Holistic Nursing of Forensic Patients: a Focus on Spiritual Care

Prisons are a unique context where nurses are required to have specific skills to ensure that prisoners receive the same type of holistic care as anyone else out of prison, including spiritual care. This discussion paper focuses on understanding how nurses deliver spiritual care in Italian prisons where there are often limited resources and where organizational priorities hinder the provision of holistic nursing. This paper draws from a previous qualitative research study that we had conducted. In this study, we observed that prison nurses reported that they experienced many difficulties related to the provision of holistic care to prisoners. This was particularly true for spiritual care in vulnerable forensic patients, such as older individuals, and physically and mentally frail prisoners. Prison officers did not allow nurses to just " listen and talk " to their patients in prison, because they considered it a waste of time. The conflict between prison organizational constraints and nursing goals, along with limited resources placed barriers to the development of therapeutic relationships between nurses and prisoners, whose holistic and spiritual care needs remained totally unattended. Therefore, prison organizational needs prevailed over prisoners' needs for spiritual care, which, while fundamental, are nevertheless often underestimated and left unattended. Educational interventions are needed to reaffirm nurses' role as providers of spiritual care.


Introduction
Prisons offer a unique setting for nursing spiritual care.For this reason, nurses who provide care to prisoners need to be adequately educated and specifically trained to provide the same type of holistic care as they would in any setting out of prison [1], and in particular spiritual care.Prisons are places designed for the expiation of crime, offering the opportunity to prisoners to redeem themselves from their guilt.For some, this entails implies undertaking a redeeming spiritual journey from guilt to innocence, and prison nurses skilled in spiritual care should be able to capture and "hear this spiritual journey" ( [2], p. 24) while providing clinical care.For this reason, the provision of spiritual nursing care in prisons, implies the development of specific competencies that enable nurses to integrate concepts such as "Restorative Nursing" [3] and "Correctional Nursing" [4] into their clinical practice to effectively address the conflict between punishment (i.e., doing harm) and caring (i.e., doing good) that prison settings raise [5].
This discussion paper draws from the data we collected from a qualitative research consisting of five focus groups held with 31 prison nurses to gain a deeper understanding of the views and experiences of prison nurses [6].Our previous qualitative research [6] was prompted by the fact that in Italy penitentiaries healthcare was transferred from the Agency of Penitentiary Medicine to the local health authorities of the National Health Service in June 2008.The reason for this is that prison is no longer a closed setting, because, due to overcrowding, large numbers of prisoners move in and out of prison and this has important social and healthcare implications also for the general public.Consequently, many nurses employed by the public local hospitals ended up caring for prisoners, often without any proper specific training.In our previous study [6], only one prison out of ten had a dedicated clinical ward, and most of the prisoners were either affected by psychiatric disorders or drug addicted.In addition, around half of all the prisoners were not Italian and this also raised issues linked to cultural differences and language barriers.

The Clash between Custody and Care
In our previous study [6], many issues emerged from the focus groups with the prison nurses, but the most serious one was the clash between the safety priorities of the prison organization and the priorities of nursing, as also confirmed by Maroney in 2005 [5], and particularly the provision of holistic and spiritual care for the more vulnerable and frail prisoners, who, more than anyone else, needed this type of care.We found that in these prisons, security priorities based on order, control, and discipline, prevailed over prisoners' healthcare needs, and on prison nurses' authority and autonomy to care for prisoners, generating feelings of frustration and powerlessness.In fact, one of the nurses during the focus groups declared: "...there are solid bars also between the prisoners and us".Consequently, the nurses included in our study had great difficulty building a relationship of trust with prisoners, realizing that they needed more specific knowledge, skills and competencies to successfully deal with penitentiary healthcare issues.However, as one of our prison nurses declared, this delicate aspect linked to need for an advanced level of education is not recognized: "In prisons, nurses have to be skilled as psychologists to work well, instead nurses are often seen as people who simply give medicines to patients and that's it.This is a misconception that prison administrators have of nurses, as if nurses had no other skills, competences or knowledge, and which they think only physicians have".
Therefore, although nurses are the main health care providers for prisoners, there is a lack of recognition of the specific competencies prison nurses need to have.This was also confirmed by the fact that "listening and talking" to prisoners was often considered just a waste of time by the prison officers, who put pressure on them to hurry up and just think about administering medications.In agreement with Willmott [7], the ethos of health care for prisoners needs to be further developed, but this requires prison nurses to gain a better understanding of concepts such as "Spiritual Nursing Care" [2], "Restorative Nursing" [3] and "Correctional Nursing" [4], integrate these into their clinical practice, but also disseminate these concepts among prison staff and administrators to change the way prison nursing is viewed.

Spiritual Nursing Care
By adopting a holistic approach, nurses cannot ignore the spiritual aspects of care [8,9] on a daily basis.Sawatzky and Pesut [2] proposed a conceptualization of spiritual nursing care that can be operationalized through the "key attributes" of spiritual care: intuitive, interpersonal, altruistic, and integrative.
Intuition is a fundamental attribute of spiritual care because the intimate spiritual sphere of a patient cannot be rationally assessed like pain or other physical symptoms, but involves "a way of knowing that bypasses usual reliance on logic and linear analysis" ([10], p. 56).Some nurses may have an innate intuitive sense that enables them to perceive when a prisoner is willing to start the redeeming spiritual journey from guiltiness to righteousness, whereas those who do not have this innate intuition can learn how to develop a sense of discernment, which is similar to intuition but based on a more rational understanding [11].On the other hand also patients, and in our case prisoners, can select the nurse with whom they feel more at ease to share their spiritual redeeming experience, and in this way they can practically confirm the nurse's intuitive approach [11].
Secondly, spiritual nursing care is "interpersonal", by engaging in a therapeutic relationship with the patient [12], but engaging in a relationship with a prisoner can be very difficult and generate in nurses many fears and anxieties, such as the fear of being manipulated [5,13,14].To overcome these fears, prison nurses require specific education in terms of verbal and nonverbal communication skills, accompanied by an attitude of openness, listening, and non-judgmental respect [15], which are all fundamental for a successful interpersonal engagement with prisoners.Interpersonal engagement is based on listening and dialogue, two essential elements of spiritual nursing care, which instead in our qualitative study were are often considered as a "waste of time" by the prison officers.
Another attribute of spiritual nursing care, which, when caring for prisoners, plays a key role, is "altruism".This typical characteristic of nursing has been defined in many ways, but for the purpose of the present paper, the most appropriate definition for altruism is "placing the needs of the patient first through the extending of self for the good of the other" ( [15], p. 703).Unlike patients in the usual hospital setting, patients in prison are subject to the intimate spiritual transition from a condition of guilt to a condition of innocence through redemption.In our experience, about 50% of the prisoners were not Italian, and had different cultural and religious backgrounds, therefore is it particularly important for prison nurses to not impose their own beliefs but rather to engage in an authentic dialogue, understand what would be more meaningful for them to do, and let the prisoners freely decide if and how they wish to be supported to go through this intimate spiritual transition [16].
The final key attribute of spiritual nursing care is "integrative", in the sense that spirituality pervades and gives meaning to all aspects of life, self, and care [17,18] especially to prisoners in their spiritual journey from being guilty to being innocent.O'Conner and Duncan (2011) in their study found that 71% of the prisoners, no matter what their religious background was, voluntarily engaged in humanist, spiritual, and religious pathways to meaning in life, and this could be used as an evidence base to confirm the effectiveness of a correctional plan [19].Prison nurses can also foster broader integrative spiritual care by facilitating connections beyond the individual, through the family, significant others and the community [2].

Conclusions
Spiritual nursing care plays a crucial role in supporting and accompanying prisoners willing to engage in a spiritually redeeming journey from guilt to innocence through atonement.This is very important because the level of some prisoners' voluntary humanist, spiritual, and religious engagement can provide a significant evidence base for the effectiveness of a prison's correctional programme.In this spiritual corrective transition, the exploration and correct management of relational and contextual factors play an important role for correctional nursing [4,20,21].Correctional nursing implies a change in the culture and concept of punishment and the way prisoners are viewed.Especially, prisoners who are physically ill experience a physical healing process that blends into their spiritual healing process; and this constitutes the cultural shift from the concept of punishment to that of correction [4,20,21].Thanks to this cultural shift nurses who care for prisoners nurses can overcome the clash between custody and care regain their professional autonomy [3].
In fact, the philosophy of postmodern punishment described by Gadow [3] based on restorative nursing offers nurses the possibility to resolve the contradiction between nursing (i.e., doing good) and punishment merely viewed as retribution (i.e., doing harm), therefore making the ethical engagement between nurses and prisoners possible.Ethical engagement involves valuing the particular characteristics and the uniqueness of a person, through a relational narrative, which implies excellent communication skills.The relational narrative enables to explore and identify the individual's emotions, memory, imagination, and perception of their own body.In this way, it is possible understand what meaning an individual gives to these aspects and consequently discover the intrinsic spiritual nature specific of that human being [3].This shows how important the role of communication between nurses and prisoners can be and how the interruption of communication reported by our nurses gives rise to many ethical, professional, and organizational issues.
Nurses who work in prisons need specific educational interventions to gain major awareness of the unique nature of their practice, where spiritual care plays a key role, and exploit this awareness to change the way punishment and care are culturally perceived among prison administrators and institutions.