The hospitals in the State of Hawaii have patients admitted into their inpatient wards for various ailments and injuries. Always, within these inpatient areas of care nursing staff work diligently to provide a direct line of care to the admitted patients per the orders of the doctors of the patients. The nursing-staff, which is employed to take care of the patients, not only have orders from the doctor based on subjective thought, the nursing staff also use a lot of their own objective care with these patients. The patients, while seen in the hospital setting are patients and these patients come from all lifestyles. The focus of this research proposal is to see whether patients with a known criminal background receive fair treatment compared to the treatment that a patient with no criminal history would receive. The researcher will be using a vignette-based survey using the five point Likert scale to assess whether or not all patients receive equal treatment. The literature review will touch on what already is known about the topic and the ethical issues involving direct patient care. In addition, the discussion of the expectation and implication of the surveys will be discussed.

Introduction

When going into a hospital, people expect that they will receive a certain amount of care to treat whatever ailment or illness they may have. Care provided is assumed, no different from a similar like illness or disease that any other human being in that hospital has. However, what if that person, example, post surgery of an appendicitis, was admitted to your inpatient ward on your evening shift. Feeling that it is just another patient, and will get the same quality care, you give all your patients. An hour later, you recognized that this new admit was on the 6:00 nightly news last night as having just been released from prison after spending 15 years for child sexual assault. The question now, will you, the nursing staff, apply the same amount of care and treatment as previously given the hour before you remembered about the patient’s criminal history, or will some bias present itself in your care?

The question the researcher is hypothesizing about is do known criminals, former, and current, receiving care by nursing staff within an inpatient hospital setting receive different care when compared to the treatment of non-criminal patients? The researcher theorizes that hospital in-patients with a known criminal background receive less care from hospital staff compared to a “normal” patient without any criminal history.

The researcher first would like to give personal knowledge as to why the interest in this topic originated. The researcher enlisted in the U.S. Army as a Medic and as a Health Care Specialist, has served, thus far, eight years in the healthcare profession, in many different aspects of the health care field. Initially the researcher was assigned to a Combat Support Hospital (CSH), an eighty-four bed field unit, and deployed to Iraq in support of Operation Iraqi Freedom (’05-’07). While deployed, the researcher worked at the Intermediate Care Ward (ICW), similar to a hospital ward or unit where patients would stay overnight, many times for many nights. While in Iraq, the researcher cared and treated over 2,000 coalition forces, contractors, local nationals, and enemy forces. The care provided was universal; there was no discrimination to the individual receiving treatment or care. Other areas in the health care field the researcher experienced includes, Tripler Army Medical Center (TAMC), Pacific Regional Medical Command (PRMC) -initially the researcher worked on a inpatient ward for one and one half years (’08-’09), then a hospital clinic (’09-’11), and as of currently, working at another clinic still located at TAMC (’11-present).

We should care because not only can the medical field be subjective, which according to the labeling process subjectivity is a need to satisfaction for the quality of life (Rosenfield, 1997), the healthcare industry can also be a very objective field, where the decision of care relies on the nursing staff providing that care. Ethics has a lot to do with one’s own moral values, and when there is a choice of how to care or how much care to give there may be conflicts of interest (Monahan, 1980). Examples of this type of care can involve the type of medication certain providers prescribe, or the amount of rehabilitation the therapist asserts into bettering the patient. There are countless amounts of discretion left to the caregiver. Bottom line, and up front, we should care about this proposal because the care provided to individuals should be universal and not just for a select few, regardless of past mistakes. Every person deserves a chance at a healthy life and if hospitals can provide that benefit to keep people healthy than they should. Medical care should not be selective or objective, it needs to be subjective for everyone.

Literature Review

The study of the medical treatment of a patient with a known criminal background has never been attempted. Therefore, the researcher would like to utilize two approaches to this topic discussed in the literature review giving need to why this topic warrants future study. Those two approaches are the nursing ethics and the labeling theory.

Nursing Ethics

Nursing means to nourish, treat and care for the sick and maintain the health and welfare of their patients until their death (Royal College of Nursing, 2003). Therefore, nursing ethics has a vital role in the care and treatment of patients. So, because of the nurse’s moral values of taking care of their patients, nurses are required to take on extremely difficult roles in the care of their patients, both professionally and personally. Like the Emergency Medical Treatment and Active Labor Act dictating by law that hospital emergency rooms and the physicians must see all patients who enter an emergency room (Zibulewisky, 2001), not to mention the Hippocratic Oath taken by providers at their graduation ceremonies from medical school, swearing an allegiance to treat their patient (Hulkower, 2010). Nurses also take part in an oath called the Nightingale Pledge (similar to the Hippocratic Oath), it is the nursing proclamation that nurses will be true to their profession and live up to the standards of nursing (Egenes, 2009). All respects consider the pledge, named after Florence Nightingale, the founder of modern nursing (Egenes, 2009).

Ethics is very important in all medical professions (Gillon, 1986), Monahan (1980) suggests that psychologists take an ethics course and that it should be part of the curriculum and made mandatory as its own separate class (16). The researcher agrees that ethics should be mandatory and all professions in the medical field go through an ethics course including nursing staff because of their hands on approach with any patient. Ethics classes discusses what is right both morally and legally which includes many things such as conflict of interest, patient rights, and privacy, plus a multitude of other ethical issues nursing staff can face (American Nursing Association Committee on Ethics, 1994).

Every patient [has rights] and is entitled to privacy per the Health Information Portable and Accountability Act (HIPAA) (United States Department of Health and Human Services, 2003). Hawai’i created the Privacy of Health Care Information Act reflecting HIPAA, it states, “Individuals have a constitutional right to privacy with respect to their personal health information and records, and with respect to information about their medical care and health status” (Sutton, 2001). In other words, just because a patient has a criminal history in their background, they have a right to medical treatment and it is private and cannot be discussed openly with others, unless it is pertinent to their treatment. It is as said, it is on a need to know basis.

Unfortunately, the researcher feels that nursing staff and the medical community sometimes forgets about ethics and patient rights. This forgetfulness can sometimes be due to labeling or the stigma carried by certain patients.

Labeling Theory

When another person labels someone, it is the same as having a stigma placed against someone, which also can cause negative consequences against the labeled person (Rosenfield, 1997). This is where the labeling theory comes into play. Not only the person labeled receives negative attention, people who encounter labeled individuals apply negative attention to those labeled as well (Ascencio & Burke, 2011). Rosenfield (1997) narrates about the change in behavior of subjects that received an article regarding someone with violent tendencies, whom after reading the article the subjects reacted negatively about the person mentioned in the article when compared to the control group (pg 290-291) who had no reaction.

The labeling theory posits that society will react differently to committers of unlawfulness; meaning, society will react to the individual who broke the law as though that individual will always be unlawful and therefore, based on the behavior of society that individual will remain to act out unlawfully (Williams, 1976). This type of reaction signifying the label, alone, implies stigma (Rosenfield, 1997) and can further impede the individual’s road of rehabilitation. As labeled “criminal” a person’s chances to recovery or have success in life become slim (Williams, 1976). In addition, that person will face stigma wherever they go and treated more as an outcast (Williams, 1976). The researcher presumes that this will lead into any facet of society, to include, when meeting others, including receiving healthcare from nursing staff in an inpatient ward in a hospital in the State of Hawai’i. The patient label as criminal will cause a reaction from nursing staff, whereby the patient will be avoided more often, not forgotten, just avoided.

For purposes of this study, the researcher will focus his attention on patients with a violent criminal history where the definition of violent crime is anyone who commits the following: homicide, attempted homicide, aggravated assault, common assault, robbery, threatening behavior, harassment, arson, and sexual crime (Fazel & Grann, 2006). The researcher believes that these crimes will attract the most attention of the labeling theory.

Consider the following, a twenty-seven year old woman hospitalized for failed suicide attempt; she will be there for a number of days because of her self-inflicted wounds to her wrists; the size of the wound requires attention and she lost a lot of blood. However she did succeed in infanticide, she killed an infant (Spinelli, 2004), she successfully drowned her 3-month-old baby before trying to take her own life. You are a nurse who is assigned to watch her on your shift. Will you be able to treat this patient no different from another patient with no criminal background? The infant whose life she had taken depended on her for survival, and now the law demands retribution (Spinelli, 2004), but now this woman depends on you for survival, can you be indifferent? The researcher is trying to prove that there is a slight possibility that this woman might not be treated the same in the hospital. However, nursing staff need to realize that the patient is not in prison where it is not sensible for her treatment (Monahan, 1980) to her wrists, and psychological impairment.

Methodology

To conduct this study the researcher will use two five-point Likert scale surveys with a vignette (scenario) based questionnaire on each survey and a certain set of matching codes. Both surveys used will be involving two different mock patients, one for each survey. A third party individual will deliver the surveys to every hospital with an inpatient ward; each ward will receive fifty surveys. This is to account for the researcher wanting to make available to every nursing staff member a survey. The researcher will seek permission from the top executive or board members at each hospital with an inpatient ward informing them of the researcher’s intent to conduct this survey. The nursing staff will not know the underlying reason for the study. The researcher does not want the knowledge about the survey to affect the answers for the treatment of patients with a criminal history. The only information given to the nursing staff is that this will be a survey about patient treatment. The third party individual will act as the intermediary between the researcher and the nursing staff at the inpatient wards at the participating hospitals. In fact, the third party will only be referred to as “Third Party” they will have no distinguishing name to be identified with. The researcher will only interact with the board or top executive officer of the hospital. This will help with the anonymity of nursing staff.

This research will be on a longitudinal study over the course of one month. On the first day of the month, the third party will deliver the first set of surveys to the inpatient wards. This survey will consist of one mock patient without any criminal background, asking those surveyed for their employment information and ten vignette questions. The questions asked on both sets of surveys will be about patient care and treatment only. The demographical questions will attempt to narrow the findings to see if there is a certain age group, gender, etc. that may discriminate more to patients with criminal backgrounds, if there is any discrimination to be found. On the last day of the month, the third party will deliver the second set of surveys. The second survey will have a mock patient with a criminal background. This second survey will be identical to the first excluding the patient type, non-criminal or criminal. Also, to help alleviate from any other discriminatory or labeling factors the researcher has decided that both mock patients will be a 37 year old white male, older in age from majority of actual criminals and the patient is white, the least discriminated against ethnicity in America, also the gender is male, the least discriminated against gender.

Once both surveys are complete, the third party will pack up the raw data and match the code of the first survey to the code of the second survey to ensure completion. The third party will not ask for names just the two coded tabs and after receiving the tabs, give the nursing staff that participated and completed the survey in its entirety a $100 Visa Gift Card.

The reason for the month lapse in surveys, the researcher is attempting to allow enough time between the first and second survey so the respondents cannot remember the answers to the questions from the original survey when they are answering the second survey since each survey has identical vignette questions. The reason for the identical questions is to help narrow in whether or not the patient with a criminal background is being labeled or there is any possibility of unethical maltreatment.

The research site used will be all hospitals in the State of Hawai’i with an inpatient ward. An inpatient ward is conceptualized as any patient who spends at least one over night (11:59p.m.-12:00a.m. is considered overnight) stay in a hospital bed located on an inpatient ward. The researcher would also like to clarify that the emergency room (ER), even though a patient is checked in at the ER does not mean they are admitted into the hospital as an inpatient.

The researcher, using a non-probability quota sampling, will target all nursing staff working in an inpatient ward at each hospital in the State of Hawai’i. The reason for the non-probability quota sampling is the target population will only consist of nursing staff employed strictly to the inpatient wards. Therefore, the researcher will also not be able to generalize the results either because, as said before, it is not representative of the entire population of nursing staff.

The inclusion set will be all adult inpatient wards and nursing staff employed there. Nursing staff that work on the inpatient wards that will be targeted are the Registered Nurse (RN), Licensed Practicing Nurse, or Licensed Vocational Nurse (LPN/LVN), and the Certified Nursing Assistant (CNA). In addition, the reason for the inclusion of strictly this area, the researcher feels that patients, regardless of background, remain there longer, allowing the opportunity for the nursing staff to develop labels about the patients and possibility for any discrimination against the patients is higher.

The excluded areas from this survey will be all of the following: pediatric wards, neonatal intensive care units (NICU), pediatric intensive care units (PICU), psychiatric wards, outpatient clinics, nursing homes, and hospice care. These areas will have the least amount of adult patients or patients that do not remain in this facility long enough to harbor much resentment or build any lasting labels by the nursing staff. Individuals excluded from this survey is any nursing students or students in training, head nurse, assistant head nurse, Non-Commissioned Officer in Charge (NCOIC) or similar individual as compared to the civilian sector like a supervisory position, ward clerks, doctors, and specialists (i.e., physical therapy, speech, audiology, social work, food servers, etc…). These individuals do not remain with patients long enough to build any resentment or label.

The independent variable to this study is the nursing staff of the inpatient wards; this will include any of the following, 4 yr Registered Nurse (BSN), 2 yr Registered Nurse (ADN), Licensed Practical Nurse, Licensed Vocational Nurse (LPN/LVN), Certified Nursing Assistant (CNA). Other independent variable that can affect this study will be the age of the nursing staff, length of employment, what time of day do they work (night shift, day shift, or swing shift), number of usual patient workload in a day, number of staff, and leadership. In addition, some other independent variable in this study is the type of inpatient ward they work at, a ward (medical oncology (MEDONC), ortho/neuro/vascular (ONV), surgical ward (SURG), etc…), intensive care unit (ICU), progressive care (PROG), and are they part time or full time. The last independent variable is the criminal background of the patient that is conceptualized as a patient who has been convicted of any violent crime, homicide, attempted homicide, aggravated assault, common assault, robbery, threatening behavior, harassment, arson, and sexual crime.

The researcher will do a quantitative data analysis utilizing the Statistical Package for the Social Sciences (SPSS) to analyze and manage future data.

All ethical consideration of the nursing staff is taken into account for anonymity and confidentiality regarding this survey. The researcher will also ensure an understanding from nursing staff that answering this survey is giving consent, but it is also voluntary. The researcher nor the third party will ask for names of the participants nor the hospital they work at. Data will be stored in a vault, which only the researcher has the combination. After the study is complete and the data is gathered the researcher will destroy all documents related to this study, except the overall results. In addition, the researcher or the third party will not disclose their own names for protection.

Please see appendix A and B for operationalization.

Discussion

The expectations that the researcher is hoping to find is that there is definitely maltreatment of patients with a criminal background. Furthermore, the researcher expects that there will be a big lack of proper ethical nursing happening on inpatient wards. The researcher understands this research has never been done, and hopes that implications for an expanded study to a national level is held to help ensure the ethical treatment of patients with a criminal background is held to the same standard as everyone else. In addition, this study will help with future enforcement of ethical treatment of all patients. The researcher feels that education is paramount to patient care and that classes in unbiased opinion/non-discrimination are necessary to ensure proper treatment of all patients. In addition, ethical classes need to be made mandatory. Nursing staff also need education in the legal ramifications of not making ethical decisions and not only labeling their patient as a criminal but treating them as a criminal as well.