CLINICAL SCHOLARSHIPSpirituality as a Predictive Factor fo.docx

CLINICAL SCHOLARSHIP
Spirituality as a Predictive Factor for Signing an Organ Donor
Card
Anat Peles Bortz, RN, PhD1, Tamar Ashkenazi, RN, PhD2, &
Semyon Melnikov, RN, PhD1
1 Lecturer, Department of Nursing, Tel Aviv University, Tel
Aviv, Israel
2 Director, National Organ Donation and Transplantation
Center, Ministry of Health, Tel Aviv, Israel
Key words
Spirituality, purpose in life, attitudes toward
organ donation, organ donor card
Correspondence
Dr. Semyon Melnikov, Department of Nursing,
Tel Aviv University, PO Box 39040, Ramat Aviv
69978, Tel Aviv, Israel.
E-mail: [email protected]
Accepted: August 10, 2014
doi: 10.1111/jnu.12107
Abstract
Purpose: To examine differences in spirituality, purpose in life,

and attitudes
toward organ donation between people who signed and those
who did not
sign an organ donor card.
Design: A descriptive cross-sectional survey conducted in Israel
with a sample
of 312 respondents from the general population, of whom 220
(70.5%) signed
an organ donor card. Data were collected during April–June
2013.
Methods: Participants completed a paper questionnaire and a
Web-based
questionnaire consisting of four sections: spiritual health,
purpose in life, at-
titudes toward organ donation, and social-demographic
questions. Descriptive
statistics, t test, chi-square test, and a logistic regression
analysis were per-
formed.
Findings: Differences in mean scores between respondents who
signed an
organ donor card and those who did not were indicated in
transcendental
spirituality (p < .01), purpose in life (p < .05), and attitudes
toward organ
donation (p < .01). No statistically significant difference was
found between
the groups in the overall spirituality mean score. The spiritual
transcendental
dimension, individual’s purpose in life, and attitudes toward
organ donation
explained 34.3% of the variance of signing an organ donor card.
Conclusions: Signing an organ donor card was found to be
correlated with
high purpose in life, positive attitudes toward organ donation,
and low level of

transcendental spirituality.
Clinical Relevance: Nurses should assess the patient’s spiritual
needs in or-
der to construct appropriate programs for promoting signing an
organ donor
card. Nurses who signed an organ donor card should be
encouraged to share
this information with their patients.
Organ donation in the Western world is entirely depen-
dent on the willingness of people to donate organs af-
ter their death. In Israel, organ donation from deceased
donors is made following the determination of donor
brain death, after which the family is required to make
a decision about whether to donate the deceased fam-
ily member’s organs. When family members are aware
of the decedent’s wish to donate organs, they will usu-
ally give consent to donate (Haddow, 2004; Merchant
et al., 2008; Rassin, Lowenthal, & Silner, 2005). When
the family isn’t aware of the decedent’s wishes, they usu-
ally will not donate (Burroughs, Hong, Kappel, & Freed-
man, 1998; Cleiren & Van Zoelen, 2002; Sque, Long, &
Payne, 2005). Signing a donor card, therefore, is a means
of expressing a desire to donate organs posthumously.
Among the variables that can affect signing or the
avoidance of signing an organ donor card (SODC)
are the individual’s religious beliefs and attitudes to-
ward organ donation and transplantation (Gauher et al.,
2013; Karim, Jandu, & Sharif, 2013; Rodrigue et al.,
2004). Religious beliefs constitute one of the barri-
ers to SODC (Wakefield, Watts, Homewood, Meiser, &
Journal of Nursing Scholarship, 2015; 47:1, 25–33. 25
C© 2014 Sigma Theta Tau International

Spirituality and Organ Donor Card Peles Bortz et al.
Siminoff, 2010), although all the monotheistic religions
(Christianity, Islam, Judaism) accept organ donation. Re-
ligion, viewed in a cultural context, encompasses sev-
eral dimensions, one of which is a person’s spirituality
(Hill & Pargament, 2003). Spirituality as a construct is de-
fined as the broad personal search for meaning, purpose,
and value in life (Baumsteiger, Chenneville, & McGuire,
2013; Ellor & McGregor, 2011). The sense of purpose in
life was found to be a key mechanism linking the im-
portance of volunteer activity to a person’s well-being
(Thoits, 2012). Since SODC is a voluntary act that repre-
sents the humanitarian ideal of helping unknown others,
it can be assumed that perceived purpose in life will be
more prominent among people who signed a donor card.
The purpose of the current study, therefore, is to exam-
ine the contribution of spirituality, purpose in life, and
attitudes toward donation to SODC.
Individuals’ Spirituality, Purpose in Life,
and Attitudes Toward Organ Donation
and Signing an Organ Donor Card
A significant gap exists worldwide between the need
for donor organs for people suffering from terminal or-
gan insufficiency and organ supply. By way of example,
117,000 patients in the United States (US) and 1,075 pa-
tients in Israel were registered on the transplant wait-
ing lists as of January 2014 (Ministry of Health Israel,
2014b). In Israel, approximately 14% of the population
has signed an organ donor card (Ministry of Health Israel,
2014a), while the proportion of the population on the

Organ Donor Register in the United Kingdom was 30%
in 2012 (Deedat, Kenten, & Morgan, 2013) and 45% of
adult (� 18 years of age) Americans in 2013 (Donate Life
America, 2013).
Two basic legal systems exist for the procurement of
postmortem organs for transplantation that respect the
decision of the deceased person. These systems are usu-
ally classified as opt-in and opt-out, with the basic dif-
ference between them the process that must be followed
in cases when the deceased did not express his or her
wish regarding organ donation before his or her death. In
the opt-in system, the default is that no removal of the
decedent’s organs will be carried out, while in the opt-
out system, organ removal is possible even if the wishes
of the deceased are unknown (den Hartogh, 2012). In
Israel the system is opt-in, namely, family consent is al-
ways required for deceased organ donation. In such a sit-
uation, when the wish of the deceased to donate his or
her organs posthumously is known, the family usually
gives the consent for organ donation (Sque, Long, Payne,
& Allardyce, 2008), but when the will of the deceased
is unknown, the family usually will not donate (Cleiren
& Van Zoelen, 2002; Sque et al., 2005). This underscores
the importance of the organ donor card as a guarantee for
donation consent and as a means to increase the amount
of available organs.
Morgan, Harrison, Afifi, Long, and Stephenson (2008)
cited previous studies identifying cognitive and noncogni-
tive variables that impact approval or avoidance of SODC.
Between the cognitive-based variables are attitudes to-
ward and knowledge about organ donation. Amongst the
noncognitive variables are disgust (“ick” factor) and the
potentiality of causing bad luck to the person who signs

an organ donor card (jinx factor).
Another significant factor affecting willingness to sign
an organ donor card is an individual’s religious faith.
Conesa et al. (2003) showed that religious motives were
among the reasons given against organ donation in a
Catholic population sample. They concluded that religios-
ity was an excuse to explain respondents’ negative atti-
tude toward organ donation, while the Catholic Church
is in favor of organ donation and transplantation (Conesa
et al., 2003). The question arises, therefore, as to whether
the term religiosity accurately reflects the explanation for
the avoidance to sign an organ donor card. Today, vari-
ous researchers are exploring the nature of the relation-
ship between religion and spirituality (Paloutzian & Park,
2013; Worthington, Hook, Davis, & McDaniel, 2011).
Expressions of spirituality span a wide range, from
the view that spirituality is one of the components
of religion (Hill & Pargament, 2003), through the use
of the terms religion and spirituality as synonymous
(Gorsuch & Walker, 2006), to the view that they are two
distinct structures with overlapping features, according
to Zinnbauer, Pargament, and Scott (as cited by Fisher,
2009; Kevern, 2012). Fisher (2009) described spiritual
health as a “dynamic state of being, shown by the extent
to which people live in harmony within relationships.”
Accordingly, the individual’s spiritual well-being consists
of four domains: personal, communal, environmental,
and transcendental. The personal domain is defined as
personal space where one relates to oneself with regard
to meaning, purpose, and values in life. The communal
domain represents an interpersonal space shown by the
quality and depth of interpersonal relationships between
self and others, relating to morality, culture, and religion.
The environmental domain is defined as something be-

yond care and nurture of the physical and biological self,
namely, a sense of awe and wonder. The transcendental
domain is defined as the relationships of self with some-
thing or someone beyond the human level (cosmic force,
transcendent reality, or God). This involves faith, adora-
tion, and worship of the mystery of the reality (Fisher,
1998). In the context of organ donation, a spiritual
26 Journal of Nursing Scholarship, 2015; 47:1, 25–33.
Peles Bortz et al. Spirituality and Organ Donor Card
connection with the transplant recipient, a spiritual con-
cern about removing organs, and attitudes toward organ
donation significantly predicted willingness to become
an organ donor for respondents in a study conducted
in China and the US (Bresnahan, Guan, Smith, Wang,
& Edmundson, 2010), and a study conducted in Korea,
Japan, and the US (Bresnahan, Lee, Smith, Shearman, &
Yoo, 2007).
According to Litwinczuk and Groh (2007), a corre-
lation was found between spirituality and the sense
of purpose that the individual gives to his or her life.
Such purpose refers to the intention, a function to be
fulfilled, or goals to be achieved (Reker, Peacock, &
Wong, 1987). A person will be seen as having a purpose
in life when he or she pursues goals and has a sense of
direction, feels there is meaning to present and past life,
holds beliefs that give life purpose, and has aims and
objectives for living (Ryff, 1989). An act of helping other
people intensifies the meaning and purpose that people
give to their lives (Son & Wilson, 2012; Thoits, 2012).

The most commonly identified reason for becoming an
organ donor was an altruistic motivation to help others
(Newton, 2011). For example, purpose in life scores were
found to be overwhelmingly high among living liver and
kidney donors (LaPointe Rudow, Iacoviello, & Charney,
2014), although the authors found it difficult to conclude
whether the sense of purpose in life was inspired by
the act of donation, or individuals with a high sense of
purpose in life were more apt to choose donation.
Despite the fact that organ donation has been in use
for decades, and many people understand its importance,
the percentages of those who sign an organ donor card
are still low. Many known factors contribute to the de-
cision whether to sign an organ donor card, but it seems
that some are still unknown. It is important, therefore,
to examine other factors that might affect willingness to
sign an organ donor card, such as spirituality, the mean-
ing that one gives to life, and attitude toward organ do-
nation and transplantation. Based on preceding studies,
we examined the following hypotheses:
� There are differences in spirituality, purpose in life, and
attitudes toward organ donation between people who
signed or did not sign an organ donor card.
� SODC is associated with spirituality, purpose in life,
and attitudes toward organ donation.
Methods
Study Design and Sample
The study was conducted using a descriptive cross-
sectional survey. A convenience sample from the gen-
eral population included 312 respondents who met the

following three eligibility criteria: age 18 years or older,
Internet access, and able to read and understand He-
brew. The required sample size was obtained by means
of the WINPEPI COMPARE2 program (USD Inc., Stone
Mountain, GA, USA), used to determine power and sam-
ple size for comparisons of two groups in cross-sectional
designs (Abramson, 2011). Power calculations based on
analysis of 43 questionnaires collected during the pilot
study showed a difference of 0.299 points between the
means of the “purpose in life” answer by respondents
who signed or did not sign an organ donor card. To de-
termine whether the difference of 0.299 between the two
groups is significant at the 5% significance level with a
power of 80% (Cohen, 1988), the WINPEPI COMPARE2
computer program calculated a required sample size of
297 respondents.
Procedure
The study was approved by the Tel Aviv Univer-
sity Ethics Committee. The 43 respondents in the pilot
study, recruited from a pool of researchers by a snowball
method, completed a hard copy of the questionnaire in
order to calculate the needed study sample and evaluate
the clarity of the questions. Only one item was changed,
from a negative to a positive wording. A Web-based ques-
tionnaire was then created and was uploaded in various
Israeli Hebrew-speaking Web forums, such as research,
social action, women’s health. The questionnaire began
with an explanation of the study aim, the nature of the
respondent’s contribution to the research, and the man-
ner in which the information would be used. The re-
spondents were told that their participation in the study
was entirely voluntary and that all information would re-
main confidential. Their agreement to answer the ques-

tions was viewed as consent to participate in the study.
The questionnaire yielded 312 respondents (269 respon-
dents from Web-based and 43 respondents from paper-
based questionnaires), after removing duplications and
questionnaries with missing data. The survey took 15 to
20 min to complete. Data were collected during April–
June 2013.
Measures
Respondents completed questionnaires regarding their
spirituality, purpose in life, attitudes toward organ do-
nation, and demographic characteristics. Spirituality was
measured by the Spiritual Health and Life-Orientation
Measure (SHALOM) developed by Fisher (2009). The
overall questionnaire includes 20 items grouped in four
dimensions: personal, transcendental, environmental,
and communal. Each dimension includes 5 items graded
on a 5-point scale (5 = very high, 1 = very low), indicating
how each item reflects the respondent’s experience most
of the time. The questionnaire was back-translated, and
Cronbach’s coefficient α values for the translated version
in the current study of personal, transcendental, environ-
mental, and communal domains were .80, .93, .85, and
.80, respectively, and .89 for all items together, indicating
high internal consistency of the scale and of each domain.
Purpose in life was assessed using a 14-item measure

derived from Ryff and Keyes’s scales of psychological
well-being (1995), graded on a 5-point scale (5 = strongly
agree, 1 = strongly disagree). Higher scores indicated greater
purpose in life and a greater sense of direction; hav-
ing meaning to present and past life; and having beliefs
that give life purpose. Back-translating the questionnaire
showed that Cronbach’s coefficient α for the translated
version in the current study was .83, indicating a high
level of internal consistency.
Attitudes toward organ donation were measured by
the Organ Donation Attitude Scale (ODAS) developed by
Rumsey, Hurford, and Cole (2003). The original ques-
tionnaire included 15 items after factor analysis, and par-
ticipants responded to each ODAS statement on a 4-point
scale (4 = strongly agree, 1 = strongly disagree). One item in
the questionnaire was adapted to the Israeli organ dona-
tion policy and included in the demographic characteris-
tics (“I signed an organ donor card” instead of “I signed
an organ donor card on the back of my driver’s license”),
as it was an independent variable. Back-translating the
questionnaire showed that Cronbach’s coefficient α of the
14 statements for the translated version in the current
study was .87, indicating a high level of internal consis-
tency. After back-translating, face validity for the three
questionnaires was attained.
Demographic characteristics included respondents’ age,
gender, level of education, level of religiosity, acquain-
tance with someone who signed an organ donor card,
and acquaintance with the activities of the Israel Trans-
plant Center (ITC).
Data Analysis
Data were analyzed using the IBM R© SPSS R© English

version 19 software (SPSS Inc., Chicago, IL, USA). Means
and percentages were used for the descriptive statistics of
the social-demographic characteristics and the main re-
search variables. A chi-square test and t test for assessing
the differences between the two groups (signing or not
signing an organ donor card) were used. A logistic regres-
sion was performed to determine how much variance in
SODC could be accounted for by spirituality, purpose in
life, and attitudes toward organ donation.
Results
Social-Demographic Characteristics and
Differences Between Respondents Who Signed
or Did Not Sign an Organ Donor Card
The majority of the respondents (75.9%) were women,
Israeli born (87.2%), and 19 to 84 years of age (mean =
44.15, SD = 15.12). Most respondents (61.2%) had an
academic degree. The mean level of religiosity on a 10-
point scale (1 = not religious, 10 = very religious) was 2.48
(SD = 2.00). Most of the respondents had signed an or-
gan donor card (n = 220, 70.5%). Social-demographic
and general information regarding both groups’ famil-
iarity with the issue of organ donation are presented in
Table 1. The percentage of SODC was higher among
respondents who considered themselves as secular
(55.3%), compared to the percentage of SODC among the
nonsecular (34.8%; p < .01). Respondents who were ac-
quainted with someone who signed an organ donor card
had significantly higher rates of SODC (93.1%) compared
to respondents who had no such acquaintance (58.9%;
p < .001). Respondents who were aware of the activities
of the ITC (74.1%) had significantly higher rates of SODC
than those who were unaware of the activities (57.6%;
p < .01).

Group Differences in Spirituality, Purpose in
Life, and Attitudes Toward Organ Donation
The mean scores of the main study variables for all
participants were above moderate, meaning that the re-
spondents tend to consider themselves as being spiritual,
having some kind of purpose in life, and positive atti-
tudes toward organ donation (Table 2). No statistically
significant differences were found between the groups in
mean total spirituality (t310 = -1.60, p = .11). There was,
however, a statistically significant difference between
the groups in the transcendental spirituality dimension
(t136.94 = -4.12, p < .01). Transcendental spirituality
was higher among respondents who did not sign an
organ donor card than among respondents who did sign
(n = 91, mean = 2.42, SD = 1.27; n = 219, mean =
1.81, SD = 0.98, respectively). Respondents who had
signed an organ donor card reported higher purpose in
life than those in the other group (n = 219, mean = 4.79,
SD = 0.69; n = 91, mean = 4.60, SD = 0.75, respectively;
t308 = 2.22, p < .05). Lastly, a statistically significant
difference was found in attitudes toward organ donation
between respondents who signed and those who did
not sign an organ donor card (t115.9 = 7.91, p < .01).
Attitudes toward organ donation were more positive
among respondents who signed a card as compared to
Table 1. Social-Demographic and General Information

Regarding the Familiarity of Signatories and Nonsignatories
With the Issue of Organ Donation
Signed an organ donor card Didn’t sign an organ donor card pa
Mean years of age (SD) 44.50 (14.74) 43.31 (16.05) .53b
Gender (%) .09c
Female 78.5% 69.6%
Male 21.5% 30.4%
Education (%) .59c
High school and less 10.9% 13.0%
Post–high school 89.1% 87.0%
Level of religiosity,
mean (SD)
2.11 (1.65) 3.36 (2.47) .00b
Acquaintance with someone who signed
an organ donor card (%)
Yes 93.1% 58.9% .000c
No 6.9% 41.1%
Acquaintance with the
activities of ITC (%)

.004c
Yes 74.1% 57.6%
No 25.9% 42.4%
Note: ITC = Israel Transplant Center. ap value for differences
between the groups. bt-test. cChi-square test.
Table 2. Means and Differences Between the Groups (t Test)
Variable Entire sample Signed an organ donor card Didn’t sign
an organ donor card t
Mean (SD) Mean (SD) Mean (SD)
Total spirituality 3.34 (0.57) 3.30 (0.57) 3.42 (0.57) −1.60
Personal 3.92 (0.63) 3.94 (0.59) 3.88 (0.72) 0.86
Communal 3.99 (0.58) 4.00 (0.59) 3.96 (0.58) 0.57
Environmental 3.43 (0.86) 3.44 (0.89) 3.41 (0.79) 0.31
Transcendental 1.99 (1.11) 1.81 (0.98) 2.42 (1.27) −4.12∗ ∗
Purpose in life 4.74 (0.71) 4.79 (0.69) 4.60 (0.75) 2.22∗
Attitudes toward organ donation 3.53 (0.46) 3.68 (0.31) 3.19
(0.56) 7.92∗ ∗
Note: ∗ p < .05; ∗ ∗ p < .01.
respondents who did not (n = 220, mean = 3.68, SD =
0.31; n = 92, mean = 3.20, SD = 0.56, respectively).
Explanation of Signing an Organ Donor Card

Transcendental spirituality was found to differ statisti-
cally between respondents who signed an organ donor
card and those who did not. In order to measure the pre-
dictive contribution of transcendental spirituality, pur-
pose in life, and attitudes toward organ donation to
SODC, a logistic regression analysis was performed. The
analysis demonstrated that transcendental spirituality,
purpose in life, and attitudes toward organ donation ex-
plained 34.3% of the variance of SODC (p < .001), while
attitudes toward organ donation and the transcenden-
tal dimension of spirituality explained SODC significantly
(Table 3). Attitudes toward organ donation made the
largest contribution in the model.
Discussion
The hypotheses of the current study were that there are
differences in spirituality, purpose in life, and attitudes to-
ward organ donation between people who signed or did
not sign an organ donor card and that SODC is associated
with spirituality, purpose in life, and attitudes toward or-
gan donation.
The main study results showed that respondents who
signed an organ donor card had more purpose in life,
a more positive attitude toward organ donation, and a
lower level of mean transcendental spirituality than the
respondents who did not sign. The importance of the
findings is that they deepen the understanding of factors
affecting the decision to sign or not to sign an organ
donor card.
Various approaches to the relationship between reli-
gion or spiritual beliefs and organ donation have been
shown (Bresnahan et al., 2010; Lam & McCullough,

Table 3. Predictors of Signing an Organ Donor Card (n = 309;
Logistic Regression Analysis)
Predictors B SE Wald (df = 1) p Odds ratio 95.0% confidence
interval
Attitudes toward organ donation 2.61 0.39 45.88 .000 13.58
6.38–28.88
Transcendental spirituality −0.31 0.14 5.01 .025 0.74 0.56–0.96
Purpose in life 0.39 0.21 3.60 .058 1.48 0.99–2.22
Constant −9.43 1.72 30.08 .000 0.00
2000; Morgan et al., 2008; Rachmani, Mizrahi, &
Agabaria, 2000). Spirituality and attitudes toward organ
donation significantly predicted willingness to sign an
organ donor card among respondents in both China and
the US, while religiosity did not (Bresnahan et al., 2010).
By contrast, religion was found to be the most significant
factor in the decision to donate organs or not among
first-degree relatives of decedents in Israeli hospitals
(Ashkenazi & Klein, 2012). The authors found that a
direct association exists between the depth of religious
belief, adherence to accepted cultural and traditional
norms, and avoidance to donate organs. Notably, in
some studies, the terms religion, spirituality, and cultural
values are used interchangeably. Furthermore, each

study defined spirituality differently and used a variety of
measurement scales. It seems, therefore, that this field is
still undefined and requires further clarification through
research and practice.
SODC may reflect and fulfill part of purpose in life
through the wish to donate organs after one’s death. As-
suming that there can be a reciprocal effect, people might
have a sense of purpose in life because they signed an or-
gan donor card. This kind of relationship was mentioned
by LaPointe et al. (2014) regarding living organ donation.
In a similar vein, the need to give purpose to life may be
explained by findings that volunteers in medical settings
experienced a high degree of life meaningfulness (Schnell
& Hoof, 2012) and that social integration and the quality
of personal relationships were associated with a higher
purpose in life (Pinquart, 2002).
The variable that contributed most to the explana-
tion of SODC in the present study was the individ-
ual’s attitudes toward organ donation. Previously it was
found that subjects with a strong positive attitude toward
posthumous organ donation were especially willing to
sign an organ donor card (Wakefield et al., 2010). Yet,
positive attitudes are not always translated into behavior
(Wallace, Paulson, Lord, & Bond, 2005), and positive at-
titudes toward organ donation alone are not enough for
a behavioral commitment to sign an organ donor card
(Ashkenazi, Guttman, & Hornik, 2005; Cohen & Hoffner,
2012). It seems that thinking about the possibility of do-
nating organs after one’s own death evokes conflicting
emotional feelings that may lead to barriers and inhibi-
tions regarding SODC. In addition, noncognitive reasons
for avoiding SODC and low self-benefits might restrict the

influence of positive attitudes in the decision to sign an
organ donor card (Morgan et al., 2008).
Another variable in this study that might have caused
an avoidance to sign an organ donor card could be the
familiarity with the activity of the ITC. Surprisingly, the
current study results showed that 57.6% of the respon-
dents who did not sign an organ donor card were ac-
quainted with the activities of the ITC. This result might
point to embedded causes for not signing a donor card,
such as cultural beliefs, religion, fear of one’s own death,
and public mistrust of the medical system. It is important
to assure the public, therefore, that the information and
the processes of organ allocation and donation are trans-
parent, and that organs for transplantation are provided
according to accredited supervised regulation.
The finding that respondents who were acquainted
with someone who had signed an organ donor card had
significantly higher rates of SODC, compared to respon-
dents who had no such acquaintance, might be explained
by social learning theory, whose principles are based
on imitation and modeling (Bandura, 1977). It can also
be explained by research exploring reasons for donating
blood among blood donors (Sojka & Sojka, 2008), which
found that a direct influence from friends/relatives and
media appeal were commonly reported. Furthermore, it
is logical to assume that people with similar cultural, de-
mographics, and behavioral characteristics will tend to
follow shared norms. Thus, a person who signed an or-
gan donor card is likely to be acquainted with someone
who also signed.
The present study focused on spirituality and purpose
in life as affecting willingness to SODC—issues that are
relevant in countries with the (opt-in) law, as in Israel,

where signing is voluntary for donating organs. How-
ever, it is important to emphasize that there are some
of other important factors affecting SODC, since sign-
ing itself evokes concerns and fears of various types,
which may be influenced by cultural or religious, social,
and political factors. Further, it is reasonable to assume
that there are people with a high level of transcendental
spirituality and low purpose in life who sign an organ
donor card.
Study Limitations
One limitation is that the sample population included
only Jews, which excluded the sizable Arab minority
population in Israel due to the likelihood that a different
culture and religion would affect the study results.
The second limitation is that the study was conducted
using an online survey, which has a number of built-in
limitations, including sampling and access issues. One
sampling issue might be that a significant population
of respondents with little computer-related experience
are unable to answer the questionnaire survey in the
Internet and Web format (Anderson, 1996). Moreover,
access to certain populations might be limited, as some
people view participating in an online survey as an
invasion of privacy (Wright, 2005). Nevertheless, the
level of truthfulness of respondent reporting in online
research is considered high, as Web administration raises

the level of reporting sensitive information, and the
accuracy of the reporting, relative to other modes of
data collection (Kreuter, Presser, & Tourangeau, 2008).
Lastly, 70% of the respondents in the study had signed
an organ donor card, while the number of people in the
adult Israeli population who have signed a donor card
is approximately 14%, which may reflect the a priori
positive attitudes of most respondents toward organ do-
nation and SODC. It might also assume that participants
who have not signed an organ donor card or those with
less positive attitudes avoided participating in the study.
Clinical Implications
The ITC, which is one of the departments of the Israeli
Ministry of Health, is led and managed by nurses. Like-
wise, nurses have a leading role in public education in the
community, such as in education for a healthy lifestyle
and for immunization.
Therefore, they can be more active and take more ini-
tiative in improving the population’s attitudes to organ
donation and to SODC. Community nurses can lead pub-
lic symposiums adapted by age, culture, and language.
Nurses can incorporate in their public symposiums and
instruction religious and spiritual leaders, intellectuals,
personal stories, and experiences of people who donated
an organ of their loved one. These actions may integrate
spirituality in the process and potentially raise positive
attitudes toward SODC. Additionally, nurses can be more
active in all media forms in increasing positive attitudes
among media consumers.
Regarding a person’s transcendental spirituality, com-
munity nurses who lead health education campaigns are
also in a position to assess the components of a client’s

spirituality, and construct programs that accord with the
spiritual needs aiming for promoting SODC. Special train-
ing to heighten these nurses’ familiarity with spiritual as-
sessment and needs might be directed to elevating the act
of organ donation card signings.
In as much as an acquaintanceship with someone who
signed an organ donor card is associated with SODC, it
is important to encourage nurses who signed an organ
donor card to demonstrate this and explain the long-
range benefits to their clients. Proposed strategies are
placing posters prominently on the nurse’s desk with
the nurse’s name and the phrase “I also signed an or-
gan donor card.” Moreover, as an acquaintance with
the activities of the ITC is connected to SODC, among
the actions we would recommend to the ITC is to pro-
vide the community nurses with the information about
the ITC activities. Subsequently, the nurses will give lec-
tures about the ITC activities to the clients.
Clinical Resources
� Donate Life America: http://donatelife.net/2013-
national-donor-designation-report-card-released/
� European Society for Organ Transplantation:
http://www.esot.org/#
� World Health Organization: http://www.who.int/
topics/transplantation/en/
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permission.
CLINICAL SCHOLARSHIP
Health Education Needs of Incarcerated Women

Shirley Dinkel, PhD, APRN, BC1 & Katie Schmidt, BSN, RN2
1 Associate Professor, School of Nursing, Washburn University,
Topeka, KS, USA
2 Director of Nursing, Topeka Corrections Facility, Topeka, KS,
USA
Key words
Incarcerated women, health education, prison
nursing, naturalistic design, qualitative nursing
Correspondence
Dr. Shirley Dinkel, School of Nursing, Washburn
University, 1700 SW College Ave., Topeka, KS
66611. E-mail: [email protected]
Accepted: February 3, 2014
doi: 10.1111/jnu.12079
Abstract
Purpose: This study identifies the healthcare education needs of
incarcerated
women in a state corrections facility.
Methods: This was a naturalistic qualitative study. Focus groups
included two
groups of adult women incarcerated in a state corrections
facility. One group
consisted of women housed in maximum security, and one group
consisted
of women housed in medium security. Data were analyzed using
a constant
comparison approach.

Findings: Three guiding questions provided the foundation for
the identified
themes. Themes included six healthcare education topics
important to incar-
cerated women and three related to health education strategies
best suited for
incarcerated women.
Conclusions: Trust, respect and empowerment are key concepts
in educating
incarcerated women about their personal health and health of
their families.
Clinical Relevance: With over 200,000 women incarcerated in
the United
States today, creating policies and practices that focus on the
healthcare edu-
cation needs of women that are woman focused may enhance
knowledge and
skills and may ultimately lead to reduced recidivism.
Over 200,000 women are currently imprisoned in the
United States, a number that has grown more than 800%
over the past three decades (Institute on Women & Crim-
inal Justice, 2009). Because the majority of prisoners are
male, prison programs often focus on issues faced by male
prisoners and overlook those faced by female prisoners
(Bissonnette, n.d; Stolnik, 2011). As the population of in-
carcerated females continues to increase at a rate nearly
twice that of males (Stolnik, 2011), health-related pro-
grams, educational opportunities, and initiatives focus-
ing on the specific needs of female inmates are becoming
more and more essential.
Incarcerated women often have a history of sub-
stance abuse; physical, sexual, and emotional trauma
(Bissonnette, n.d.); and limited access to healthcare ser-
vices (Palmer, 2007). The World Health Organization

has identified this trend globally, as research conducted
in the United Kingdom (Palmer, 2007) revealed simi-
lar conclusions. Because of intense, pre-incarceration liv-
ing situations, women often neglect their health while at
liberty. When they enter prison, they make great de-
mands on corrections health services (Yeager, 2012).
The limited research conducted on incarcerated females
throughout the United States consistently identifies the
intense physical and mental health needs of both the
newly and long-term incarcerated woman, including care
of chronic health conditions (Binswanger, Mueller, Clark,
& Cropsey, 2011).
A need for a radical increase in specific health-related
educational opportunities for the incarcerated female has
emerged. Women entering prison are more likely to re-
quire healthcare education to help them build a self-care
skill set to better prepare them for release. This skill set
may ultimately lead to reduced recidivism (Robertson-
James & Nunez, 2012; Zaitzow, 2010). Hatton and Fisher
(2011) stress the importance of using participatory meth-
ods to examine and educate this high-risk population.
The purpose of this qualitative study, therefore, was to
understand the health education needs of female inmates
in a state correctional facility.
Health Education Needs of Incarcerated Women Dinkel &
Schmidt
Methods

A qualitative, naturalist design was used for this
investigation. Two focus groups were conducted at a Mid-
western, state correctional facility for women. The facil-
ity houses three groups of women: minimum-, medium-,
and maximum-security inmates. Because focus groups
were conducted within the correctional facility, inmates
provided unique insight into their lives within prison
walls. Their responses to guiding questions were al-
lowed to unfold and guided the development of emergent
themes.
Recruitment and Informed Consent Procedure
Approval was obtained from the university institu-
tional review board (IRB) and the state Department of
Corrections (DOC) IRB. One inmate was chosen by the
DOC to serve on the university IRB as required. The chair
of the university IRB met with the inmate at the correc-
tional facility, provided IRB training, and reviewed each
section of the proposal. The inmate granted her approval
of the proposal.
Two focus groups were conducted to assess the health-
care educational needs of women incarcerated at this fa-
cility. The Director of Nursing at the prison posted par-
ticipation information in public areas. Participants were
selected from inmates who indicated an interest in the
project. Final selections were made by the prison Direc-
tor of Nursing to represent diversity in race or ethnicity,
age, and educational accomplishments. All participating
inmates provided written, informed consent and were in-
structed to offer no personal identification. All inmates
were numerically identified based on which group they
were in and how they entered the room.

Data Collection
Confidential, aggregate demographic data were ob-
tained from the prison Director of Nursing. Focus groups
were conducted in correctional facility classrooms with
guards posted outside the door. Women were counted
when entering and leaving the classrooms. Each group
was conducted in English and lasted approximately 1 hr.
While healthcare education is offered at this facility, to
better understand the experiences of inmates, three guid-
ing questions were asked of each group. They included:
“What are the top ten health education needs of inmates
in this facility?”; “What is the best method for educat-
ing inmates on these topics?”; and “What would a health
fair look like for you?” Participants freely shared informa-
tion and stimulated other participants to elaborate, con-
tradict, and add to the discussion. Knowledge generation
was viewed as participatory and co-created by all mem-
bers of each focus group. Groups were allowed to answer
each question until no inmate had additional new infor-
mation to offer. While one interviewer presented guid-
ing questions to the inmates, the second interviewer kept
written field notes. Participants were not known to the
researchers and no prison staff were present in the class-
room during the focus group discussions.
Data Analysis
Two research team members are doctorally prepared,
with one having expertise in qualitative analysis. The
third research team member has expertise in correctional
health care. All three were involved in data analysis.
Prior to thematic analysis, the research team members
reviewed and discussed inmate comments. Data were an-

alyzed using a constant comparison approach to identify
emerging patterns using a concept map approach. Field
notes were reviewed and initial themes were identified
for each guiding question. Repeating ideas were com-
pared and contrasted across the interview groups to en-
sure that each category adequately conveyed the perspec-
tive of the participants. The process continued until the
research team felt satisfied that all pertinent data were
discussed and categorized. The summarized data were
written in narrative description and reviewed for clarity
and accuracy. While data were reviewed to reflect an-
swers to guiding questions, researchers identified an ad-
ditional theme that emerged from focus group observa-
tions. All are discussed below.
Results
Participants
The sample was a purposive sample. Focus Group
One consisted of eight women housed in the maximum-
security building and ranged in age from 25 to 51 years.
Focus Group Two consisted of eight women housed in
medium security. Their ages ranged from 22 to 48 years.
Six Black women, six White women, and four Latina
women participated in the groups. Projected release dates
ranged from less than 1 year to 19 years.
Health Topics Important to Incarcerated Women
When asked about the top health education needs
of incarcerated women in this facility, inmates identi-
fied a variety of topics. While all overlapped, six specific
themes emerged. They included the importance of nutri-
tion and exercise to prevent and treat obesity, women’s
health concerns, communicable disease transmission and

Dinkel & Schmidt Health Education Needs of Incarcerated
Women
prevention, dental hygiene, pathophysiology and com-
plications of chronic disease, and mental health condi-
tions. Group One specifically identified hygiene as an
additional important topic, while Group Two identified
information on terminal disease as a health education
need.
It is well understood that healthful nutrition and reg-
ular exercise promote health and prevent obesity. In-
carcerated women share this understanding, but with
two particular considerations: limited choices in nutrition
and exercise needs of those living in small spaces. While
all inmates receive nutritionally balanced meals, several
women in both groups expressed concern about the dif-
fering nutritional needs of women as compared to men,
and the changing nutritional needs of women across the
lifespan. Inmate G17 stated that meals for all prisons in
the state are the same for both men and women and is
concerned that her needs as a woman might be differ-
ent from her male counterparts. She also stated, “Some-
one who is in their 20–30s may need something different
than someone in their 50–60s or older.” Women in both
groups requested an assessment of their individual nu-
tritional needs based on age, height, weight and health
conditions.
Conversation about nutrition naturally led to discus-

sion about exercise. Women in both groups talked about
how hard it is to exercise daily while living in an 8-foot
by 14-foot space often shared with other inmates. Many
participate in the prison sponsored running club. How-
ever, women from both groups expressed concern about
how foot health and a lack of access to high quality ex-
ercise shoes impair their ability to exercise. Inmate G14
requested information on foot health, specifically injury
prevention and treatment, as part of an overall exercise
program. “If your foot is messed up then the rest of you
is messed up” (Inmate G27).
Women’s health was the second theme and encom-
passed a broad range of topics, including age-specific
screenings, menstruation and menopause, physiologic
changes related to aging, and signs, symptoms, and
treatment of chronic diseases more commonly seen in
women. Overall, women wanted to know what they
could expect as they aged and how they could stay
healthy. Inmate G25 stated succinctly, “We just want
to know the normal signs of aging and what to ex-
pect as we get older.” “I want to see what I’m lead-
ing up to as I get older” (Inmate G18). Younger women
in both groups wanted health educators to teach prison
staff and other inmates about menstrual health and hy-
giene. “Women bleed and we have different cleanliness
needs [than men]” (Inmate G17). Lastly, women from
both groups expressed a need for education on healthy
sexual relationships. “We need information on how to
have healthy relationships. Some of us may make differ-
ent choices on the outside” (Inmate G23).
Communicable disease was the third theme identified
by inmates. Two primary topics emerged: skin infections
and sexually transmitted infections (STIs). Because of

close quarters and shared bathrooms, women in both
groups were concerned about disease transmission and
infection control. Inmate G23 is knowledgeable about
measures to decrease the spread of disease and stated,
“You’re never gonna live with me because I am uned-
ucated. I’m gonna bleach you every 5 seconds!” All pro-
fessed to their own cleanliness but wanted other inmates
to be educated on measures to prevent the transmission
of disease. “They don’t get that they can get stuff . . .
drinking after each other . . . sharing make-up . . .” (In-
mate G15).
Sexually transmitted infections were a concern for both
groups, and although women in each group felt knowl-
edgeable on the topic, they wanted other inmates to re-
ceive information. “We are all open—when we wipe with
a towel—we have more risk than men” (Inmate G12).
While prohibited, inmates did discuss masturbation and
the potential to spread STIs to each other. “. . . women
don’t know that they can still pass disease and how infec-
tions are passed” (G14). Women in both groups expressed
the need for community resource information upon re-
lease to prevent and treat STIs.
Dental hygiene was a topic that women from both
groups felt passionate about and it emerged as the fourth
theme. Inmate G17 felt that women in her facility don’t
understand the importance of proper dental care and “. . .
how dangerous poor mouth care can be. It affects nu-
trition and other diseases.” Inmate G28 was more con-
cerned about “how to tell people that they need to brush
and floss because gingivitis and pyorrhea is nasty.”
The fifth theme identified was a need for more in-
formation on the process of aging and, specifically, on
the signs and symptoms of chronic diseases most af-

fecting women in adulthood. There was concern about
being able to distinguish age-related changes from
disease-related changes. Inmate G25 was more concerned
about the warning signs of stroke, aneurysm, and early
Alzheimer’s disease. She stated, “I need to know what
is normal and what is not.” Discussion on heart disease
ran parallel with discussion on diabetes. Inmate G13 de-
scribed a situation where she “ain’t feeling quite right,”
was prescribed medication, and now feels she “traded
in symptoms for medication-related symptoms.” While
death and dying were not openly addressed, Inmates G23
and G27 felt information on the potentially fatal diseases
of hepatitis C, chronic obstructive lung disease, and breast
and cervical cancer would be important. Interestingly,
younger inmates from both groups expressed the need
Schmidt
to know more about diabetes and arthritis so they could
support other inmates.
The last theme was mental health. As with women’s
health, this topic was broad and included stress man-
agement/coping, testing and treatment of mental health
conditions related to substance abuse, recovery, and
preparation for release. Many inmates receive mental
health services while incarcerated. However, Inmate G18
was interested in learning more about being proactive
with her mental health and “not just things to reverse
damage.” Several women in Group Two expressed an in-

terest in knowing more about nonpharmacologic stress
management and coping. Inmate G23 illustrated this
when she stated, “[We need to know] what happens to
the brain when you put in good, including good thoughts
and motivation.” She went on to say that early in her
incarceration she “. . . let my time do me. Now I am
doing more for myself. I want to be ready when I’m
out.” Education on drug detoxification and potential out-
comes of long-term addiction was identified as an im-
portant need. “Face it . . . we are inmates and most all
drug addicts” (Inmate G23). Inmate G27 wanted more in-
formation about pharmacological treatment of substance
abuse so she would not be “not going from one drug to
the next.” Women in both groups were concerned about
returning to illicit drug use upon release and wanted
information on community treatment resources such as
Narcotics Anonymous and credible websites. To stop the
familial pattern of drug addiction, Inmate G23 believed
that drug addicts should have education about genetic
testing for children of those addicted to drugs.
The Best Methods for Educating Inmates
Question Two asked inmates “What are the best meth-
ods for educating inmates on these topics?” Answers were
similar in both groups and included two primary themes.
The first theme was respect for adult learners. Inmate
G15 stated, “Inmates want do decide on something that
is meaningful.” Inmate G12 followed with, “Don’t talk to
me like I’m two. We are not stupid.” Within Group One
there was a resounding need to have optional health ed-
ucation experiences that are not open to all inmates “. . .
to prevent bitch fests . . .” (Inmate G12). Inmate G22, of
Group Two, identified similar concerns when she stated,
“People need to be interested so others don’t be loud and
ruin it for everyone else.” Lastly, Inmate G22 expressed

that having an opportunity to share stories in small group
settings would enhance learning.
The second theme, about preferred educational meth-
ods, was use of a variety of teaching and learning
techniques that include hands-on activities. Inmate G12
stated that pamphlets “. . . go in the trash.” She went on
to say “[the information] needs to be more important to
us . . . [and we need] to be able to see, touch and feel.”
Inmate G15 believed that if the information was dull, pic-
tures “can shine it up.” Inmate G13 then added, “I can
remember what I’ve seen but not always what I hear.”
Inmates G23 and G25 expressed a need for information
on credible websites so they could have “resources avail-
able when [they] get out.” Additionally, there was con-
sensus between both groups that a variety of presenters
are necessary to stimulate learning.
Visions of a Health Fair
The third guiding question was related to the inmates’
vision of a health fair. Responses to Question Three
were similar between groups where women envisioned a
health fair where inmates were free to walk around and
visit educational booths that used color, words, images,
and hands-on activities to make information appealing.
All stressed that topics must be significant to inmates in
order to positively impact learning. Both groups also ex-
pressed an interest in obtaining screenings pertinent to
their healthcare needs, such as cholesterol, blood pres-
sure, bone density, and cancer, with a private area where
inmates could have an individualized interaction with a
healthcare expert. Inmates in Group Two specifically re-
quested information pertinent to release, such as commu-
nity resources, information on child health, and genetic

testing. However, Inmate G23 stated, “Needs are differ-
ent based on time. If you’re here for 6 months—don’t say
anything . . .,” implying that those with longer sentences
have the greater long-term need for inmate participation.
Based on responses, it is clear that there is a need for ad-
ditional investigation on the healthcare education needs
of female inmates over time.
Overall, women in this study articulated a need for
comprehensive health education at all levels of preven-
tion. They clearly expressed a desire for involvement
in the educational process and offered suggestions that
would be interactive and interesting to meet the needs of
these adult learners. In addition to the themes expressed
specifically by inmates, the interviewers observed an ad-
ditional theme: the intersection of respect, trust, and em-
powerment in this correctional facility, which is discussed
in the following section.
Discussion
While women discussed specific issues related to the
three guiding questions, embedded within the conver-
sations was the complex relationship between respect,
trust, and empowerment. In this study, women described
a scenario where empowerment involves respect for and
Dinkel & Schmidt Health Education Needs of Incarcerated
Women
from others. Self-respect was expressed when women

talked about how to be proactive in their health care,
both while incarcerated and after release. This idea was il-
lustrated by Inmate G13 when she stated, “When I am 45
and I hit this gate, I need to be ready.” Inmates from both
groups expressed concern for other incarcerated women.
Inmate G17 succinctly stated, “Help us help each other
and help ourselves.”
The need for respect was most evident in discussions
involving the best methods for educating inmates. As
stated earlier, women from both groups wanted an op-
portunity to provide input into meaningful topics, to be
provided with an adult learning environment, and op-
portunities to choose which educational sessions they at-
tended. Inmate G12 stated, “Knowledge is power. We are
not stupid. We have to do our part.” Inmate G15 sup-
ported this idea when she replied, “Inmates want to de-
cide on something that is meaningful.” The researchers
believe that the mere opportunity to participate in the
focus groups and potentially make a valuable contribu-
tion to their future health care while incarcerated may
have contributed to building respect for self and for
others.
Respect is paramount to trust. Bissonnette (n.d.) de-
scribed trust in the corrections environment as the pro-
vision of culturally competent care with an under-
standing of women within the context of their lives
prior to and during incarceration. While participants did
not expressly describe trust during the focus groups,
trust was evident. Women spoke freely about sensitive
health topics. They listened and responded respectfully
to other inmates within the groups and expressed ap-
preciation to the researchers. They validated each other’s
experiences.

Lastly, the concepts of trust and respect have been
linked to empowerment (Bissonnette, n.d.; Laschinger
& Finegan, 2005). Kanter (1977) defined empowerment
as having access to information and the opportunity to
learn and grow. Laschinger and Finegan (2005) built on
this definition and linked empowerment to interactional
justice, respect, and organizational trust. They defined
interactional justice as the “perception of quality of in-
teractions among individuals involved in or affected by
decisions” (p. 2). Interactional justice includes the extent
to which individuals are treated with respect and dig-
nity and how information is provided in a timely and
meaningful way. While much of the work by Kanter
(1977) and Laschinger and Finegan (2005) is grounded
in workplace settings and employee satisfaction, these
concepts are equally visible in corrections. Bissonnette
(n.d.) has woven similar concepts into a program of
trauma-informed practice. Inmates and staff are encour-
aged to build an environment that is culturally compe-
tent, creates an atmosphere of respect, strives to maxi-
mize women’s choices and control, and solicits women’s
input in designing and evaluating services. While inmate
empowerment was not measured in this study, the re-
searchers believe that participation in the focus groups
may have increased their personal sense of empower-
ment. Women in each group were given access to in-
formation, participated in meaningful dialogue with each
other and researchers, were treated with respect and dig-
nity, and identified opportunities for choice in healthcare
education. While the translation of these data into poli-
cies and practices has yet to emerge, the stepping stones
to healthcare education at this facility have been set.
Trustworthiness and Limitations

Trustworthiness in qualitative research has inherent
bias and limitations. This study was no exception. All
attempts were made to maintain credibility, dependabil-
ity, confirmability, and transferability during data collec-
tion and analysis. Credibility was strengthened in three
ways. By using a nonrandom, purposive sample, infor-
mants provided unique insight. Including the perspec-
tives of women from diverse cultural backgrounds and
who are incarcerated for various lengths of time pro-
vided depth and breadth of experience. Credibility was
also strengthened by the confidentiality of the groups. No
prison staff was present during the sessions. Dependabil-
ity was enhanced by utilizing a constant comparison ap-
proach to examine the data by all research team mem-
bers. Confirmability is most challenging. Two research
team members have experience working in corrections
and offer some understanding of the healthcare needs
of incarcerated women. However, researchers were un-
able to share the analyzed data with participants. This
is partially due to some participants being released from
prison prior to full data analysis. Continued efforts are
being made to share conclusions with participants. To en-
hance transferability, thick descriptions of healthcare ed-
ucational needs of incarcerated women as well as the use
of direct quotations are included. However, transferabil-
ity is limited. All participants were from the same correc-
tional facility; therefore, findings may not be transferable
to women incarcerated at other facilities, nationally or
internationally. Additionally, women incarcerated in the
minimum-security setting were not included in the focus
groups. Their experiences, especially related to trust, re-
spect, and empowerment, might be quite different from
those in medium- and maximum-security settings. Lastly,
the length of incarceration may be a factor that influences
healthcare education needs. This difference was not con-
sidered as part of the investigation.

Schmidt
Implications for Practice and Future
Research
Results from this study highlighted several areas ger-
mane to future practice and research. Participants in this
study clearly identified healthcare education needs. This
can directly translate to healthcare practice considera-
tions. Opportunities to build intra-agency healthcare edu-
cational programs, collaborate with community resources
such as schools of nursing, and develop peer programs
addressing health education are evident. Strategies may
include a health fair, formal healthcare educational pro-
grams offered by experts in the community, and one-on-
one sessions between individual inmates and corrections
healthcare providers. Part of any corrections healthcare
education program must include an atmosphere that is
respectful of women’s needs for safety, respect, and ac-
ceptance, and it must involve inmates in designing and
evaluating services (Bissonnette, n.d.).
This study focused on a diverse group of women in
a midwestern, medium- and maximum-security correc-
tional facility. Clearly, an understanding of the same
needs of women in minimum security is desirable. Ad-
ditionally, while this study included women from diverse
backgrounds who are incarcerated for various lengths of
time, a better understanding of the impact of length of in-

carceration on healthcare educational needs is necessary.
Similarly, educational needs of those about to be released
may be substantially different from those who will not be
released in their near future.
Lastly, this study revealed the links between trust, re-
spect, and empowerment of female inmates and their po-
tential impact on healthcare learning. Special considera-
tions may need to be given to those in continuous segre-
gation who have different opportunities for building trust
and respect with staff and other inmates. Further under-
standing of the complex relationship between these con-
cepts may guide correctional agencies to further develop
gender-informed policies, procedures, and practices.
Conclusions
There is a continuing challenge in health care to pro-
vide culturally relevant care to vulnerable populations
(Palmer, 2007). This includes incarcerated women. The
Department of Justice, Department of Corrections, Na-
tional Institute of Corrections, and Substance Abuse and
Mental Health Services Administration have made great
efforts to operationalize gender-informed practices with
female inmates (Bissonnette, n.d.). Continuing to provide
quality, safe health care and proactively providing health-
care education that is meaningful to women may im-
prove the health of incarcerated woman and ultimately
reduce the recidivism rate of women released from prison
(Bissonnette, n.d.).
Clinical Resources
� Clinical care of incarcerated adults: http://www.
uptodate.com/contents/clinical-care-of-incarcerated-
adults

� Creating trauma-informed correctional care: http://
www.seekingsafety.org/7--11--03%20arts/2012%
20miller%20naj%20trm%20corrs%20ejp.pdf
References
Binswanger, I., Mueller, S., Clark, C. B., & Cropsey, K. L.
(2011). Risk factors for cervical cancer in criminal justice
settings. Journal of Women’s Health, 20(12), 1839–1845.
doi:10.1089/2Fjwh.2011.2864
Bissonnette, L. (n.d.). Innovators. National Resource Center on
Justice Involved Women. Retrieved from http://
cjinvolvedwomen.org/innovator-massachusetts-
correctional-institution-at-framingham
Hatton, D., & Fisher, A. A. (2011). Using participatory
methods to examine policy and women prisoner’s health.
Policy, Politics & Nursing Practice, 12(2), 119–125. doi:10.
1177/2F1527154411412384
Institute on Women & Criminal Justice. (2009). Quick facts:
Women & criminal justice. Retrieved from http://www.
wpaonline.org/pdf/Quick%20Facts%20Women%20and%

20CJ%202009.pdf
Kanter, R. M. (1977). Men and women of the corporation. New
York: Basic Books.
Laschinger, H. K., & Finegan, J. E. (2005). Using
empowerment to build trust and respect in the workplace:
A strategy for addressing the nursing shortage. Nursing
Economics, 23(1), 6–13.
Palmer, J. (2007). Special health requirements for female
prisoners. In L. Moller, H. Stover, R. Jurgens, A. Gatherer,
& H. Nikogosian (Eds.), Health in prisons: A WHO guide to the
essentials in prison health (pp. 157–170). World Health
Organization. Retrieved from http://www.euro.who.int/
data/assets/pdf file/0009/99018/E90174.pdf
Robertson-James, C., & Nunez, A. (2012). Incarceration and
women’s health: The utility of effective health education
programming—A commentary. American Journal of Health
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Stolnik, K. (Ed.). (2011). Special issues of women prisoners.
In A jailhouse lawyer’s manual (9th ed., pp. 1–22). New York:
Columbia Human Rights Law Review.
Yeager, M. (2012). Women’s healthcare in prison. Correctional
Institution Inspection Committee Report, Ohio General
Assembly. Retrieved from http://ciic.state.oh.us/download/
401-women-s-healthcare-in-prison-2012.htm
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Reproduced with permission of the copyright owner. Further
reproduction prohibited without
permission.
NSG3029 W4 Project
Research Template Name
Cite both articles reviewed in APA style:

***In the template, any direct quotes from the articles needs to
only include the page number.
Week 4 Template
Quantitative Article
Qualitative Article
Identify and describe the sample including demographics, in the
studies chosen in W2 Assignment 2
Discuss the steps of the data collection process used in the
studies
Identify the study variables (independent and dependent)
Identify the sampling design
Describe the instrument, tool, or survey used in each article.
Summarize the discussion about the validity and reliability of
the instruments, tools, or surveys used in each article
Identify the legal and ethical concerns for each article,
including informed consent and IRB approval

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