Introduction

Worldwide, aged populations have increased substantially in most countries and regions leading up to 2017, and this increase is expected to accelerate in the future.1 In Australia, population trends showed a 36.8% increase in the number of Australians who are 50 years and older between the years 2000 and 2010.2,3 It is expected that the number of Australians over 65 years will double by 2055.4 This increase in the aging population is also occurring within the correctional setting.5,6 This is supported by the Bureau of Statistics in Australia, which showed an increase of 95% in older prisoners from 2000 to 2012.2,7

The increase in the aging population has given rise to increasingly complex healthcare needs, including dementia, both within the general and prisoner populations.8,9 The World Health Organization defines dementia as "a syndrome, usually of a chronic or progressive nature, caused by a variety of brain illnesses that affect memory, thinking, behavior and ability to perform everyday activities".10^(p.2) These impairments are irreversible and generally have a gradual onset and progression, leading to a decline in the person's ability to perform self-care activities.11,12 People with dementia have symptoms similar to those with cognitive impairment, including altered perceptions, memory loss (specifically short term), loss of cognitive skills, behavior changes, language difficulties, altered mobility and personality changes.11,12

The natural progression of dementia often results in difficulty following directions, as well as a decline in the ability to attend to simple hygiene tasks, or understand processes within the environment.7 Reports in the literature claim that prisoners who are unable to undertake these activities or follow directions are likely to receive punishment or disciplinary action for non-compliance, which could advance the progression of the disease.13-16 Failure to identify cognitive impairment and dementia in prisoners could lead to such adverse outcomes as victimization, inability to follow complex instructions, and poor judgment resulting in disciplinary actions.13,16-18

Research around dementia focuses on the older person in acute care and aged care settings; however, it is estimated that within the correctional population, there is a higher prevalence of cognitive impairment and dementia.13-15,19 A review of literature conducted in the United States reported that in the general population about 13% exhibit signs of dementia, while in the correctional population, it was estimated that up to 44% of people exhibit these same signs.13 It has been acknowledged that there could be many unrecognized instances of dementia in prisons, and this has been exacerbated by correctional healthcare services focusing on acute health care rather than long-term preventive measures.14,15

Nurses working in the correctional environment are integral to providing healthcare services to prisoners. However, they are often not educated to care for the complex needs of prisoners or the increasing aging population.20,21 It is acknowledged that there is a shortage of staff with geriatric training who can adequately care for the aging prisoner population and their increasing health problems.20 With the increase in chronic diseases including dementia in the prisoner population, healthcare professionals need to be provided with training in various specialty areas including aged and dementia care.12,22

Prisoner health care presents correctional nurses with challenges due to the diversity of existing problems ranging from substance abuse and mental health disorders to acute and chronic health issues.23 There are also differences within the population due to variations in their sentencing and the location of their incarceration, which can lead to prisoners developing a loss of normative behaviors.23 Some of these challenges for correctional nurses may impact the development of nurse-patient relationships and, ultimately, delivery of care.23 Correctional nurses require a broad scope of practice with a diverse skill set in order to provide quality care, although it is reported that they are not always able to source training specific to their role due to staffing requirements and heavy workload.21,24

Correctional nurses need to care for a group of people who are advancing in age and who exhibit higher morbidity rates than the general population, while being expected to deliver care that is equal to that provided in the general community setting.25 The World Health Organization has developed a guideline to promote health in prisons, which identifies the need for nurses to have professional independence equivalent to nurses in the general community.26 If nurses are restricted with their practice and lack professional independence, the health care they provide may be suboptimal.26 It has been recognized that the quality of nursing care provided in the correctional environment is fragmented and erratic, which impacts adversely on nurse education, job satisfaction and staff retention.23 There is minimal indication that evidence-based best practice is being integrated into correctional nursing practice.23

Furthermore, security requirements in the correctional environment can create barriers to the correctional nurse delivering safe and autonomous care.27 All nurses need autonomy in their practice to be able to provide and plan care for individuals; however, this autonomy is blocked in the correctional setting by the need to seek permission from security holders for any nursing actions.27 This lack of autonomy can create a conflict between the healthcare needs of the prisoners and the custody requirements of the system.28 Privacy for the prisoner in the correctional setting is absent, whereas within a healthcare setting, privacy is essential; therefore, nurses have an ethical dilemma.28,29 Providing compassionate care and developing a therapeutic relationship with patients is a core component of nursing practice.30,31 Security in the custodial environment creates difficulties for nurses to develop a therapeutic relationship with their patients, and it affects whether patients feel they can communicate openly about their concerns.27,32 These barriers to nursing care can generate problems with retention of staff, forcing correctional nurses to work longer shifts due to lower staffing levels.27

It is well known that the care of people with dementia can be of poor quality due to inadequate staff knowledge and skills, as well as lack of confidence to deliver care.33,34 It is recognized that providing person-centered dementia care improves the quality of life of those with dementia.33 There is limited research around person-centered dementia care training in relation to correctional nurses' development of knowledge and skills, or how it supports their confidence to provide dementia care.33

To improve the quality of care provided to people with dementia, staff training and education are needed.35 To date, research on staff training in dementia care focused on aged and acute care areas.33-43 Therefore, the training and education needs of nurses in the correctional environment have not been adequately recognized or addressed. Studies have identified the need for dementia-specific training but fail to state what specific educational components should be included.35 For example, in the acute setting it has been acknowledged that people with dementia experience dehydration, falls, malnutrition, delirium and functional decline.35 Poor quality of care has been attributed to a negative attitude by caring staff, as well as poor knowledge and skills around caring for people with dementia.35 Although initiatives have been developed around staff training in the aged and acute setting for dementia care, there is limited information about the best and most effective approaches to training for correctional nurses.35

Research on dementia care education for nurses in aged and acute care settings could provide strategies to implement in the correctional environment.35-37,40,44 These approaches may be adapted to ensure staff are providing care equivalent to that in the general community. A cluster randomized controlled trial was used to develop an understanding around staff attitudes, their knowledge and their care approach.40 This study identified that knowledge translation and education specifically around dementia improved nurses' attitudes, their approach to care and their knowledge base.40

This review will search the literature relating to correctional nurse education and training to care for prisoners in the correctional setting, including those with dementia. A preliminary search has been conducted and the databases/sources searched were the JBI Database of Systematic Reviews and Implementation Reports, the Cochrane Library (which includes the Cochrane Database of Systematic Reviews), PROSPERO and MEDLINE. One systematic review was identified that investigated the impact on dementia in the prison setting; however, this review did not explore nurse education and training needs around this population.45 Due to a lack of published studies or protocols registered for this topic, there is scope for a systematic review to inform correctional nurses and organizations about education needs for nursing staff. Due to a lack of primary studies and because personal experiences are not widely disseminated beyond the correctional setting, the opinions, comments and conclusions of government bodies and experts in the field will be explored. This will include criteria developed by the Royal Australian College of General Practitioners in their Standards for health services in Australian prisons46, and the World Health Organization's47 guide for prison health.

A systematic review of available expert text and opinion would assist in formulating a training strategy for nurses working in the correctional setting with prisoners who are experiencing dementia. With the numbers of older prisoners growing at a faster rate than in the general population, this systematic review is timely and potentially valuable to policy makers within the correctional nursing environment. This could result in policy makers developing an education strategy to support nurses in an isolated work environment, thus resulting in better outcomes for vulnerable prisoners.

Inclusion criteria

Participants

The types of participants to be considered for inclusion for this review will be correctional nurses, regardless of gender, who are responsible for the health care of adult prisoners, including those with dementia.

For this review, a nurse is defined as a person who has completed a tertiary level program of study which has led to registration or licensing in his/her respective country.36,50 Due to the nature of the environment, correctional nurses will generally be identified as civilians working in the correctional setting. Correctional service officers/guards will be excluded. Papers exploring adult prisoners with diagnosed mental illness or substance misuse, and prisoners recently discharged from a correctional facility will be excluded.

Interchangeable terms have often been used to refer to prisoners in the correctional environment: prisoner, crim, criminal, inmate, offender, convict, incarcerated.49

Phenomena of interest

The phenomenon of interest for the review is the training and education requirements for correctional nurses working with prisoners with dementia. Education and training for prisoners, other healthcare professionals and correctional officers will be excluded.

The definition for education is the process where a person develops a body of knowledge through being systematically instructed.51 Training is where a person acquires knowledge, skills or experience for a particular behavior, such as nurses receiving "in-service training" within the hospital or correctional setting.52

Context

The context considered in this review is adult correctional settings. These settings are defined as "any building, enclosure or place legally declared to be a prison for the lawful custody of persons committed by lawful authority".53^(p.5)

Interchangeable terms have often been used to refer to the correctional environment: corrections, correctional setting, correctional facility, correctional institution, prison, jail, gaol, lock-up, penal institution, penitentiary, incarceration.48 This setting is characterized by having been developed to confine persons and segregate them from the general population.54 Any facility other than an adult correctional setting will be excluded, such as: juvenile detention center, prisoners in home detention, community corrections and prisoners in police lock-up.

Types of publications

The sources of information considered for this review will include text and narratives describing expert opinion pieces, expert opinion-based guidelines, expert consensus, published discussion papers, unpublished dissertations, reports accessed from professional organization websites and government policy documents. Only papers written in English will be included in this review.

Methods

The proposed systematic review will be conducted in accordance with the Joanna Briggs Institute (JBI) methodology for systematic reviews of text and opinion.55

Search strategy

The search strategy aims to locate both published and unpublished text and narratives. An initial limited search of MEDLINE and CINAHL will be undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles, were used to develop a full search strategy for MEDLINE (see Appendix I). The search strategy, including all identified keywords and index terms, will be adapted for each included information source. The reference lists of all studies selected for critical appraisal will be screened for additional studies. Text and narratives published only in English will be considered for inclusion in this review. This search will not be limited by publication dates in order to find all available published and unpublished literature on correctional nurse education and training around caring for prisoners with dementia.

Information sources

Databases to be searched using the Ovid platform will be: MEDLINE, CINAHL, Embase and PsycINFO.

The search for unpublished papers will include: Google Scholar, OpenGrey, ProQuest Health and Medical Complete and Criminal Justice Abstracts full text using the ProQuest platform and ProQuest Dissertations and Theses.

Institutional websites to be accessed will be:

* Dementia Australia website (formerly Alzheimer's Australia)

* Alzheimer's Disease International

* World Health Organization

* Australian Institute of Health and Welfare

* The Royal Australian College of General Practitioners

* National Commission on Correctional Health Care.

Initial search terms to be used will be: cognitive impairment, dementia, Alzheimer's disease, education, training, staff education, development, correctional/corrections nurse, prison nurse, nurse, prison.

Paper selection

Following the search, all identified citations will be uploaded into EndNote (Clarivate Analytics, PA, USA) and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Potentially relevant studies will be retrieved in full and their citation details imported into JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI) (Joanna Briggs Institute, Adelaide, Australia). The full text of selected studies will be assessed in detail against the inclusion criteria by two independent reviewers.

Full-text studies that do not meet the inclusion criteria will be excluded, and reasons for exclusion will be provided in an appendix in the final systematic review report. Included studies will undergo a process of critical appraisal. The results of the search will be reported in full in the final report and presented in a PRISMA flow diagram.56 Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.

Assessment of methodological quality

Text and opinion papers selected for inclusion will be assessed by two independent reviewers for authenticity prior to inclusion in the review, using standardized critical appraisal instruments from the JBI methodology of systematic reviews of text and opinion.57 Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Papers will not be excluded based on their quality. The results of the critical appraisal will be reported in narrative form and in a table.

Textual data extraction

Textual data will be extracted from papers included in the review using the standardized data extraction tool from the JBI methodology of systematic reviews of text and opinion.57 The following will be included in the data extraction form for textual data: types of text and the people represented, stated allegiance or position of the paper, setting and its geographical context, cultural context, logic of the argument and experts' conclusions (where provided).55,57 If the expert does not specify a conclusion, it will be determined from the themes and metaphors identified in the paper. The conclusion will be supported, where possible, by a quotation from the source paper, and this quotation will be cited with the page number. During this process, each conclusion will be assigned a level of credibility depending on its consistency with supporting data within the text.55,57 Finally, a summary will be provided of the strengths and weaknesses of the paper and how they refer to the review objective and questions. Authors of papers will be contacted to request missing or additional data where required.

Textual data synthesis

Textual papers will, where possible, be pooled using JBI SUMARI. This will involve the synthesis of conclusions to generate a set of statements that represent that aggregation, through assembling and categorizing these conclusions on the basis of similarity in meaning. These categories will then be subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the conclusions will be presented in narrative form. This review will follow the JBI approach to synthesizing information collated from textual and non-research papers to ensure credibility of each as a relevant source to guide practice.55,57

Assessing certainty in the findings

The synthesized findings will be graded according to the ConQual approach for establishing confidence in the output of text and opinion and presented in a Summary of Findings.58 The Summary of Findings includes the major elements of the review and details how the ConQual score is developed. Included in the table are the title, population, phenomena of interest and context for the specific review.59 Each synthesized finding from the review is then presented along with the type of expert opinion informing it, a score of dependability, credibility and the overall ConQual score.

Acknowledgments

This systematic review will form part of the submission for the award of Doctor of Philosophy for the primary reviewer, and as such, a secondary reviewer will only be used to ensure validity of included papers.

Appendix I: Search strategy for MEDLINE

MEDLINE (Ovid MEDLINE[R] Epub ahead of print, in-process and other non-indexed citations, Ovid MEDLINE[R] daily and Ovid MEDLINE[R] 1946 to present)

References