices N = 55
Engaged in support groups
Get Adequate rest
Engage in leisure activities
Never
35 (70%)
Sometimes 12 (24%)
Most of time 2 (4 %)
Always
1 (2%) (n = 50)
Never
13 (25%)
Sometimes 14 (16%)
Most of time 23 (44%)
Always
3 (6%)
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”
“Debriefing services are
important for nurses after
critical incidents (death,
violence, suicide, riots,
hostages)”
Strongly agree 9 (16%)
Agree
23 (42%)
Disagree
14 (26%)
Strongly disagree 9 (16%)
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