Convocation spotlight: Stewart MacLennan

PhD graduate continues his work to address pain management in correctional healthcare settings while hoping to improve the mental health of incarcerated individuals.

23 November 2022

Stewart MacLennan, an associate teaching professor at the Faculty of Nursing, College of Health Sciences, University of Alberta, and a recent PhD graduate plans to continue researching ethics and pain management in correctional healthcare settings. 

With Fall 2022 convocation celebrations happening this week, MacLennan spoke to us about his passion for this understated research area, how prisons are healthcare settings, and why incarcerated individuals' mental health matters, too. 

Why did you decide to become a nurse? 

It was accidental. I was studying electrical engineering and during the summer before entering my fourth year, I decided to work for a crisis intervention telephone line. My parents pointed out this career discrepancy while we were walking past the home of a neighbour who is a nurse. They suggested that “I could be a nurse like Kathy and do mental health work." I started nursing school at the University of New Brunswick that fall.

What is your research focused on? 

My research focuses on ethics in correctional healthcare settings. My doctoral research focused on developing a nuanced understanding of how people who are incarcerated experienced pain. I used a relational ethics approach to interpret the data and develop clinical recommendations. While the focus of the research is on pain and ethics in prison settings, the findings highlight how isolation, fear, and existential crisis, can impact pain experiences. These psychological dimensions must therefore be meaningfully understood and addressed in order to improve the pain experiences.

What inspired you to pursue this unique research area of focus?

I was placed in a youth detention center during the 4th year of my undergraduate nursing program. While reviewing healthcare requests from some of the youth, I encountered a patient who was requesting to be issued a bar of higher-quality soap for medical reasons, such as eczema or psoriasis. On a cursory review, there did not seem to be any compelling factors that would warrant dispensing higher-quality soap and promptly refused their request. Afterwards, I was reading through their chart and came across a section written by a psychologist detailing the abuse the youth endured from their mother. One of the most compelling was that as punishment, the mother would withhold hygiene products causing the youth to be embarrassed in public situations, including school. At that moment, I knew that my decision was procedurally correct, but failed the youth from a psychological perspective. The relationship I had with the youth crumbled because, from their perspective, I was not better than their abuser. 

This was the impetus to integrate psychiatric and mental health care in all of my day-to-day clinical interactions when working as a primary care nurse, and later a nurse practitioner, in correctional health. As I became more experienced in correctional healthcare and recalled my earlier experience, I began to question day-to-day clinical decisions and processes. Were there other routine clinical practices that appear procedurally correct but are poorly responsive to the complex subjective experiences of people who are incarcerated? Clinically pain intensity seemed to worsen amongst my patients, existing pain measures did not seemingly measure pain adequately in this population, and higher than average prevalence of psychiatric and addiction co-morbidities further complicated pain treatment. Given that pain management is viewed as a fundamental human right, I felt compelled to explore this topic further.

Are prisons often overlooked as healthcare settings? 

One of the big strengths we have in Alberta is that correctional health services are contracted through AHS. This was done when AHS was created over 10 years ago and has since been replicated in other provincial jurisdictions. This provides an added layer of oversight to ensure that health care services are not overlooked and model care standards are expected in other AHS settings. This is very important and over the past 10 years or so, healthcare services provided to people incarcerated in Alberta provincial facilities have improved dramatically. 

How should incarcerated individuals' mental health be supported? What supports already exist? What needs to change? 

People who are incarcerated often present with complex physical and psychiatric healthcare needs. Unfortunately, many people who are incarcerated have been victimized themselves. Some of the trauma is associated with gang involvement or injuries sustained when perpetrating crimes, such as high-speed collisions or being shot. However, many of our patients have also been victimized through no direct result of their criminal histories. The majority seem to have horrific childhood trauma due to abuse and neglect. 

This is one of the reasons why clinicians working in correctional settings should have a strong psychiatric/mental health background. I do have an interest and specialized education in psychiatric and mental health nursing but leave most of the psychiatric care to the psychiatry and mental health team. Rather, I’m interested in working with people who are incarcerated and have mental health disorders in a primary care role to advance their overall health. The real challenge is about building trust and working diligently with our patients to increase the chance that they engage in health services. For someone who distrusts the health system, having them become engaged to undergo screening tests or treatment for the management of chronic conditions can be hard. The difficulty becomes even more challenging when a person’s paranoia, distrust, or challenging personalities, due to mental illness, are at play. 

You might notice that I do not use the term “inmates” this is intentional as it helps refocus why I am involved with this population in the first place. People who are incarcerated are people who have a strong desire to be treated humanely. And, as a society, we have the commitment to treating everyone humanely. 

In my research about having pain when incarcerated, some participants who felt abandoned by staff described either trying hard to get the attention of the healthcare staff or just giving up and disengaging from any healthcare services. In the former, some participants were led to believe that they needed to “prove their pain” through diagnostic imaging and other empirical tests or exaggerate their symptoms to get pain management. This creates a nurse-patient relationship that is based on a lie and may lead to additional health care costs by needlessly ordering diagnostic tests or placing a patient’s health at risk if inappropriate drug therapy is prescribed. Using strong relational principles to understand and attend to the vulnerabilities and uncertainties of our patients can foster the development of more effective therapeutic relationships where the patient’s perspective, including those distorted by mental illness, may be better understood.

What advice do you have for RNs considering graduate nursing studies? 

If you are thinking about graduate studies, don’t delay looking for the “right time”. Just jump in, have a bit of faith, and just do it.

In celebration of our recent rankings, 1st in Canada and top 10 globally (QS Global Rankings by Subject), we are pleased to offer our incoming September 2023 cohort of PhD students a funding guarantee of $15,000 for the first year of study. LEARN MORE