advanced degrees and have less experience resulting in recruitment and retention problems (Roberge, 2009). The pool of educated and professional employable people in rural areas has been limited, further challenging the creation of and Cultivating Change 8 sustainability of healthcare teams in forensics. In secure settings, nurses are often the primary care provider requiring strong theoretical and practical knowledge. At times forensic nurses have faced scope of practice issues (White & Larsson, 2012). Even with these challenges, the autonomy offered and potential for growth are welcome opportunities. Motivation for Change Legal In the landmark case of Estelle v. Gamble in 1976, the Supreme Court assured all people in prison have the right to adequate medical care (Trestman, 2014). Assurance of health care through the court was a necessary step to address the barriers as mentioned earlier in forensic nursing. Negative views of people who are incarcerated have made them victims of torture and subjects of despicable research. Today, people held involuntarily are highly protected as human subjects (U.S. Food and Drug Administration (FDA), 2010). Legal issues have continued to permeate forensic nursing. Challenges to the constitutionality of civil commitment have widened the chasm between nursing and persons committed under these laws. Nurses working in forensic psychiatric settings have struggled to develop therapeutic relationships when there exists a real or perceived impact on the discharge status of their patients (Jacob, 2012). Litigation and threats of litigation regarding the health care provided are common. Moral support and guidance from experienced nursing leaders would likely help close the gap legal issues have created between nurses and their patients. Standards of care While movement towards the protection of human rights has occurred, quality and safety standards still need to be applied and monitored. Patient safety and patient-centered care are hallmarks of traditional health care settings. Standards for correctional health care continue to be Cultivating Change 9 developed since the landmark case in the late 1970s. Accreditation is a tool for achieving and maintaining organizational performance; however, accreditation has remained voluntary in correctional settings Some large prisons have more sophisticated systems; however, health care has notoriously been minimalist and only in response to federal requirements. Studies have described a lack of equipment, limited staffing, and lack of contact with other health care professionals, specifically physicians (Almost et al., 2013; Chafin & Biddle, 2013; Flanagan, 2006). Health care in any setting is complex but in forensic settings the multifaceted challenges has created an even higher need for patient safety protections. Quality evidence in forensic nursing has been sparse due to difficulties obtaining Institutional Review Board and facility approvals. Additionally, it is estimated that doctorally-prepared nurses in forensics are few. Reliable data on the number and characteristics of nurses in the specialty are not even available. The paucity of research that is available has been poorly disseminated especially to rural forensic nurses. Immune to safety and quality standards required for accreditation and reimbursement in traditional healthcare settings, forensic settings have survived on smaller, innovative actions of a few rather than system-wide change to meet the needs of patients. Social and Political Context Nursing ethics Nursing presence has been integral to meeting the needs of the imprisoned. As mentioned, this has been by way of champions in the field versus wide-spread adoption of nursing ethics. Some facilities train nurses as correctional officers and teach them they are an officer first and a nurse second. This has created turmoil for nurses’ whose focus is patient care (Christensen, 2014; Dhaliwal & Hirst, 2016; Weiskopf, 2005). Nurses in forensic settings have Cultivating Change 10 described caring as accepting patients who are incarcerated as human beings and treating them with respect and in a non-judgmental manner (Weiskopf, 2005). In secure settings, distant relationships are commonly prescribed in the name of social control and safe boundaries. Restrictions on the expression of caring have caused nurses frustration and anger (Weiskopf, 2005). However, distancing has also occurred in response to feelings of fear, repulsion, and hopelessness towards patients who are offenders (Holmes, Perron, & O'Byrne, 2006; Jacob, Gagnon, & Holmes, 2009). Difficult patients, uncaring co-workers, and feelings of helplessness and stress have furthered alienation of forensic nurses from the nursing profession and its code of ethics. Integrity calls for deliberation and reflection of the context, knowledge, experience, and information on complex and conflicting issues (Edgar & Pattison, 2011). In order to maintain integrity in forensic nursing, key factors are personal reflection, understanding of nursing ethics, professional dialogue with experienced forensic nurses, and respect for human dignity. Politics The climate of forensic settings has fluctuated with changes in political offices and subsequent changes in the administrators appointed by politicians. The concept that some people are inherently evil or incapable of change has persisted and experienced a resurgence in the