The Nurses' Experience in Providing Health Care for Criminals in General Hospital

Providing health care for criminals is very complex, stressful, and challenging for the general hospital nurses who are usually not habituated to treat them. The nurses are required to keep their caring and professional work. Providing health care for criminals puts the nurses into a risky working environment. They are susceptible to physical and psychological aggressions that can influence their practices and their applied nursing care quality. The objective of this research is to explore the general hospital nurses' experience in providing health care for the criminals. This is qualitative method research with a phenomenological approach. The data collection was done by a deep interview for 10 nurses. The applied data analysis is the Interpretative Analysis Phenomenology (IPA). The six themes found in the research are: 1) feeling discomfort in working, 2) experiencing emotional conflict, 3) working in an unsafe environment, 4) having difficulties in creating a therapeutic relationship, 5) unnatural caring emergence, and 6) not wanting the police officers to get involved in treating the patients. The security and emotional feeling factors of the nurses become the greatest challenges. They make the nurses difficult to create a therapeutic relationship and lead to unnatural caring committed by the nurses. Therefore, it is important for the nurses to internalize and reflect sincere caring as the essential principles in the nursing profession. Thus, it can reach the objectives of nursing, service equality, and patient recovery.


INTRODUCTION
The criminality rate in the world is still very high. According to the United Nations Office on Drug and Crime data (1), the criminality occurrence in Central America, in 2015, reached ±24 million, in Europe ±9 million, and Southern-East Asia ±3.5 million. Indonesia is a country with 319 million citizens. It has a 25 million poverty rate or 9% of the total number of citizens. High numbers and poverty among citizens make Indonesia a susceptible country due to criminal actions. This high criminality rate increases criminality perpetrators in Indonesia (2). Based on data from the Bureau Statistics Agency, the criminality rate in Indonesia, in 2016, reached 357.197 occurrences.
Criminals are usually attached to stigma and discrimination from society, including health workers. Criminal perpetrators belong to a susceptible population due to health problems. About 80-90% of criminal perpetrators need medical treatment under health problems such as mental problems, surgery, chronic disease, and drug abuse record. However, the growing concern about this deal with the occurring gaps and discrimination in administering health services (3)(4)(5). Nurses in a hospital have important roles in delivering health services for the criminals, started when they access the health facility until the referral process. Thus, the general hospital nurses have great responsibilities in treating those patients. Nurses provide health services including emergency state services, surgery, even mental health service, so they are required to have high professionalism and integrity to carry them out (6,7).
Nurses who work at correctional institutions have been trained to treat any criminals in a safe and controlled environment. However, it is different from nurses who work at a general hospital. They are not habituated to treat criminals in an unsafe environment. Treating criminals has different challenges for them. The security and emotional feeling factors are the greatest challenges for them. They have difficulties in providing qualified services, to create a patient-nurse relationship, and even to apply sincere nursing care for individuals who have hurt, raped, or even murdered other people. Caring is an essential value for a nurse and it is the comparative power between a nurse and other health workers. A nurse must have sincere care and realize that without caring, it is difficult for patients to get recovered (8,9). Those challenges have influenced their quality and practice. Based on the phenomena, this study intends to explore the general hospital nurses' experience in providing health care for the criminals.

Design
This is qualitative research with a phenomenological approach based on Cresswell's theory that is, the design of research derived from philosophy and psychology in which researchers describe the individual's life experience of a phenomenon according to the emplacement told by participants. The description culminates in the essence of the experiences of some individuals who have all experienced the phenomenon. The phenomenological approach has a strong philosophy basis and involves interviewing (10). Within this design the participants were allowed to explore their subjective experiences while treating criminal perpetrators. It aims to seek the essence or as to the essence of the conscious participant experience, also describing, analyzing, and interpreting data in-depth, complete, and structured. The data is a quintessence of the experience of participant life in creating of criminal perpetrators in the form of narratives or stories thus shaping a meaning.

Participant
The number of participants consisted of 10 nurses. They worked at a general hospital in Makassar, Indonesia. There were 6 male and 4 female nurses with the age interval of 27-42 years old. The participants' years of service in the hospital were averagely 5 years. However, there were 2 participants with 2 years of service. Those four participants had Diploma in Training Program in Nursing. Five participants had nursing degree. Meanwhile, one participant had a nursing master. The participants were selected by these following criteria: 1) the participants had ever treated criminal perpetrators, 2) the participants had worked in the hospital for at least a year, 3) the participants were willing to join the research voluntarily by signing up the informed consent, and 4) the participants were willing to be interviewed and recorded by a voice recorder during the research.

Data Collection
The data collection technique was done by a in-depth interview with a semi-structured interview guideline. The interview was followed at least twice with duration of 1-2 hours for each participant. Before interviewing, the researcher explained the time contract with the participants and explained the research procedures and ethics. The researcher used a voice recorder to record each participant's words and a field note to document the expression and non-verbal language of the participants.

Ethical Eligibility
This research has been granted ethical eligibility consent from Makassar Health Ministry Polytechnic, number 1178/KEPK-PTKMKS/XII/2019.

Data Analysis
The technique of data analysis was the Interpretative Phenomenological Analysis (IPA) proposed by Smith & Osborn (11). Data analysis with IPA techniques are one of data analysis method for phenomenology approaches that analyze in detail how participants perceive and meaning about their experience. Furthermore, IPA is widely used to analyze data collected through semi-structured interviews. The steps of IPA data analysis consisted of 1) reading and re-reading 2) initial noting, 3) developing emergent themes, 4) searching for connection across emergent themes, 5) moving the next cases, and 6) looking for patterns across cases. Before determining the theme, the researcher selecting the keywords, determining the categories and sub-theme, and constructing the themes. It was done starting from the first until the tenth participant so it could create a unity of the meanings that represented all participants' experiences.

RESULTS
The interpretation results of the participants' data were the meaning of each participant's statements. This research found six themes which werefeeling uncomfortable in working, experiencing emotional conflict, working in an unsafe environment, having difficulties in creating a therapeutic relationship, unnatural caring emergence, and having preference not to let police officers involved in providing health care for the patients.

Theme 1: Uncomfortable feeling
This uncomfortable feeling was caused by the nurses' alert feelings. It appeared because the nurses realized they were working with individuals that committed crimes and makes to not focus while working. It is supported by the participant's statement as follows.
"Absolutely I am afraid although the patient is powerless. But since the patient is a criminal, we need to be alert" (P5, Male) "If we keep alert while working, then automatically we will not focus on work because our attention is distracted" (P4, Female) Besides that, this uncomfortable feeling was also caused by the emergence of greater energy needed by the nurses during treating criminal patients. This complex administration procedure and the absence of the patient family made them feel burdened. It is supported by the participant's statement as follows. Providing nursing care for criminals raised a conflicting feeling felt by the nurses. They were annoyed because of the perpetrations committed by the patients. However, they also felt sorry for the conditions of patients who were powerless because of their diseases or being shots. It is supported by the participant's statement as follows.
"Honestly, in my heart, I am angry with patients that raped children. It is because I have children but on the other hand, I am also sorry for the patient's condition." (P5, Male) "Actually, from the humanism side, I am so sorry for the patients moreover when they are screaming because of feeling hurt. However, when I remember his crime, I get angry with the patient" (P2, Female) "I do not have the heart to do so but when I remember his crimes and it makes me emotional to the patients" (P10, Male)

Theme 3: Working in an unsafe environment
Working by treating the criminal perpetrators put the nurses in a dangerous situation. The nurses were worried about their safety. It is supported by the participant's statement as follows.
"The patient has been habituated with acts of violence and they would do anything to flee, including by injuring the nurses. Thus, I feel like being threatened" (P7, Female) "Surely, it is my job as a nurse to care for the patients. However, I should also be safe and prevent any dangerous thing that happened to me" (P1, Male) Several participants also stated that they did not want to be recognized by the criminals for the sake of their safety. It is supported by the participant's statement as follows.

"I always put on my mask so it covers my face and the patient cannot recognize me" (P2, Female)
"I do not want to be remembered by the patient because I am afraid if he leaves the hospital and he has bad intention to me. We never know what is inside someone's heart or mind" (P10, Male) An unsafe feeling of working is triggered by the hospital environment. The hospital environment has been not set to treat the criminals. It is supported by the participant's statement as follows.
"I am afraid because this room is still accessible by any patient, including criminals. Here, the room has been set up with special prison for criminals" (P4, Female) "There has not been any special room for criminals in this hospital. Thus, the patients are treated together with other patients although they are handcuffed" (P8, Male)

Theme 4: Having difficulties in creating a therapeutic relationship
The participants felt difficult to create a therapeutic relationship with the patients. The participants explained that it was difficult to develop trustworthiness between nurse and patient. It was because the participants felt that the patients usually manipulated the data. It is supported by the participant's statement as follows. This difficulty to create a therapeutic relationship was also caused by a negative assumption and stigma toward the criminal perpetrators that was not right. It is supported by the participant's statement as follows.
"They are criminals, they must be the bad and dangerous guys" (P5, Male) "They usually have tattoos. When they have tattoos, there should not be any communicable disease" (P6,

Female) "Many patients have tattoos. Just in case, I am afraid if they bring any communicable virus, such as HIV or hepatitis" (P10, Male)
There was a bad assumption or stigma that created gaps between patient-nurses. It is supported by the participant's statement as follows. Caring is the basic principle in nursing profession. However, it appeared unnaturally from the nurses when they noticed the patients were criminal perpetrators. The nurses still committed discrimination by altering the patients' care to other nurses, especially female nurses. They tended to alter their care for the patients to the male nurses. It is supported by the participant's statement as follows.

"So, when the patient is a criminal, I will call the male nurses" (P2, Female) "That is what happens here. When the patient is a criminal, the nurses should be male. If there are no male nurses who are at work, then the solution would be the female nurse" (P6, Female)
The participants also expressed that treating the criminals was done only because of the nurse's tasks and responsibilities. It is supported by the participant's statement as follows. The unnatural caring emergence was also caused by the emotional feeling of the participants for the patients. It is supported by the participant's statement as follows. The involvement of police officer who brought the patients in the nursing care process caused an uncomfortable feeling for the nurses. The participants said that the police officers sometimes were not cooperative with the nurses. It is supported by the participant's statement as follows.
"Some police officers did not allow any action for the patients, such as administering analgesics. They said it was to make them deterrent" (P10, Male) "Usually, the police officers instructed me. Thus, I, by perforce, followed the instruction although deep in my heart I did not want it" (P9, Male) "The police officer sometimes asked me. Thus, I had to ensure whether the instructions of the police officers were violating the regulation or not" (P3, Male) The participants also stated that they did not want police officers to get involved in treating the patients. It was due to their intimidating actions toward the participants. It is supported by the participant's statement as follows.
"Actually, we are not allowed to violate the regulation. However, there were pressures from the police officers" (P8, Male) "We expect to work without any intimidation from the police officers" (P7, Female) "Finally, I felt losing my freedom in working because there were pressures from the police officers" (P1, Male)

DISCUSSION
Treating the criminals was very complex for the nurses and it triggered conflict and dilemma for the nurses. The nurses said that their care given for the criminals were different when it was compared to other patients. Six themes about caring problem reveals from this study which were feeling uncomfortable in working, experiencing emotional conflict, working in an unsafe environment, having difficulties in creating a therapeutic relationship, unnatural caring emergence, and having preference not to let police officers involved in providing health care for the patients. The most influential factor was the health and emotional problem of the nurses. The security was assumed to be the most important factor in treating the patients with criminality record. Working under a general hospital environment that had not been set to treat criminals put nurses into a dangerous environment. It is in line with Walsh and Weiskoph that the nurses' experiences in caring for criminals are full of physical and emotional aggression risk potencies (12,13). It put the nurses in a risky working environment in terms of their personal safety. A hospital should provide a specific room that is completed by lockup so it would make the nurses safe and can carry their works (7). The absence of training provided to participants has made participants incompetent in treating the criminal perpetrators, so additional training for nurses would also be useful to improve the nurses' skills and confidence to work safely, to be able to identify and manage dangerous risks (14).
The emotional feeling of the nurses also influenced their nursing care service for the patients. The nurses told that treating criminals would trigger an emotional conflict of a contrasting feeling in them. Nurses experience conflicting feelings between pity and want to caring for patients but also anger to patients due to patient criminal deeds and it would influence their service practice and quality. It is in line with Crampton and Harris who state that treating criminals is full of emotion, dilemma, and effort. The nurses had difficulties in overcoming their anger toward the patients but were still asked to treat and compassionate for them (15,16).
The police officers who accompanied the patients also made the participants feel uncomfortable working. They felt all police officers were not cooperative with the nurses. They frequently intimidated the nurses. Police officers also intervene participants so they will disturb participants in work and have violated patient's privacy. It is in line with Junewicz, Wesikopf and Zust who state there is a challenge in caring for the criminals. It was the police who escorted the patients. The nurses were frustrated due to the police officers' involvement in the nursing process. Even, the police officers had been assumed to interrupt the nursing process, the patient resting time, to violate the patient's privacy, and even to commit ruthless action for the patients (13,17,18). The nurses carrying out the treatments for the criminals should develop a proper relationship with the police officers. They should prove their attitudes between the nurses and police officers could cooperate although they had different roles. Thus, the police officers could differ the authority differences between police officers and nurses, respect nurses, and support their processes. It would create authority and independence of the nurses and comfortability of the nurses in treating the patients (13).
An individual that works as a nurse does not only deal with treating the patients. However, they should also care for them sincerely (19)(20)(21). This research found that when the patients were criminal perpetrators, then the caring of the nurses would change and become unnatural. Besides that, such uncomfortable feelings in working, the manipulative attitude, the stigma, and the difficulties to create a nursepatient trust relationship would worsen the application of sincere caring principle by the nurses. It also made them have difficulties in creating appropriate nurse-patient therapeutic relationship.
Treating the criminals was not something easy. Especially when it must involve nursing care for the patients. This study showed that when treating criminals perpetrators, participant's caring would appear unnaturally. It is influenced because of the difficulty of participants to control their emotional feelings, and also because participants are difficult to caring for someone who has injured, raped, and killing others. The nurses needed efforts, struggles, and professionalism in defending emotional feelings. The patients should be aware that nursing care was an essential principle in the nursing profession. It should be applied sincerely and naturally by respecting the dignity and value of the patients. They should accept the patients completely, respect them, and provide service without any discrimination (22).
The nurses are also encouraged to foster an intimate relationship between the patient and the nurse based on their trust (23). The nurses must involve their sincere care, create a therapeutic relationship, and supportive conditions to recover the patients. It is to motivate and encourage patients to get fully recovered (7). By involving the sincere care and creating the expected therapeutic environment, it is expected to improve service practice and quality for the sake of the patients' recoveries. Therefore, it is important for the nurses to get involved and to reflect their caring practices in providing nursing treatments to reach the cure and reach the purpose of nursing.
The nurses found many experiences and challenges in providing nursing care for the criminals under the dangerous environment. The security and emotional feeling factors of the nurses become the greatest challenges. They make the nurses difficult to create a therapeutic relationship and lead to unnatural nursing care committed by the nurses. Therefore, it is important for the nurses to internalize and reflect sincere caring as the essential principles in the nursing profession. Thus, it can reach the objectives of nursing, service equality, and patient recovery.
Result of this research indicate the need a standardized procedure, facilities and work environment for nurses in treating the criminals to protect the nurse and ensure patient right fulfillment during the care. Moreover, the nurses are also required further training about treating criminal perpetrators, especially training to control their emotional feelings, improve the nurses' skills and confidence to work safely, and able to identify and manage dangerous risks.