Nursing Effectiveness of Implications Research Discussion

Nursing Effectiveness of Implications Research Discussion

Nursing Effectiveness of Implications Research Discussion

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Objectives. To examine relationships among actionable drivers and facilitators of stigma and nurses’ intentions to provide the standard of maternal care recommended by the Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN) for incarcerated women. Methods. We conducted a Web-based survey of perinatal nurses in the United States (n = 665; participation rate 98.0%; completion rate 95.3%) in July through September 2017. We used multivariable logistic regression to predict higher than median intentions to provide the standard of care. Results. Lower stigmatizing individual attitudes and institutional norms and higher perceived autonomy when caring for an incarcerated woman were significantly associated with higher care intentions. Knowledge of the AWHONN position statement on the standard of care or their own state’s shackling laws was not associated with higher care intentions. Conclusions. We documented significant associations among actionable drivers and facilitators of stigma and the intentions of a key health care provider group to deliver the standard of maternal care to incarcerated women. Individual- and institutional-level stigma-reduction interventions may increase the quality of maternal care and improve perinatal outcomes for women who give birth while incarcerated.

Although the overall incarceration rate in the United States has fallen since 2009, incarceration rates for women remain historically high.[ 1] Institutionalized racism has led to the disproportionate incarceration of Black women,[ 2] with the highest female imprisonment rates in Black women of reproductive age.[ 3] Local jurisdictions also disproportionately criminalize women in poverty, with mental illnesses, or with substance use disorders,[ 4] resulting in increased jail incarceration rates for women.[ 1] An estimated 4% to 5% of women are pregnant upon incarceration.[[ 5]] Women who are incarcerated during pregnancy have higher risks for adverse pregnancy outcomes.[ 7] Reducing the adverse impact of incarceration on maternal health outcomes requires the elucidation of the mechanisms through which incarceration creates or exacerbates maternal health disparities.

Incarceration limits pregnant women’s autonomy and ability to care for themselves. Confinement thus makes incarcerated women dependent on custody staff and health care providers to ensure their survival and that of their fetuses. Most US departments of correction do not design correctional facilities to safely house pregnant women.[ 8] The availability in correctional facilities of pre- and postnatal care that meets community standards is highly variable.[[ 9]] Incarcerated pregnant women are transported to community hospitals to give birth. Custody officers routinely apply nonmedical restraints, commonly called “shackles,” during transport and the time outside the custody setting for the purported reasons of preventing escape and harm to self or others.[11] Shackles create potentially life-threatening safety hazards for pregnant women and their fetuses by limiting movement during labor and postpartum recovery and increasing the time to assessment and intervention in emergencies.[12] Being shackled may contribute to or exacerbate women’s behavioral health conditions and posttraumatic symptoms.

Health care provider organizations and states have implemented population-level efforts to improve maternal care for incarcerated women. The major US obstetric[12] and nursing[13] organizations have statements outlining acceptable standards of maternal care specific to this population. The standards recommend care that is of the same quality and as safe as that of nonincarcerated people as well as provider advocacy of the removal of shackles in the absence of imminent safety or escape risks. Laws covering approximately half of US states, the District of Columbia, and the Federal Bureau of Prisons and policies in most other areas restrict the use of shackles during some part of pregnancy to women who present risks of harm or escape.[14] The majority of shackling laws authorize their removal at the request of a health care provider. Evidence suggests that routine shackling continues,[10] even in states with shackling laws.[15]

As nurses are key members of the health care team when people give birth in hospital settings, their intentions to adhere to professional standards are paramount for improving maternal care. Behavioral intentions are influenced by attitudes toward a behavior, perceptions of social pressure to perform the behavior, and perceived control over the ability to perform the behavior.[16] The continuation of shackling may stem from stigmatizing attitudes held by health care providers toward incarcerated women and structural stigma–reflected social norms within the hospital environment. Stigma is a fundamental cause of health, education, and economic adversities in people with a history of incarceration.[17] Research assessing nurses’ attitudes toward incarcerated people, although scant, suggests a high degree of negativity.[[18]] Judgmental institutional norms of the care of this population have also been identified.[20] Nurses caring for incarcerated people in carceral and community settings also report a lack of full professional autonomy because of tension with custody officers.[[20]]

Guided by the Health Stigma and Discrimination Framework,[22] we examined the relationships among actionable drivers and facilitators of stigma and nurses’ intentions to provide the Association of Women’s Health, Obstetrics, and Neonatal Nurses’s (AWHONN’s)[13] recommended standard of maternal care to incarcerated women. The figure in Appendix A (available as a supplement to the online version of this article at http://www.ajph.org) illustrates our adaptation of the framework to depict stigma experienced by pregnant woman who are incarcerated.

Stigma drivers comprise individual providers’ discriminatory attitudes toward the stigmatized group. Facilitators can be positive (e.g., protective laws, professional position statements) or negative (e.g., unit-level norms marking incarcerated women as stigmatized and deserving of discrimination) influences on stigma outcomes, such as shackling in the absence of risks. The term “actionable” indicates that these factors may be amenable to intervention. We tested the following hypothesis among nurses with experience caring for an incarcerated pregnant woman in a hospital setting: stronger intentions to provide the standard of maternal care to incarcerated women would be associated with knowledge of the AWHONN position statement against shackling, knowledge of whether their states had shackling laws, lower stigmatizing individual attitudes and institutional norms, and greater perceptions of autonomy over care when a patient is incarcerated.

METHODS

Between July and September 2017, we conducted an anonymous online survey of AWHONN members. AWHONN is the largest US professional organization for perinatal nurses. This study on stigma was part of a parent study investigating nurses’ general experiences with and knowledge of the care of incarcerated pregnant and postpartum women.[23] We recruited members who designated their work areas as antepartum, intrapartum, postpartum, or mother–baby hospital units (n = 11 274 eligible nurses). Nurses with and without experience caring for incarcerated women were eligible for the parent study. Only data from respondents with experience caring for an incarcerated woman are reported here. We recruited participants through an e-mail sent by AWHONN, with 2 emails sent in total. As an incentive, we offered a $1 charitable contribution per participant to the National Diaper Bank Network.

Measures

Our survey contained adapted and investigator-developed measures of demographic and background characteristics, actionable drivers and facilitators of stigma, and intentions to provide the standard of maternal care to incarcerated pregnant women. Appendix B (available as a supplement to the online version of this article at http://www.ajph.org) includes the survey measures reported here. Before deployment, we tested the survey for content, readability, and redundancy with a pilot sample of 9 experienced perinatal providers (5 nurses, 4 obstetricians).

Demographic and background characteristics.

We gathered information on demographic and background factors associated with general US adult attitudes toward currently or formerly incarcerated people. These included gender (1 = female), race/ethnicity (1 = non-Hispanic/Latinx White), personally known someone who has been incarcerated (1 = yes), friend or family member in law enforcement or corrections (1 = yes), and history of victimization (1 = yes). We also asked respondents’ highest level of nursing education, years of nursing experience, and the state in which they practiced nursing.

Actionable drivers and facilitators of stigma.

We measured 5 potentially actionable drivers and facilitators of stigma in the perinatal care environment. We first assessed knowledge of the 2011 AWHONN statement as the nursing standard of care and knowledge of their states’ shackling laws. We gave 3 response options to each knowledge question: yes, no, and I don’t know/I’m not sure.

To assess individual stigmatizing attitudes toward incarcerated pregnant women, we adapted an existing instrument assessing the attitudes of perinatal nurses toward women who use substances during pregnancy.[24] Respondents were asked to rate on a 5-point Likert scale how much they agreed with 13 statements about incarcerated pregnant women. During the adaptation, we removed questions not applicable for already incarcerated people and added 2 questions on specific attitudes toward shackling, 1 question on whether participants felt fearful when providing nursing care to incarcerated pregnant women, and 2 questions comparing attitudes toward incarcerated and nonincarcerated pregnant women. We reverse scored questions with a positive valence. We summed each item to create the scale score (range = 13–65), with higher scores indicating higher levels of stigmatizing attitudes. The internal consistency reliability of this scale was an α of 0.83.

To assess institutional norms, we asked respondents to estimate using a 5-point Likert scale the opinions of other professionals in their hospital units whose opinions they value. We measured their perceptions of unit-level opinions on the necessity of shackling for safety, the dangerousness of shackling, and the importance of advocacy to remove shackles. Higher scores on this scale indicate more stigma, with the last 2 questions being reverse scored (range = 3–15). The internal consistency reliability of this scale was an α of 0.82. Nursing Effectiveness of Implications Research Discussion

To assess perceived autonomy when caring for incarcerated pregnant women, we asked respondents to rate on a 5-point Likert scale how much they agreed with 6 statements. The first 2 indexed their sense of control over shackle placement and removal. The last 4 assessed the perceived difficulty of advocating shackle removal if other professionals (corrections officers, hospital security, physicians, other nurses) want them to remain on. The total score on this scale was a sum of each item (range = 6–30), with the last 4 questions reverse scored. Higher scores on this scale indicate higher perceived autonomy. The internal consistency reliability of this scale was an α of 0.83. Nursing Effectiveness of Implications Research Discussion

Intentions to provide the standard of maternal care.

We developed 3 questions to measure nurses’ intentions to provide the AWHONN recommended standard of care.[13] Respondents were asked to rate, using a 5-point Likert scale, the strength of their intentions to promote patient safety for incarcerated pregnant women, advocate the removal of shackles in the absence of risks, and provide the same quality of care to incarcerated women as they do for nonincarcerated women. We summed each item to create the scale score (range = 3–15), with higher scores reflecting stronger intentions to provide the standard of care. The internal consistency reliability of this scale was an α of 0.67. Nursing Effectiveness of Implications Research Discussion

Analysis

We coded answers to the knowledge questions as correct or incorrect. For questions measuring knowledge of the AWHONN statement, we coded no and I don’t know/I’m not sure as incorrect. We coded shackling law responses using each respondent’s practice state to determine whether they lived in the District of Columbia or 1 of the 22 states that had enacted legislation at the time of this study. We coded as incorrect respondents who inaccurately reported that their state had or did not have a shackling law and those who answered “I don’t know or I’m not sure.” Nursing Effectiveness of Implications Research Discussion

We then calculated univariate statistics. To address negative skew in our outcome, we dichotomized care intentions scores at the median of 13 to identify nurses with higher (greater than median) and lower (less than or equal to median) intentions. We used bivariate analyses (χ² or t test) to examine associations between the binary intentions score and each of the demographic and background characteristics and actionable drivers and facilitators of stigma. We then created multivariable logistic regression models of the endpoint intentions using all variables with a significant bivariate association.

RESULTS

In total, 988 nurses clicked on the survey link, 968 continued to the second page, and 923 completed the survey, for a participation rate of 98.0% (respondents who signaled agreement to participate by continuing to the second page divided by those who clicked on the survey link) and a completion rate of 95.3% (respondents who completed the survey divided by those who continued to the second page).[25] Seventy-four percent (n = 690) reported experiences caring for incarcerated pregnant women in hospital perinatal units, and 665 of the experienced group completed all included scales. Respondents with experience caring for incarcerated women during pregnancy reported more years of nursing experience than did those with no experience caring for them. One fifth (n = 144) of respondents with experience reported caring for more than 20 incarcerated women during pregnancy over the course of their careers.

Table 1 includes descriptive statistics for the demographic and background characteristics, actionable drivers and facilitators of stigma, and intentions scores. Our sample was overwhelmingly female (99.8%), non-Hispanic/Latinx White (83.9%), educated at the bachelor’s level or higher (85.0%), and experienced in nursing (86.0% with 10 or more years of experience). More than half of respondents (61.1%) personally knew someone who had been incarcerated, and a similar proportion had a friend or family member who worked in law enforcement (59.8%). Almost half (45.3%) reported a history of crime victimization.

TABLE 1— Demographic and Background Characteristics, Actionable Drivers and Facilitators of Stigma, and Perinatal Nurses’ Intentions to Provide the Standard of Maternal Care to Incarcerated Women: United States, July–September 2017

4 Note. ADN = associate degree in nursing; AWHONN = Association of Women’s Health, Obstetric and Neonatal Nurses; LPN = licensed practical nurse; LVN = licensed vocational nurse.

Although all of the respondents were active members, less than 1 in 5 knew about AWHONN’s standards on perinatal care for incarcerated women. More than half (58%) practiced in a state with a shackling law. Less than 10% correctly knew whether their states had or did not have shackling laws. The majority of respondents did not know or were not sure whether AWHONN had a position statement (79.7%) or their states had shackling laws (88.5%). Nursing Effectiveness of Implications Research Discussion

Table 2 includes bivariate associations between respondents with lower and higher intentions to provide the standard of maternal care, each of the demographic and background characteristics, and actionable drivers and facilitators of stigma. The demographic and background characteristics did not have significant bivariate associations with care intentions. With the exception of knowledge of state shackling laws, all of the actionable drivers and facilitators of stigma (knowledge of the AWHONN position statement [χ² = 11.9; P = .001], individual stigmatizing attitudes [t = 16.0; P < .001], stigmatizing institutional norms [t = 10.7; P < .001], and perceived autonomy [t = 7.3; P < .001]) were significantly associated with higher care intentions. Nursing Effectiveness of Implications Research Discussion

TABLE 2— Bivariate Associations Between Individual Characteristics, Actionable Drivers and Facilitators of Stigma, and Lower and Higher Intentions to Provide the Standard of Maternal Care to Incarcerated Pregnant Women: United States, July–September 2017

• 5 Note. ADN = associate degree in nursing; AWHONN = Association of Women’s Health, Obstetric and Neonatal Nurses; LPN = licensed practical nurse; LVN = licensed vocational nurse.

1 a χ² or t test P ≤ .01 for comparison between respondents with the lower and higher care intentions. Nursing Effectiveness of Implications Research Discussion

Table 3 includes results of the multivariable models. We first created a model with knowledge of the AWHONN position statement, individual stigmatizing attitudes, stigmatizing institutional norms, and perceived autonomy. In the multivariable model, knowledge of the AWHONN position statement was no longer significantly associated with care intentions, and removing the knowledge variable had no effect on the estimates. Stigmatizing institutional norms and individual-level attitudes and perceived autonomy remained significantly associated with higher intention scores, with individual stigmatizing attitudes having the strongest association. For every 5-point decrease in the individual stigmatizing attitudes score, respondents were almost 3 times as likely to have higher care intentions (odds ratio [OR] = 2.8; 95% confidence interval [CI] = 2.3, 3.4). For stigmatizing institutional norms, every 5-point decrease was associated with a doubling of the likelihood of having higher intentions (OR = 2.2; 95% CI = 1.4, 3.5). Every 5-point increase in the perceived autonomy score was associated with 1.4 times increased likelihood of higher care intentions scores (OR = 1.4; 95% CI = 1.1, 1.7). Nursing Effectiveness of Implications Research Discussion

TABLE 3— Multivariable Relationships Among Higher Intentions to Provide the Standard of Maternal Care to Incarcerated Women and Actionable Drivers and Facilitators of Stigma in US Perinatal Nurses: United States, July–September 2017

6 Note. AWHONN = Association of Women’s Health, Obstetric, and Neonatal Nurses; CI = confidence interval; OR = odds ratio.

DISCUSSION

Our study builds on previous research identifying individual and facility-level stigmatizing attitudes and a perceived lack of autonomy when caring for incarcerated people[[19]] and connects them to nurses’ intentions to provide the standard of care to incarcerated pregnant women in particular. Our results demonstrate the potential deleterious effects of stigma on the maternal care provided to incarcerated pregnant women in community hospitals. Although the distribution of our intentions data suggests that nurses had strong overall intentions to provide the standard of maternal care recommended by their professional organization, stigmatizing attitudes and institutional norms remained significant; these are negative predictors of having the expected high level of commitment.

Professional position statements and legislation are necessary but may not be sufficient to ensure that incarcerated women receive the standard of maternal care. In our study, knowledge of existing population-level efforts to improve the care of incarcerated pregnant women was low. Knowledge was also not associated with nurses’ intentions to promote the safety of incarcerated patients, to provide them with the same quality of care as other pregnant patients, or to advocate shackle removal in the absence of safety or flight risks. Not addressing institutional norms, individual attitudes, and nurses’ perceived ability to control the care of their incarcerated patients could put women at further risk for potentially life-threatening safety hazards if providers fail to advocate shackle removal or for the same quality of care provided to nonincarcerated women.

Stigma-reduction interventions must be multilevel, addressing individual drivers and institutional-level facilitators. At the individual health care provider level, effective approaches for reducing mental illness and substance use–related stigma may be adapted for this purpose.[26] These include teaching providers about mass incarceration and incarceration-related stigma, as well as creating opportunities for them to build skills related to caring for incarcerated women and communicating effectively with custody officers. Nursing Effectiveness of Implications Research Discussion

Joint training between health care providers and custody staff could facilitate shared goal setting on safety while also promoting understanding of the different roles played by these professional groups. In doing so, joint training could increase nurses’ perception of autonomy in their own roles when caring for incarcerated women. Another effective strategy includes collaborating with the stigmatized group in the development and delivery of the stigma-reduction intervention.[27] Involving formerly incarcerated women increases health care provider contact with them in a safe space outside the often stressful patient–provider interaction, humanizes them, breaks down stereotypes, and grounds the educational material in women’s lived experiences. A blended intervention, which uses self-directed learning modules in addition to an in-person session, could address the primary feasibility issue of limited staff time for additional learning activities.[27]

Ideal providers of stigma-reduction interventions include obstetric and nursing professional organizations and hospitals with contracts to care for incarcerated people. These efforts synchronize well with the Council on Patient Safety in Women’s Health Care nationwide campaign to reduce racial/ethnic disparities in maternal morbidity and mortality through adoption of a peripartum safety bundle.[28] The development of a safety bundle for the care of incarcerated pregnant women could enhance hospital recognition of disparities in the care delivered to this group and support systems to accurately document when patients are incarcerated so that adverse outcomes can be identified and quickly addressed. The use of a checklist on admission of any incarcerated woman would prompt nursing assessment of these risks. As bias is most active in stressful, fast-moving situations, which are common in hospital settings, the checklist could also be beneficial in slowing health care providers down long enough to focus on the woman’s behavior, not her status as an incarcerated person. Nursing Effectiveness of Implications Research Discussion

Limitations

Our sample of nurses was homogenous in terms of gender, race, and years of experience. We also recruited from a professional organization. Thus, they may not represent the larger population of US perinatal nurses with experience caring for incarcerated pregnant women in hospital settings. Gender and racial homogeneity accurately reflect demographics of the recruiting organization and the US nursing workforce.[29] Despite a lack of demographic diversity, the sample had adequate variability on the background factors known to be associated with general US adult attitudes toward justice-involved people. We were unable to compare these factors between our sample and the larger nursing workforce, as these data are not available, to our knowledge.

Although care intentions account for a substantial proportion of the variance in actual health care provider behavior,[30] our survey was vulnerable to response bias, and we did not measure the actual care nurses provided to incarcerated women. We also did not measure women’s birth experiences or health outcomes. We focused on health care providers because stigma in health care settings is particularly dangerous, although it is amenable to intervention.[26] We used an anonymous online survey to reduce the effect of social desirability on the study findings. Reliability for the intentions scale was also questionable, likely because of the low number of items. In response to our pilot survey reviewers’ concerns about respondent burden, we chose to limit the number of items. Future research in this area should refine the measurement of provider intentions, assess the care provided against the standards, and report birth experiences and health outcomes of incarcerated women and their newborns.

Lastly, we measured only incarceration-related stigma, not the intersectional stigma experienced by incarcerated women. Racism, poverty, mental illness, and substance use likely factor into stigma affecting this population. We are unable to disaggregate the individual effects of each on nurses’ intentions to provide the standard of maternal care. To be most effective, interventions to improve the care of incarcerated pregnant women likely need to address stigma from an intersectional perspective. In particular, racism likely plays a large role in nurses’ intentions to provide the standard of maternal care to incarcerated women given that it defines the US criminal justice system and is embedded in US health care systems. Nonincarcerated women of color are more likely to report health care provider mistreatment during pregnancy and childbirth than are White women, even when controlling for other stigmatizing social risks.[31] Although our study was not designed to assess the impact of racism on the maternal care of incarcerated pregnant women, we acknowledge that this is an important future area of study.

Public Health Implications

Our findings suggest that stigma manifested as lower intentions to provide the standard of maternal care may be a mechanism through which incarceration contributes to maternal health inequities. Incarcerated women’s pregnancy status and impending motherhood conjure deep judgment against them.[32] To improve the health of this population, our results argue for incarceration stigma–reduction interventions, in addition to advocacy of passing or strengthening shackling legislation. Our results provide the groundwork for the development of theory- and evidence-based stigma-reduction education for health care providers.

More broadly, our findings argue for nonpunitive responses to the poverty, mental illness, and substance use that bring women into contact with the justice system. By reducing our reliance on criminal legal responses, we can prevent the effects of incarceration-related stigma on maternal care, prevent incarceration-related maternal–child separation, and address the root causes of women’s incarceration.[33] Research is needed to build the evidence base for community alternatives and determine the most effective mechanisms for scaling them up to meet the needs of pregnant women who are at risk or currently justice involved.

ACKNOWLEDGMENTS

The Association of Women’s Health, Obstetric, and Neonatal Nurses and the March of Dimes funded this study. K. L. Stringer was supported by the National Institute of Drug Abuse (award 5T32DA037801 and R25DA037190).

These data were presented at the American Public Health Association’s 2018 Annual Meeting.

We thank members of the New York Coalition for Women Prisoners for inspiring us to investigate this topic. We acknowledge Shiela Strauss and Michelle Secic for assistance with data analysis.

CONFLICTS OF INTEREST

We have no conflicts of interest to disclose.

HUMAN PARTICIPANT PROTECTION

The City University of New York integrated institutional review board determined that this study was exempt from review.

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By Lorie S. Goshin; D. R. Gina Sissoko; Kristi L. Stringer; Carolyn Sufrin and Lorraine Byrnes

Reported by Author; Author; Author; Author; Author

Lorie S. Goshin, D. R. Gina Sissoko, and Lorraine Byrnes are with the Hunter-Bellevue School of Nursing, Hunter College, City University of New York, New York. Kristi L. Stringer is with the Social Intervention Group, Columbia University School of Social Work, Columbia University, New York, NY. Carolyn Sufrin is with the Department of Gynecology and Obstetrics and the Department of Health, Behavior and Society, Johns Hopkins University School of Medicine, Baltimore, MD.

Lorie S. Goshin, D. R. Gina Sissoko, and Lorraine Byrnes are with the Hunter-Bellevue School of Nursing, Hunter College, City University of New York, New York. Kristi L. Stringer is with the Social Intervention Group, Columbia University School of Social Work, Columbia University, New York, NY. Carolyn Sufrin is with the Department of Gynecology and Obstetrics and the Department of Health, Behavior and Society, Johns Hopkins University School of Medicine, Baltimore, MD.

Lorie S. Goshin, D. R. Gina Sissoko, and Lorraine Byrnes are with the Hunter-Bellevue School of Nursing, Hunter College, City University of New York, New York. Kristi L. Stringer is with the Social Intervention Group, Columbia University School of Social Work, Columbia University, New York, NY. Carolyn Sufrin is with the Department of Gynecology and Obstetrics and the Department of Health, Behavior and Society, Johns Hopkins University School of Medicine, Baltimore, MD.

Lorie S. Goshin, D. R. Gina Sissoko, and Lorraine Byrnes are with the Hunter-Bellevue School of Nursing, Hunter College, City University of New York, New York. Kristi L. Stringer is with the Social Intervention Group, Columbia University School of Social Work, Columbia University, New York, NY. Carolyn Sufrin is with the Department of Gynecology and Obstetrics and the Department of Health, Behavior and Society, Johns Hopkins University School of Medicine, Baltimore, MD.

Lorie S. Goshin, D. R. Gina Sissoko, and Lorraine Byrnes are with the Hunter-Bellevue School of Nursing, Hunter College, City University of New York, New York. Kristi L. Stringer is with the Social Intervention Group, Columbia University School of Social Work, Columbia University, New York, NY. Carolyn Sufrin is with the Department of Gynecology and Obstetrics and the Department of Health, Behavior and Society, Johns Hopkins University School of Medicine, Baltimore, MD.

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