Correctional health nurses practice in unique settings with unique challenges. Incarcerated individuals are entitled to quality, unbiased care; however, they live within a highly restricted environment and often have complex physiological and psychosocial conditions. Loss of freedom and privacy, combined with cramped and unfamiliar living quarters, can initiate or exacerbate these conditions, complicating care delivery. In addition, correctional nurses must balance their respect for patient privacy with the safety of guards and other prisoners. 

These are some of the factors that have likely contributed to the heightened attention to correctional health nurse liability. Claims against nurses in this specialty have increased in recent years, according to a 2026 report from NSO and CNA. The percentage of correctional facilities involved in closed claims rose from 4.4% in 2020 to 6.2% in 2025. Over the same time, the average total cost incurred for closed claims increased from $219,924 to $262,272. Areas at particular risk of liability include failure to treat, delayed urgent care, and failure to respond to mental health issues, such as the risk of suicide.

Fortunately, correctional health nurses can reduce their risk. This effort requires understanding key concepts of incarceration and healthcare delivery, the impact of documentation gaps on legal defense, and the nature of the correctional health practice environment. Once nurses have a firm grasp of these areas, they can take steps to protect themselves.

Incarceration concepts

An incarcerated person’s right to quality care is embedded in the U.S. Constitution: The Eighth Amendment forbids “cruel and unusual punishment.” As noted by the Legal Information Institute, 42 U.S. Code § 1983 allows U.S. citizens to sue any state and local government official who violates their constitutional or legal rights. Correctional health nurses are frequently government employees.

A common issue in correctional health liability is “deliberate indifference,” which in the context of healthcare refers to a person’s conscious disregard for a prisoner’s known medical condition. In the 1976 landmark case of Estelle v. Gamble, the U.S. Supreme Court noted that deliberate indifference violates the Eighth Amendment. 

Attorney Taylor D. Brewer writes that although the definition of deliberate indifference can vary by state, it generally requires proof that the defendant was aware of the plaintiff’s serious medical need, knew there was a substantial risk of harm if it was not addressed, but failed to act.

Incarcerated patients have privacy rights under HIPAA, although provisions related to correctional health settings exist, as outlined in 45 CFR 164.512. The provisions cover situations where disclosure to an administrator or correctional officer is permitted, such as when the patient’s health status could affect the health of others. For example, a patient who has a respiratory infection needs to wear a mask. Other situations include potential safety risks to others, including officers and other incarcerated people. In these cases, it is important only to share essential information. 

A common problem in correctional health is provider bias. Examples of bias include routinely believing patients to be untruthful and misinterpreting health-seeking behavior for attention-seeking behavior. These biases can lead to poor care, patient harm, and legal liability.

Vital role of documentation

Consider this scenario: A correctional health nurse knows her patient, who has been taking a prescribed antipsychotic medicine, is on a suicide watch. One day, the nurse does not administer the medication, and the patient subsequently dies by suicide. Unfortunately, the review of documentation in the electronic health record does not show why the nurse omitted the drug. There could have been valid reasons (e.g., patient refusal, a serious adverse effect), but without documentation, the nurse has little defense in court. 

This case illustrates the crucial role of documentation in mounting a legal defense. Adverse outcomes alone do not establish negligence. Rather, four elements must be present: the provider had a duty to care for the patient, the provider breached the standard of care, the breach caused the injury, and the patient suffered harm as a result. Proper documentation helps establish that the provider followed the standard of care. In addition, if a patient claims injury, but the record shows none occurred, the provider’s case is strengthened.

Good practices for proper documentation by nurses include basing entries on objective data (not subjective opinions); recording all assessments, administered drugs, and immunizations; detailing patient progress towards treatment goals; and making timely entries. Timestamped access, a hallmark of electronic health records, enables a clear view of who documented what and when. Nurses should document the rationale for situations such as treatment delays, deviations from standard treatment, and clinical decision-making.

Practice environment

Few nurses experience correctional health during school, so those entering the specialty require significant education about the role and its responsibilities. Too often, however, short staffing leads to short orientation. 

Once on the job, correctional health nurses have few nurse colleagues to work alongside. This, along with the nature of the incarceration setting with locked doors and limited access, can cause feelings of isolation and stress. Pressure from officers or administrators about how patients are managed can add to stress levels. In addition, nurses may be practicing in an aging facility with aging equipment while they care for a complex patient population. Finally, nurses may feel anxious about their personal safety.

Reducing liability

The following actions can help reduce a correctional health nurse’s liability risk. 

• Practice within your state’s scope of practice and follow the facility’s policies and procedures. Ensure that standard protocols and orders are current. Policies, procedures, standard protocols, and standard orders should be reviewed on a regular basis, usually at least annually. 
• Follow general nursing standards of care from the American Nurses Association. 
• Follow standards of care related to the correctional setting, such as those from the National Commission on Correctional Health Care, which has standards for jails, prisons, juvenile facilities, mental health services, and opioid treatment programs. It also has guidance for specific situations such as the medical treatment of substance use disorders and many position statements addressing specific situations such as breastfeeding, adolescent sleep hygiene, and the diagnosis and management of hepatitis C. The organization publishes a journal and offers education resources. 
• Be aware of potential biases that could cause you not to provide appropriate care (e.g., stereotyping those with substance use disorders as being untruthful about pain)(See sidebar).
• Provide education to patients at the appropriate education level and in the preferred language. Document education was provided, and the patient’s understanding.
• Ensure privacy. Follow HIPAA guidance related to correctional settings. For example, share patient information with guards only on a need-to-know basis (e.g., suicide risk, infectious disease precautions, physical accommodations, dietary restrictions). Avoid sharing why these things are needed, for example, diagnoses or specific conditions. 
• Maintain professional boundaries with incarcerated people and correctional officers. 
• Check that emergency equipment is available and in good working order. 
• Ensure that medications, especially controlled medications, are properly stored and that access is restricted to authorized personnel to reduce the risk of diversion.
• Ensure that patients at risk for suicide are closely monitored. 
• Document assessments and care. If the patient’s condition worsens, notify the appropriate provider and document this notification. Documentation should include your findings, the person contacted, the method of communication (e.g., phone, email), and the resulting plan of action. Escalate to the next level if the response is insufficient. 
• Engage in continuing education in key areas such as infection prevention, emergency response, substance use disorder, and suicide prevention. It may be helpful to become certified as a correctional health nurse through NCCHC. A useful education and networking resource is the American Correctional Nurses Association. 
• Maintain malpractice and professional liability insurance. 
• Advocate for patients and system change as needed. For example, ensure that older adults are screened for cognitive impairment and receive regular health assessments for sensory deficits and fall risk. This patient population may also be victims of elder abuse. 
• Remember that your first responsibility is to the patient, not to administrators of the facility.
• Protect your mental health. Correctional nursing can be a particularly stressful setting. Take steps to reduce stress, which could lead to errors as a result of psychological distress. Network with other nurses in the specialty.
• Above all, be proactive in taking steps to reduce your risk. This will also help patients receive better care.

Serving patients while
protecting oneself

All incarcerated patients deserve quality healthcare, yet caring for them can be challenging. Correctional health nurses can help these patients, who often have significant physiologic and psychosocial issues predating incarceration, receive the best possible care. At the same time, nurses can implement measures in this article to protect themselves from legal action. 

Avoiding cognitive bias

Incarcerated people are often victims of cognitive bias, which is the inherent tendency of people to interpret events and other people based on their own beliefs, perceptions, and experiences, which can lead to inaccurate conclusions. Cognitive bias can negatively affect patient care. For instance, it might cause a correctional health nurse to discount a patient’s pain, incorrectly attributing it to drug-seeking behavior rather than an undiagnosed medical condition.

In an article, Rollings-Mazza and Williams list 11 forms of cognitive bias. For example, confirmation bias refers to valuing information that supports our existing ideas and ignoring information that does not. Anchoring bias refers to the tendency to rely too much on the first information we receive, and the bandwagon effect occurs when we adopt behaviors or beliefs because we believe they are pervasive (“everybody’s doing it).

Among the tactics the authors provide for overcoming cognitive bias are:

• Be aware that biases are more likely to distort decision-making when you are rushed, multitasking, or tired;
• Play “devil’s advocate” with your own beliefs or suppositions; question yourself;
• Acknowledge the possibility that you might not be right; be aware of your own limitations; and
• Consider data from all positions, weighing them equally.

Refer to the article for the entire list.

Source: Rollings-Mazza P, Williams T. Beware the dangers of cognitive bias. CorrectCare. 2023;37(2):12-13.

This article does not constitute legal advice.

References

American Nurses Association. Nursing: Scope and Standards of Practice, 4th Ed. 2021.

Bieber C. Medical negligence: Legal definition & examples. Forbes. 2022.  https://www.forbes.com/advisor/legal/medical-malpractice/medical-negligence/

Brewer TD. The evolving test for deliberate indifference in correctional healthcare. 

Code of Federal Regulations. § 164.512 Uses and disclosures for which an authorization or opportunity to agree or object is not required. https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-E/section-164.512

Legal Dictionary. Estelle v. Gamble. 2019. https://legaldictionary.net/estelle-v-gamble/

Moran Reeves & Conn PC. 2024. https://moranreevesconn.com/news/the-evolving-test-for-deliberate-indifference-in-correctional-healthcare/

CNA, NSO. Nurse Professional Liability Claim Report, 5th Ed. 2026.

Legal Information Institute. 42 U.S. Code § 1983 – Civil action for deprivation of rights. n.d. https://www.law.cornell.edu/uscode/text/42/1983

Legal Information Institute. § 164.512 – Uses and disclosures for which an authorization or opportunity to agree or object is not required. n.d. https://www.law.cornell.edu/cfr/text/45/164.512

National Commission on Correctional Health Care. Care for aging patients in the correctional setting. 2024. https://ncchc.org/position-statements/care-for-aging-patients-in-the-correctional-setting/

National Commission on Correctional Health Care. Jail guidelines for the medical treatment of substance use disorders. 2025. https://www.ncchc.org/wp-content/uploads/2025-MAT-Guidelines-for-Substance-Use-Disorders-3-6-25.pdf

National Commission on Correctional Health Care. Professional certification. n.d. https://ncchc.org/professional-certification/

National Commission on Correctional Health Care. Standards: a framework for quality. n.d. https://ncchc.org/standards/

Rollings-Mazza P, Williams T. Beware the dangers of cognitive bias. CorrectCare. 2023;37(2):12-13.

Disclaimer: The information offered within this article reflects general principles only and does not constitute legal advice by Nurses Service Organization (NSO) or establish appropriate or acceptable standards of professional conduct. Readers should consult with an attorney if they have specific concerns. Neither Affinity Insurance Services, Inc. nor NSO assumes any liability for how this information is applied in practice or for the accuracy of this information. Please note that Internet hyperlinks cited herein are active as of the date of publication but may be subject to change or discontinuation.

This risk management information was provided by Nurses Service Organization (NSO), the nation’s largest provider of nurses’ professional liability insurance coverage for over 550,000 nurses since 1976. The individual professional liability insurance policy administered through NSO is underwritten by American Casualty Company of Reading, Pennsylvania, a CNA company. Reproduction without permission of the publisher is prohibited. For questions, send an e-mail to service@nso.com or call 1-800-247-1500. www.nso.com.

Reprinted with permission from Nurses
Service Organization (NSO).