Fewer than one percent of U.S. nurses works in correctional facilities. Yet, clinicians across care settings see the health impacts of incarceration, says Kristin Merss, PhD, RN, a postdoctoral trainee at the University of Wisconsin–Madison School of Nursing.
According to the Prison Policy Initiative, 1.9 million people are behind bars in the United States. Nearly twice that number are on community supervision, which includes probation, parole, and extended supervision. “That doesn’t count the folks who are off of community supervision,” Merss says. “At some point in your practice, you will work with someone who’s been involved in the criminal legal system.”
Increasingly, caring for people who are or were incarcerated means caring for older adults with complex needs.
“Because of policy decisions in the 1980s and 1990s like tough on crime and war on drugs, we locked up all these people, especially men and men of color,” says Merss. “We locked them up when they were in their 20s and 30s, but now it’s 40 or 50 years later. They’re not 20 or 30 anymore. But they’re still living in institutions that were designed and built with 20- and 30-year-olds in mind. It’s like the system is frozen in time.”
“We don’t know very much about the health of folks who are in prison,” she adds. “And what we do know isn’t very good.”
For example, the physical demands of prison or PADLs are anything but age friendly.
“Prison activities of daily living is a relatively new concept that I think is essential,” says Merss. “PADLs are inclusive of traditional ADLs—eating, bathing, dressing—but also inclusive of unique things that people in prison have to do. So, not only does the person have to eat and use utensils, but they also have to walk carrying a tray of food. They might be expected to climb into a top bunk. They might be expected to walk while shackled or handcuffed. Think about what that does to your balance, to your mobility.”
The number of older people behind bars is significant and growing. They are aging in an environment that doesn’t accommodate their needs. Many struggle to carry out PADLs in a system that denies them help.
In addition, people who are incarcerated may experience age-related health issues earlier in life.
“Prison represents a relatively unique episode of acute on chronic stress,” explains Merss. “Even if you’re in a ‘nicer’ prison, you have a chronic, high level of stress. Then you have acute stressors layered on top of that,” such as violent incidents and interactions with correctional officers (COs).
“We know the impact of stress on the body,” she says. “Someone who’s exposed to chronic stress for 10, 30, 50 years—we can imagine what that does to their body.” Because of the health consequences, an incarcerated person is “considered geriatric at age 50 or 55, as opposed to age 65 in the community.”
Merss became interested in the intersection of health and incarceration as an undergraduate student at UW–Eau Claire. A public health professor encouraged her to participate in one of the community health immersions offered by the Wisconsin Area Health Education Centers (AHEC).
“When I was looking at the list of options, one of them was incarcerated folks,” she says. “I was a junior in nursing school. I remember thinking, ‘I don’t know anything about this population.’ I never once thought about what happens to health when people go to prison or jail. So, I thought, ‘well, let’s do it and see what I learn.’”
Merss now directs AHEC’s immersion on incarceration, health, and well-being.
“My goal in this program is to give students a better understanding of what incarceration means,” she says. “So, when they’re working with these people in a community setting, they can do so empathically, with a foundational knowledge of incarceration as a social or structural determinant of health. They can provide competent care.”
Merss’ research focuses on correctional officers as well as transitions of care.
“The COs aren’t clinicians. They shouldn’t be treated as such,” says Merss. “But COs see people who are incarcerated every single day. Every single hour of their 16-hour shift. We know that the COs understand this person’s baseline. With older adults, small changes can be related to issues like delirium or a loss of physical mobility. The COs are more likely to notice that, rather than the nurse, who might see this patient infrequently, perhaps only annually.”
People transition between prisons, go from prison to hospital and vice versa. “I want to look at these transitions of care with a focus on how to navigate this time of vulnerability for older adults,” says Merss.
“We know from Barb King’s and Linsey Steege’s work that when folks are in the hospital, they can experience a decrease in mobility because of lack of ambulation,” she says. If the patient is incarcerated, “they transition back into a system where not only will they have to ambulate independently, they also have those PADLs. So they have to ambulate independently while carrying a tray of food or while walking with handcuffs. And we know that there can be barriers to assistive devices. A cane can be a pretty handy weapon.”
To Merss, the broader context is key. Before prison, many people didn’t have access to primary care. After prison, many need support to navigate a community they may not have lived in for decades. While in prison, many face barriers to receiving care.
“Everything in prison is filtered through a lens of security first and then health,” she says. “Healthcare is a constitutional right for people who are incarcerated. But there are structural, financial, policy, and logistic barriers to providing optimal care for this highly stigmatized population.”
–Diane Farsetta