**5.3. Correctional healthcare services (incorporation of health performance framework)**

Prisoners within the correctional setting are seen as being in communities which are isolated and self-contained, away from the general population and the public health umbrella [61]. As a consequence, many opportunities for health improvement have been missed for both the individual and the community inside and outside the prison [61]. The health status of prisoners does not match their counterparts in the community for physical, social and mental wellbeing, resulting in a much poorer health status and outcomes [17, 18, 54].

Correctional healthcare services are responsible for the provision of care to prisoners and are the key personnel to support those with cognitive impairment and dementia [62]. The increase in the numbers of older prisoners, and their higher incidence of chronic disease and disability, are challenging and place a burden on correctional healthcare service providers who are generally not educated in aged care [40]. Therefore, where there are prisoners with multiple comorbidities, and especially for prisoners with mental health or cognitive impairment such as dementia and who have a reduced capacity to articulate their health problems, this can lead to under diagnosis of conditions/illness.. This is compounded by the key system issue of the regime in the correctional setting. Furthermore, as these regimes have not been developed with consideration of older prisoners with frailer and poorer health, many conditions and illnesses go unrecognised. More recently, overcrowding within correctional settings has compounded the complexities in delivering best practice healthcare, service provision and diagnosis of people with cognitive impairment [19].

guide for prison health is that healthcare staff within the correctional setting need to have professional independence and this should be to the same level as healthcare staff in the

Re-Framing and Re-Thinking Dementia in the Correctional Setting

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Healthcare needs of prisoners and care delivery by healthcare professionals is affected adversely by the culture in the correctional environment and the tension this creates can affect the recruitment and retention of nursing staff in the prison [62]. Due to staffing retention issues, nurses may undertake longer or double shifts to ensure healthcare coverage which means spending longer hours behind bars, and this can lead to similar feelings to the prisoners of isolation and segregation from the community which could lead to mental illness such as depression [64]. Nurses working in the correctional environment can feel marginalised by other staff such as doctors who are in attendance for a short time, and who instruct the nurses on what to do without really understanding the complexities of setting and without being with the prisoners for long periods of time [64]. Correctional officers, although in attendance for similar periods of time, have a vastly different role and do not have the same pressures as the nurse who is expected to sort out the health problems of the prisoners [64]. Innovative delivery of healthcare in the correctional setting is often obstructed and the initiation and ongoing management of

In Australia each state and territory government is responsible for the healthcare provided in their correctional facilities [3]. As a result there are variations between jurisdictions about how and what healthcare service is provided [3]. The differences in healthcare provision and the function of clinics can range both between and within states and territories [3, 34]. Some jurisdictions will provide allied health and mental health services within the prison healthcare setting, while others will use external providers [3]. While there is restricted access to different allied healthcare professionals, there are challenges with retention and recruitment of staff [34]. There is limited information about the differences between prison healthcare in the different states in Australia, and how they identify and support prisoners with cognitive

California Men's Colony (CMC) provides an environment with areas specifically for those inmates with moderate to severe dementia and provides tailored programs for those with cognitive impairment [7]. This prison identified that there was a need to assist prisoners with severe cognitive impairment in order to reduce the incidence of victimisation and meet the needs of this group of prisoners [10]. The outcome of these programs has provided evidence that there is an improvement in social skills, attention levels and depression [7]. They also have a program where they buddy a prisoner without dementia with one that has dementia [7]. The prisoner buddies need to have a record of good behaviour, and receive training from the Alzheimer's Association so they can provide care for those with dementia and protect

Onomichi prison has a ward for older prisoners which provides nutritional support, and they changed the requirement that prisoners march in formation so that it wasn't as strict as other areas in the prison [65]. This environment was designed for prisoners who are not very

these resources is held back by environmental procedures [62].

impairment and dementia in their jurisdictions.

**5.4. Case study (international initiatives)**

them from victimisation and bullying [7, 10].

community [22].

Correctional healthcare services have a strong focus on acute healthcare issues rather than long term preventive measures [33]. In fact, correctional healthcare services are in an optimal position to deliver primary healthcare services that can be a disease prevention and health promotion service that is equivalent to that received on the outside [9]. If this style of healthcare is delivered within the correctional setting not only will it reduce the impact on communities once prisoners have been released, it will also provide optimal care within the national health performance framework and provide equivalent care to the community [9, 54].

It has been identified that prisoner's healthcare needs can be complex, and many are too extensive for prison healthcare services to manage [33]. In Australia, this leads to the health system performance in the correctional setting not meeting the requirements of the National Health Performance Framework [54]. This causes inequity across the range of patient care needs because the service provided within the correctional environment is vastly different to that in the general community [18, 54].

Correctional facilities were not designed for prisoners who are dependent on others for care, creating challenges for correctional healthcare services in identifying and supporting those with cognitive impairment and dementia [63]. This leads to incidences where care needs have gone unrecognised and health needs have been unmet [63]. There is very little information in the literature about early screening, identification and support of prisoners with cognitive impairments or dementia, and as a consequence there is little evidence to direct practice around this vulnerable group in the correctional setting.

Effective healthcare provision in the correctional environment can be obstructed due to the routine of the prison, correctional staff unavailability, time constraints and demands from prisoners [62]. There are barriers for nurses to develop therapeutic relationships with those they are caring for due to correctional requirements and the physical environment which can affect nurse-patient relationship building [64]. Correctional health clinic attendance is dependent on prisoners being able to attend, and this can be restricted by correctional services procedures and constraints [34, 62]. This creates a competition between the custody aspects of the correctional environment and the caring aspects, at times providing barriers to care and limiting nurse's autonomy [64]. A key point from the World Health Organisation guide for prison health is that healthcare staff within the correctional setting need to have professional independence and this should be to the same level as healthcare staff in the community [22].

Healthcare needs of prisoners and care delivery by healthcare professionals is affected adversely by the culture in the correctional environment and the tension this creates can affect the recruitment and retention of nursing staff in the prison [62]. Due to staffing retention issues, nurses may undertake longer or double shifts to ensure healthcare coverage which means spending longer hours behind bars, and this can lead to similar feelings to the prisoners of isolation and segregation from the community which could lead to mental illness such as depression [64]. Nurses working in the correctional environment can feel marginalised by other staff such as doctors who are in attendance for a short time, and who instruct the nurses on what to do without really understanding the complexities of setting and without being with the prisoners for long periods of time [64]. Correctional officers, although in attendance for similar periods of time, have a vastly different role and do not have the same pressures as the nurse who is expected to sort out the health problems of the prisoners [64]. Innovative delivery of healthcare in the correctional setting is often obstructed and the initiation and ongoing management of these resources is held back by environmental procedures [62].

In Australia each state and territory government is responsible for the healthcare provided in their correctional facilities [3]. As a result there are variations between jurisdictions about how and what healthcare service is provided [3]. The differences in healthcare provision and the function of clinics can range both between and within states and territories [3, 34]. Some jurisdictions will provide allied health and mental health services within the prison healthcare setting, while others will use external providers [3]. While there is restricted access to different allied healthcare professionals, there are challenges with retention and recruitment of staff [34]. There is limited information about the differences between prison healthcare in the different states in Australia, and how they identify and support prisoners with cognitive impairment and dementia in their jurisdictions.
