Original Article
Evaluating an Adolescent Behavioral Program: Leadership, Education, Achievement, and Development for Adolescent Female Offenders in Corrections Denise M. Panosky, DNP, RN, CNE, CCHP, FCNS and Deborah Shelton, PhD, RN, NE-BC, CCHP, FAAN
ABSTRACT This article reports the findings of a pilot study designed to: test the feasibility of implementation, assess implementation barriers, and determine the effectiveness of a modified evidence-based program designed for adolescent female offenders in a women’s correctional facility in the United States. A therapeutic expressive arts behavioral program, Leadership, Education, Achievement and Development (LEAD), has been used in community settings as a health promotion program. This behavioral program was adapted to LEAD-Corrections (LEAD-C) and serves incarcerated adolescent female offenders. Results of this pilot study show that it is feasible to offer LEAD-C in a correctional setting. Positive effects were noted on session satisfaction surveys as well as formative and summative evaluations. Implementation of LEAD-C, using therapeutic expressive arts interventions, included coping strategies to help adolescents become confident and self-assured and review better choices. Adolescents were taught to utilize these learned coping strategies in their life, which may help to overcome adversity, enhance resilience, and support youth transition at the time of reentry to the community. KEY WORDS: adolescent female offenders; corrections; expressive arts; health promotion; resiliency
he aim of this article is to report the findings of a pilot study designed to test the feasibility of implementation, assess implementation barriers, and determine the effectiveness of a modified evidence-based program designed for adolescent female offenders in a women’s correctional facility in the United States. The goal of the program was to enhance resilience by strengthening coping strategies and decision-making skills for incarcerated youth.
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Author Affiliation: School of Nursing, University of Connecticut. Funding for this study was received from the Viola Bernard Foundation and Sigma Theta Tau International Mu Chapter. The authors declare no conflict of interest. Correspondence: Denise M. Panosky, DNP, RN, CNE, CCHP, FCNS, School of Nursing, University of Connecticut, 231 Glenbrook Road, Unit 4026 Storrs, CT 06260. E-mail: [email protected]. Received March 21, 2015; accepted for publication June 20, 2015. Copyright © 2015 International Association of Forensic Nurses DOI: 10.1097/JFN.0000000000000082
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It was believed that these skills would help to overcome adversity, enhance resilience, and support youth transition at reentry to the community.
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Background and Significance
In 2011, U.S. law enforcement agencies made almost 1.5 million juvenile arrests; 29%, or 429,000, of these arrests involved female offenders (Puzzanchera, 2013). Gender differences are seen in juvenile offending and need to be recognized so that effective programming can be tailored to meet the unique needs of these adolescents. In comparison with their male counterparts, female juvenile offenders present with a higher prevalence of physical and sexual abuse, mental health challenges (Cook, Barese, & Dicataldo, 2010; Grande et al., 2012; Guthrie, Cooper, Brown, & Metzger, 2012; Palmer, Jinks, & Hatcher, 2010), and exposure to trauma (Solomon, Davis, & Luckham, 2012), which must be considered when planning effective programs Volume 11 • Number 3 • July-September 2015
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(Lederman, Dakof, Larrea, & Li 2004; Lewis, 2006; Martin, Martin, Dell, Davis, & Guerrieri, 2008). In addition, family dysfunction, substance abuse problems, high-risk sexual behaviors, school problems, and affiliation with deviant peers (Hubbard & Pratt, 2002) are seen more frequently among incarcerated women, further supporting the need for gender-sensitive programs within the legal and criminal justice systems. There are few studies that specifically target adolescent incarcerated women. Palidofsky and Stolbach (2012) described a drama therapy program used with incarcerated girls with trauma histories, to perform musicals based on their experiences, which led to therapeutic benefits for participants. In a single-case effectiveness study (N = 4), Lenz, Speciale, and Aguilar (2012) found that a nine-session relational– cultural therapy intervention helped incarcerated women to foster relational empowerment and engagement. Furthermore, gender-specific substance abuse interventions have been found to reduce problems related to social and personal functioning in incarcerated female adolescents (RobertsLewis, Welch-Brewer, Jackson, Kirk, & Pharr, 2010). Lederman et al. (2004) suggest that interventions that have been developed for assisting incarcerated adolescents have the potential to help them turn their lives around. Rew and Horner (2003) further suggest that using a resilience framework to address the needs of female adolescent offenders may be beneficial through the use of early interventions designed to reduce risky behaviors and associated negative outcomes later in adolescence. Different study outcomes have proven effectiveness for incarcerated women, but they are limited in number and may focus on only one aspect of their lives. Using a resilience framework may help focus adolescent female offenders be successful with reentry into the community with a strong foundation of resilience strategies.
Adolescent Resilience Polk’s (1997) resilience theory was the fundamental theoretical framework used for the Leadership, Education, Achievement, and Development-Corrections (LEAD-C) program. Resilience is important to this work as it has been shown that resilient adolescents are individuals who have positive outcomes in the face of adversity and may increase competence; build connections; and develop communication, academic, decision making, and extracurricular skills (Rew & Horner, 2003). Furthermore, “resilience represents the interaction between risk factors (vulnerability) and protective resources (protection)” (Rew & Horner, 2003, p. 379) and is often “viewed as an adaptive stress-resistant personal quality that permits one to thrive in spite of adversity” (Ahern, Ark, & Byers, 2008, p. 32). LEAD-C applies strategies to build resiliency. Nurses working with adolescents can use and teach strategies to help enhance resiliency to improve outcomes. Journal of Forensic Nursing
Therapeutic Arts Intervention LEAD (Shelton, 2008, 2009) is an evidence-based therapeutic expressive arts program designed for use in a community setting to reduce the risk of minority youth involvement with the juvenile justice system. In collaboration with the author of LEAD, LEAD-C was adapted for a correctional setting and pilot tested with a sample of incarcerated female adolescents. The LEAD-C program used therapeutic expressive arts and coping skills strategies to enhance resilience among the incarcerated youth who participated. It was expected that these skills would transfer to the community upon reentry. To determine the effectiveness of the therapeutic arts program, adaptations were made for LEAD-C to prevent misuse of self-disclosed personal information that would put participants at high risk for abuse or manipulation within this closed environment. Expressive arts (drawing, poetry, music, drama, and drumming) permit healing from within without verbal disclosure through the expression of self and the experience each individual has, even if no words are used (Fox, 2003). In this way, the arts provide the opportunity for communication and healing to occur on an individual basis, especially in an environment where the potential for misuse of verbal disclosures is high. Journaling, a means of private written expression, provided opportunity for guided reflection and active counseling between group leaders and individual participants in a confidential manner. Writing was completed in the group, and journals were collected and returned to participants in the next group with comments from group leaders. This provided safe keeping of the journals, as personal space was limited for participants’ personal items within their living environments in the correctional setting. Upon release, the journals were mailed to participants if wanted. This study also sought to assess the feasibility of implementing the LEAD-C program in a women’s correctional facility. Of interest were implementation issues related to the correctional environment (e.g., space, staff coordination) as well as implementation and evaluation of the effectiveness of the logistical curriculum content (which was adapted to meet safety and security of the environment), programmatic structure (e.g., length of session, instrumentation, size of group), and recording of barriers so that they could be addressed when the program was replicated. There is a lack of gender-specific programming in many correctional facilities (Albrecht, 1994), especially evidencebased treatment programs designed for correctional health settings. Many needs of young offenders are often unmet, including mental health, social, and educational needs, with few offenders having any form of intervention (Chitsabesan et al., 2006). Teaching adolescent offenders coping and problem-solving strategies to help make better choices may indeed promote confidence, positive thinking, positive www.journalforensicnursing.com
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attitudes, and self-assurance and improve reentry outcomes such as retention in school. This pilot study explored the feasibility, implementation, barriers, and effectiveness of an evidence-based therapeutic expressive arts program for adolescent offenders in a women’s correctional facility. The study sought to answer the clinical question, “Can the LEAD-C program be implemented effectively with female adolescents in a women’s correctional setting?”
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Methods Design This feasibility study utilized a repeated measures design with a 6-month follow-up to examine program satisfaction and effectiveness. Descriptive and qualitative approaches were utilized for programmatic evaluation. The setting was in a northeastern state prison facility in the United States that houses all female juvenile and adult offenders. Institutional review board approval was obtained from the University of Connecticut (Protocol No. H09-153), Duquesne University (Protocol No. 09-90), and the Connecticut Department of Correction (DOC; Protocol No. 2010CAU-72).
Criteria for Participation English-speaking adolescent female offenders aged 15–17 years, of any race or ethnicity, and who had a DOC release date (sentenced or remanded) of at least 7 weeks after the start date of the LEAD-C program were eligible to participate in the study. Because the groups took place off the living units, only youth who were behaviorally stable to obtain a pass off their unit to attend the group were eligible.
Participant Recruitment Procedures Potential participants were identified by treatment teams and asked if they wanted to participate. If they verbally agreed to participate, permission forms were mailed to their parents/guardians. Once completed permission forms were obtained, the principal investigator (PI) met with the adolescents to explain the LEAD-C program and obtain assent along with a declared commitment to participate in the program for 6 weeks. Although there were minimal risks involved with participation in the LEAD-C program, as per DOC protocol, the PI agreed to make a verbal referral to the treatment team member on duty if a participant was emotionally upset or tearful during or after a program session. At the start of the program, six female adolescent offenders agreed to participate in the pilot LEAD-C program. Five of the participants were 17 years old, and one was 16 years old (mean age = 16.8 years). One participant responded that she was White, four indicated that they were multiracial (White/Hispanic, Hispanic Black, Hispanic/ American Indian, Black/American Indian), and one chose not to answer this question. 146
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Implementation of the LEAD-C Program LEAD-C was implemented over 6 weeks; two sessions were offered twice a week after school, for 1.5 hours. These sessions were closed group sessions, implying that, once a group program began, it was closed to new participants. The number of participants was purposely kept small to allow for both individual and therapeutic group participation. Each LEAD-C session was structured with an introduction of the session’s focus, relaxation, a journaling assignment, an expressive arts activity, cleanup, and an anonymous evaluation of the program session. Topics included coping skills and tools, exploration of self (identity and uniqueness, within the family and environment), social networks, anger management, self-talk and affirmations, and role expansion. The LEAD-C curriculum was designed in a manner that allowed for a relaxation activity at the close of each session, which further provided the PI with the opportunity to observe each individual participant for signs of being upset, which would have required a referral to treatment staff. Data were collected at various intervals. Demographic data forms were completed on the first week of LEAD-C, and participants had the opportunity to evaluate each LEAD-C session. At the 6-week point (program end), a Client Satisfaction Questionnaire (CSQ; Larsen, Attkisson, Hargreaves, & Nguyen, 1979) was completed by participants. In addition, upon completion of the program, certificates were provided at a small celebration of completion. A postprogram evaluation was conducted to determine if: (a) the participant would participate in a community-based LEAD program if it was offered; and (b) arrangements were made to mail journals to the participant’s address once released from the DOC. Reincarceration rates were reviewed at 6 months after the program to see if an adolescent was sent/committed/sentenced back to prison. Feasibility, implementation, and effectiveness of the LEAD-C program were evaluated weekly throughout the 6 weeks of the program. Weekly reviews of barriers, the implementation process, program attendance, and monthly reviews at administrative meetings with the correctional facility team members were also completed.
Instruments Demographic Data Form A demographic data form was developed by the PI for use in this study. Demographic data (age, race, and ethnicity) were collected and used to describe the population. This form was filled out by each participant in Session 1.
Program Session Satisfaction Scale The Program Session Satisfaction Scale was also developed by the PI for this pilot study. The four-item analog scale, with seven numbered sad/happy faces (representing “not very satisfied” to “very satisfied”), was completed by Volume 11 • Number 3 • July-September 2015
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participants after each LEAD-C session to rate that session’s activities, specifically the session’s curriculum focus and programmatic structure, for example, the length of session, sequence of activities, assessment and satisfaction measures, and size of group (see Figure 1). Participants reported their satisfaction with the program session by
circling the faces with the numbers that corresponded to their feelings about the activities in each session, and dropped their evaluations off in a box on their way out the door. The higher numeral response was correlated to a higher satisfaction level. One open-ended question asked if there was anything else participants wanted to add. The
FIGURE 1. LEAD-C program session satisfaction. LEAD-C = Leadership, Education, Achievement and Development-Corrections. Journal of Forensic Nursing
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PI reviewed all written responses after every session and made improvements and/or changes to programming as needed. For example, if participants stated they wanted more journaling time, or more guided imagery time, this was added into the future sessions.
satisfaction; (b) the assessment of implementation barriers; and (c) the effectiveness of the modified therapeutic expressive arts program designed for young female offenders.
Client Satisfaction Questionnaire
Implementing and running a program in a correctional facility cannot be accomplished without the support from those working in the correctional facility. Adolescents needed to arrive on time and attend each LEAD-C program session. Factors that supported implementation of the LEAD-C program included tremendous support from the DOC, including the warden, custody staff, and treatment team members. Obtaining support from custody, including correctional officer supervisors and correctional officers, was necessary. Treatment team meetings were facilitated before beginning this study. Correctional officers were available, and support continued throughout the 6 weeks for all 12 LEAD-C program sessions. Before each LEAD-C session, the PI arrived early to meet with the correctional officer responsible for escorting participants to the group sessions. A list of LEAD-C participants was given to the correctional officer, who made a telephone call to the Pod (living area), for the participants to arrive on time for each session. Participants were aware of each program session and ready to attend when called. Participants were informed, during the assent process, and agreed to attend all LEAD-C sessions. A correctional officer always had a room available for the LEAD-C program. Coordination and cooperation were always accomplished, and all available participants arrived as planned to each LEAD-C session. Attendance of participants in every LEAD-C program session was recorded by the PI. The first session was attended by all six participants. The second and third sessions were attended by five participants; one participant was not allowed, by DOC staff, to attend for disciplinary reasons. Further sessions were not attended by all participants (w = 3.58, median = 3, mode = 3). The original design for the LEAD-C program was to have sessions twice a week, for 2 hours, for 6 weeks. Because of school and dinner time conflicts, an adjustment of the 2-hour time frame was necessary. The length of LEAD-C sessions was adjusted to 1.5 hours. This time was sufficient for LEAD-C sessions, especially with our small group of participants. There was enough time for program curriculum and an adequate amount of time to give each participant individual attention if needed.
This eight-item, 4-point Likert scale, structured questionnaire was used without modification. The questionnaire asked participants about the quality of services received, if it was the service wanted, the extent the program met their needs, if they would recommend the program to a friend in need, how satisfied they were with the amount of help received, if the services helped with their problem, overall satisfaction with the program and services, and whether they would participate in the program again (Larsen et al., 1979). Overall scores ranged from 8 to 32, with the higher score indicating higher satisfaction. In many studies, the reliability of the CSQ-8 has been reported with the internal consistency, as measured by coefficient alpha, ranging from 0.83 to 0.93, with values of 0.86 and 0.87 in two of the largest samples. Validity has been indicated by higher satisfaction scores among participants who completed a program as compared with participants who did not complete a program (Attkisson, 2012).
Field Notes The PI’s personal notes and observations made while implementing the program were retained for use in evaluation of the pilot data and to guide later replication of the program. These notes were compared between the PI and the research mentor for process modifications. Facilitation of the implementation process was measured by adolescent movement from living area to program room by corrections officers, program dates, times, room availability, correctional officer availability, parent or guardian permission, and participant assent obtainment. Process evaluation measures were reviewed weekly by the PI and at monthly administrative meetings with the DOC Research Advisory Committee, the DOC treatment team, and the correctional facility warden. Confidential minutes of the meetings were kept by the PI, and qualitative review of the implementation process was ongoing with improvements and/or minor changes made as necessary. Summative evaluation measures included dropout rate and loss to release from corrections into the community and were also reviewed at monthly administrative meetings.
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Results
This pilot study sought to answer the clinical question, “Can the LEAD-C program be implemented effectively with female adolescents in a women’s correctional setting?” The findings of this pilot study will be reported in three sections: (a) the feasibility of implementation and program 148
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Feasibility of Implementation and Program Satisfaction
Program Session Satisfaction Scale Results on the program satisfaction scale (7-point analog scale) included satisfaction with the following: the time length of the sessions (w2 score = 6.6), the activities completed (w2 score = 6.4), the size of the group (w2 score = 6.6), and the overall session program (w2 score = 6.6). Responses to a fifth Volume 11 • Number 3 • July-September 2015
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open-ended question asking if there was anything else participants wanted to add or let the PI know were recorded. Results from the four satisfaction questions/program areas were recorded. The average scores of participants for questions about time, group size, and overall program were between 6 and 7 constantly (w2 = 6.6), indicating a high level of satisfaction. The average scores of participants for the question about activities were between 6 and 7 for Sessions 2–12 (w2 = 6.4), with the exception of Session 1 where the average score fell slightly below 6 (w2 = 5.7). Participants’ satisfaction for the LEAD-C program shown by the overall trend lines for all LEAD-C program session satisfaction surveys increased from Sessions 1 to 12 in all four areas (w2 = 6.6, median = 6.7, mode = 6.7). Reasons for increased program satisfaction may include adolescents being comfortable with, and getting to know, the group leader and other participants in the group setting over time. Participants verbalized feelings of trust and confidentiality within LEAD-C program sessions. The group leader also recognized programming curriculum that worked well with these adolescents and what did not work well. For example, group participants wanted to spend more time writing in their journals and less time listening to guided imagery CDs. Minor changes to the LEAD-C program sessions were made, and activities focused on the needs of the group.
Client Satisfaction Questionnaire Upon completion of all sessions, the CSQ (Larsen et al., 1979) was completed by the remaining LEAD-C participants (n = 2) during the last session of the program in Week 6. Participants answered eight questions (see Figure 2). These two participants were very satisfied (mean = 4) with the quality of services received and mostly satisfied (w2 = 3) with the overall satisfaction of the program services. The lowest average score (w2 = 2.5) was for the extent the program met their needs. For all remaining five questions on the CSQ,
participants were between mostly and very satisfied (w2 = 3.5) with the LEAD-C program.
Implementation Barriers Implementation barriers included obtaining parent/guardian permission, environmental challenges, and participation availability/nonattendance. Identification of barriers is important to address so that changes can be made and improved when the LEAD-C program is replicated. Before the implementation of LEAD-C, parental/ guardian permission was necessary. A cover letter explaining the LEAD-C program and a permission form was mailed to all adolescent offenders’ parents/guardians by the PI, with the assistance of medical records staff. Signed forms were to be mailed back to the PI within 2 weeks, in a selfaddressed stamped envelope provided, to the medical records department at the correctional facility. Returned forms were difficult for the PI to find and were not received in a timely manner. Locating a returned signed parental/ guardian permission form was an unforeseen barrier. Communication between all collaborators and correctional team members was necessary. Another barrier was that parental/guardian permission was difficult to obtain. Reasons for this may have included parents/guardians not living at addresses on record and/or moving frequently; homelessness; physical, emotional, and/or mental health issues; alcohol and/or drug use/abuse; and uncaring/uninvolved parents. This problem of unobtainable parental permission forms may be difficult to resolve. The Department of Children and Families (DCF) was the guardian for three participants. Follow-up with these adolescents’ DCF case workers/guardians was completed in a treatment group administrative meeting. Signed permission forms were easily obtained at this meeting, in the mail, or by fax from adolescents’ DCF case workers.
Environmental Challenges Safety and security take precedence in a correctional setting. The correctional environment can be a difficult place to run programs because of the lack of resources including correctional officer assistance and/or room availability. With the right planning and involving appropriate individuals in the correctional setting, these potential barriers can be overcome. Security awareness and the safety of environment, personnel, and group participants were necessary at all times. Room reservations for the LEAD-C program and being flexible with unforeseen changes were crucial. Maintaining professional relationships with the correctional officers was essential.
Participation Availability/Nonattendance FIGURE 2. Client Satisfaction Questionnaire. Journal of Forensic Nursing
The pattern of attendance varied by session. Six participants attended the first LEAD-C session; two participants completed the program. Unforeseen reasons for nonattendance www.journalforensicnursing.com
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and program completion included disciplinary infractions participants received that were not related to the LEAD-C program, court hearings, and/or participants being released from the DOC earlier than planned. Two participants were released from the DOC after the third session. A third participant was released from the DOC after the sixth session, and a fourth participant was released after the 11th session, only missing the last session. Four participants left before LEAD-C was completed; the remaining two participants completed the LEAD-C program.
Effectiveness of the Modified Therapeutic Expressive Arts Program Satisfaction Program session satisfaction surveys were reviewed after every session by the PI. Results were confidentially recorded on an Excel spreadsheet, which was updated weekly. Modifications were made as needed to address individual participant and group needs. The open-ended question asking if there was anything else a participant wanted to add or let the group leader know was helpful. One participant filled in a response every week. Her comments related to the expressive arts activity and the discussion and support that followed. Her responses included “I liked today’s group, it was nice,” “Thank you miss, it was very great,” “It was the best time I ever had here,” and “It was nice expressing myself.” The other participants rarely filled in responses. These responses included “Thank you for taking your time to help me and all the other YOs” (youthful offender) and “I liked the relaxation music.” Participants were very appreciative of this LEAD-C program, verbalizing it was nothing like any other group program they have attended in this correctional facility. LEAD-C program sessions ran smoothly for the most part. There were a few sessions where participants did not agree with each other, but arguments were made with civility, and group rules, which the participants set in the first program session, were followed. No referrals, for a participant being emotionally upset, needed to be made for this first pilot program of LEAD-C. Participants in the first LEAD-C program who were released from the DOC were not reincarcerated at the 6-month follow-up.
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Discussion Feasibility The LEAD-C program was feasible for a small group (N = 6) of adolescents for 6 weeks, but there were some barriers that needed to be overcome. Most barriers were easily and quickly conquered; however, there are still two barriers that need to be resolved and/or improved: parental permission because of permission forms not being returned and attendance related to participants’ disciplinary infractions, court hearings, and/or early release. 150
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A barrier that may be difficult to overcome is obtaining parental/guardian permission for this adolescent population. Making LEAD-C a regular part of correctional programming for this population would eliminate this barrier. Parental permission would not be necessary for this specific program, and adolescents would be able to attend this program. Another strategy may be to recruit adolescents at a different time when parents may still be present and available to sign a permission form for this program. This may include when adolescents are arrested or are at their court hearing. Consistent attendance was another barrier for several reasons. Participants were informed that a disciplinary infraction would most likely mean they could not attend this program and/or would miss a group session(s). This happened to one participant only once. She shared how upset she was that she had to miss a session, which opened up a discussion among all group members who then agreed to “follow all rules” so that they would not miss any future sessions. No participants had further disciplinary infractions during the time LEAD-C ran. As we want participants to attend all program sessions to reap the benefits of each session, working with DOC for alternative methods of disciplinary infractions (other than missing LEAD-C) may help. Court hearings were another reason participants missed sessions but are unavoidable, and dates are unforeseen. Finally, early release was an issue but can be addressed with additional eligibility criteria. Recruiting participants earlier, when first admitted (sentenced or remanded) into the DOC, may help retain participants for the entire program. Adding an ongoing open group design for sessions/programming, where new participants can join at any time, would be beneficial. Each open group session would need to be modified to include benefits if a participant only attends an individual session.
Implementation Implementation of the LEAD-C program for female adolescent offenders in a correctional setting was successful. Through formative and summative evaluations, the satisfaction and effectiveness of the program were measured. All six adolescents who participated in the pilot LEAD-C program responded favorably to the program as measured by the program session satisfaction questionnaire and the CSQ. Adolescents who attended actively participated in every LEAD-C activity session and showed engagement with the program content. Participants stated they looked forward to coming to LEAD-C every week and were sad to see the program end. In the last session, the remaining participants spoke about how this program “is like no other program here” (in the DOC), and one participant stated, “I have learned more about myself in the past six weeks than I ever knew” and “It was good to work through some trauma in my life; I now know that I am a good person.” Volume 11 • Number 3 • July-September 2015
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Original Article Collaboration The support and collaboration of vital correctional team members including the warden, deputy warden, lieutenant, psychologists, psychiatrists, nurses, medical records staff, adolescent treatment team members, and correctional officers was essential. Continuing involvement with all correctional treatment team members working with the adolescent population needs to be ongoing for future LEAD-C programs. Correctional facility staff were very helpful and welcomed LEAD-C as another after-school program.
Application to Other Settings This LEAD-C program was offered to adolescent female offenders in a women’s correctional facility. With the limited number of female adolescent offenders in the women’s facility, feasibility and implementation in a boys’ facility are recommended. LEAD-C may be applied and used, with little adaptation, for male adolescent offenders in boys’/men’s correctional facilities. Male adolescents usually have longer sentences in a correctional facility because of the more serious nature of crimes committed (Office of Juvenile Justice and Delinquency Prevention, 2008), which increase the probability of attending the entire 6-week program sessions of LEAD-C. LEAD-C may also help with resiliency for the male adolescent offender population. LEAD-C may also be implemented and offered to the 18- to 21-year-old population in women’s and men’s correctional facilities, and parental permission for these young adults would not be required. There is little programming for women in this age group at this correctional facility, and LEAD-C may be very valuable and beneficial for this population. The LEAD-C curriculum would need to be adjusted slightly for this population of young adults. Implementation of LEAD-C in other correctional facilities, and also into the community with newly released offenders, may prove to be very valuable and help to decrease recidivism.
Limitations A limitation of this pilot study was the small sample size of participants who completed the LEAD-C program because of attrition. Youth were released from the facility and unable to complete the program. This issue will need to be addressed for future programming. An open group design allowing adolescents to enter and leave the group as needed based on their length of stay in the DOC facility may be an option. A more rigorous design is needed to show clinical outcomes of LEAD-C. Random assignment to control treatment comparison groups and longitudinal postrelease follow-up would indicate effectiveness of the intervention. Inside–outside models are considered valuable for criminal justice populations (James, 2015) and would provide an alternative design for program delivery. Journal of Forensic Nursing
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Implications for Practice, Policy, and Future Research
There are not many nurse-led evidence-based treatment programs in correctional settings. Nurses are at the forefront of delivering healthcare in this unique setting on a daily basis. They have the knowledge, education, and leadership skills to influence practice and run programs that can make a difference for the patients they serve in correctional settings. Using a theoretical framework focusing on resilience of the female adolescent offender population and/or the effect of an evidence-based therapeutic expressive arts behavioral program is essential. Continuing the LEAD-C program in this correctional facility and placing more LEAD-C programs in other correctional facilities may obtain similar results as that in the community. This would be beneficial for the adolescents and also for society and the communities in which we live. Providing evidence-based programming, including LEAD-C, for female adolescent offenders and other populations in correctional settings may promote resilience in all these vulnerable populations. Nurses can make a difference for these adolescent offenders and for society as a whole. Based on the success of the LEAD-C program pilot, nurses should be encouraged to continue with implementation of this program in other correctional facilities. Using a resilience framework, including sociocultural context, individual risk factors, and protective resources, can strengthen resiliency and protective resources for youth (Rew & Horner, 2003) and improve health outcomes for adolescents. This, in turn, may help decrease recidivism. Longitudinal follow-up in clinical practice would be needed to review adolescent offender outcomes, including residency. Community support would be necessary, including funding, and this would be another area for clinical nursing practice, policy development, community education, and research for nurses. Implementation of policies in correctional settings and/or organizations is also needed to assure that programming meets the needs of adolescent offenders. Female adolescent offenders need resources, services, and more evidence-based programming in correctional settings. Allocation of resources is needed so that adolescents may receive programming to help foster resilience. Resources include financial resources, time, and clinical nursing practice availability to implement new policy changes necessary to provide evidence-based treatment programs for adolescent offenders. Future research with continuation of the LEAD-C program for adolescent female offenders in a women’s correctional facility is recommended. Funding and/or nursing resources, specifically time, are needed to continue this program. Eligibility criteria must be reevaluated. Four adolescent offenders who were not sentenced, and who participated in this pilot program, were released from corrections earlier than planned and therefore were not able to complete the LEAD-C program. Eligibility criteria included www.journalforensicnursing.com
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participants having a release date from corrections at least 7 weeks from the start of the program; however, when the adolescents went for their court hearing, they were released early. For this reason, eligibility criteria for closed groups would remain the same, but criteria for open groups would be altered to eliminate the release date criteria of 7 weeks from the start of the program. Another option to evaluate may be to have more flexibility with the length of time/ weeks of the LEAD-C program. An alternative to explore would be to offer the same amount of LEAD-C program sessions (12) over 4 weeks by increasing program sessions to three times per week. Shortening the LEAD-C program to 4 weeks, from 6 weeks, may increase the number of participants who may be able to complete the program. The number of program sessions would remain the same. Therapeutic evaluations of adolescents would need to be completed by clinicians to test outcomes of a shortened program, as compared with the 6-week LEAD-C program, for this vulnerable population. A comparison between LEAD-C participants and nonLEAD-C participants would be beneficial. It is recommended that eligible/assenting adolescents not participating in LEAD-C programs be assigned to one of the after-school sessions offered, which is treatment as usual (TAU). TAU groups, which are considered usual and customary “standard of care,” are offered routinely for adolescents in the DOC and may consist of different programs throughout the year. In contrast to LEAD-C, the TAU after-school programs are highly structured and may include Girls Circle, yoga, exercise programs, addiction services, and anger management. None of the programs combine the aspects of LEAD-C, and none of the programs utilize them with the therapeutic emphasis designed in the LEAD-C curriculum. Comparison analysis of adolescent offenders who participate in the therapeutic expressive arts LEAD-C program may be evaluated for increased self-esteem, resilience, and behavioral control and if participants are able to address issues of interpersonal/domestic violence and/or stress when compared with the TAU group. The LEAD-C program can enhance resiliency, help to overcome adversity, improve outcomes, and positively influence the lives of adolescent female offenders in a women’s correctional facility. The six adolescents participating in LEAD-C were taught coping strategies, through the use of therapeutic expressive arts, to begin the healing process to foster resilience. Nurses have an important leadership role and must be actively involved in future planning and implementation of new policy, programs, and research for all patients, especially for the vulnerable adolescent female offender population.
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Acknowledgments
The authors would like to thank the Department of Correction facility Warden, treatment team members, 152
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correctional officers, and all others who helped in many essential ways for their collaboration and support implementing this pilot study in a correctional setting. The authors would also like to thank all participants of the first LEAD-C program who made this possible.
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References
Ahern, N. R., Ark, P., & Byers, J. (2008). Resilience and coping strategies in adolescents. Pediatric Nursing, 20(10), 32–36. Albrecht, L. (1994). Understanding juvenile female offenders: There is a difference. 1994 Juvenile Female Offenders Conference: A time for change (pp. 15–46). Lanham, MD: American Correctional Association. Attkisson, C. C. (2012). Client Satisfaction Questionnaire (CSQ scales): Administering and scoring the CSQ scales. Mill Valley, CA: Tamalpais Matrix Systems, LLC. Retrieved from http:// www.csqscales.com/pdfs/Brief%20Summary%20of%20the %20 Client%20Satisfaction%20Questionnaire%20(CSQ% 20Scales).pdf Chitsabesan, P., Kroll, L., Bailey, S., Kennings, C., Sneider, S., MacDonald, W., & Theodosiou, L. (2006). Mental health needs of young offenders in custody and in the community. The British Journal of Psychiatry, 188, 534–540. Cook, N. E., Barese, T. H., & Dicataldo, F. (2010). The confluence of mental health and psychopathic traits in adolescent female offenders. Criminal Justice and Behavior, 37(1), 119–135. doi:10 .1177/0093854809350607 Fox, J. (2003). Poetry and caring: Healing the within. In Kirklin, D., Richardson, R. (Eds.), The healing environment: Without and within. London, England: Royal College of Physicians. Grande, T. L., Hallman, J., Rutledge, B., Caldwell, K., Upton, B., Underwood, L. A., . . . Rehfuss, M. (2012). Examining mental health symptoms in male and female incarcerated juveniles. Behavioral Sciences & the Law, 30, 365–369. Guthrie, B. J., Cooper, S. M., Brown, C., & Metzger, I. (2012). Degrees of difference among minority female juvenile offenders’ psychological functioning, risk behavior engagement, and health status: A latent profile investigation. Journal of Health Care for the Poor and Underserved, 23(1), 204–225. Hubbard, D. J., & Pratt, T. C. (2002). A meta-analysis of the prediction of delinquency among girls. Journal of Offender Rehabilitation, 34, 1–13. James, N. (2015). Offender reentry: Correctional statistics, reintegration into the community and recidivism. Congressional Research Service. Retrieved from https://fas.org/sgp/crs/misc/ RL34287.pdf Larsen, D. L., Attkisson, C. C., Hargreaves, W. A., & Nguyen, T. D. (1979). Assessment of client/patient satisfaction: Development of a general scale. Evaluation and Program Planning, 2, 197–207. Lederman, C. S., Dakof, G. A., Larrea, M. A., & Li, H. (2004). Characteristics of adolescent females in juvenile detention. International Journal of Law and Psychiatry, 27, 321–337. Lenz, A. S., Speciale, M., & Aguilar, J. V. (2012). Relational– cultural therapy intervention with incarcerated adolescents: A single-case effective design. Counseling Outcome Research, 3(1) 17–29. Lewis, C. (2006). Treating incarcerated women: Gender matters. The Psychiatric Clinics of North America, 29, 773–789. Martin, D., Martin, M., Dell, R., Davis, C., & Guerrieri, K. (2008). Profile of incarcerated juveniles: Comparison of male and female offenders. Adolescence, 43(171), 607–622. Volume 11 • Number 3 • July-September 2015
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Original Article Office of Juvenile Justice and Delinquency Prevention. (2008). Census of juveniles in residential placement 2006. Washington, DC: Author. Palidofsky, M., & Stolbach, B. C. (2012). Dramatic healing: The evolution of a trauma-informed musical theatre program for incarcerated girls. Journal of Child & Adolescent Trauma, 5(3), 239–256. doi:10.1080/19361521.2012.697102 Palmer, E. J., Jinks, M., & Hatcher, R. M. (2010). Substance use, mental health, and relationships: A comparison of male and female offenders serving community sentences. International Journal of Law and Psychiatry, 33(2), 89–93. doi:10.1016/ j. ijlp.2009.12.007 Polk, L. V. (1997). Toward a middle-range theory of resilience. Advances in Nursing Science, 19(3), 1–13. Puzzanchera, C. (2013). Juvenile arrests 2011. Juvenile Offenders and Victims: National Report Series, 1–11. (pp. 1–11). Retrieved from http://www.ojjdp.gov/pubs/244476.pdf Rew, L., & Horner, S. D. (2003). Youth resilience framework for
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reducing health-risk behaviors in adolescents. Journal of Pediatric Nursing, 18, 379–388. Roberts-Lewis, A., Welch-Brewer, C., Jackson, M. S., Kirk, R., & Pharr, O. M. (2010). Assessing change in psychosocial functioning of incarcerated girls with a substance use disorder: Gender sensitive substance abuse intervention. Journal of Offender Rehabilitation, 49(7), 479–494. doi:10.1080/10509674.2010. 510771 Shelton, D. (2008). Translating theory into practice: Results of a 2-year trial for the LEAD programme. Journal of Psychiatric and Mental Health Nursing, 15, 313–321. Shelton, D. (2009). Leadership, education, achievement, and development: A nursing intervention for prevention of youthful offending behavior. Journal of the American Psychiatric Nurses Association, 14(6), 429–441. Solomon, B. J., Davis, L. E. G., & Luckham, B. (2012). The relationship between trauma and delinquent decision making among adolescent female offenders: Mediating effects. Journal of Child & Adolescent Trauma, 5(2), 161–172. doi:10.1080/19361521.2012.672546
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Evaluating an Adolescent Behavioral Program: Leadership, Education, Achievement, and Development for Adolescent Female Offenders in Corrections Denise M. Panosky, DNP, RN, CNE, CCHP, FCNS and Deborah Shelton, PhD, RN, NE-BC, CCHP, FAAN
ABSTRACT This article reports the findings of a pilot study designed to: test the feasibility of implementation, assess implementation barriers, and determine the effectiveness of a modified evidence-based program designed for adolescent female offenders in a women’s correctional facility in the United States. A therapeutic expressive arts behavioral program, Leadership, Education, Achievement and Development (LEAD), has been used in community settings as a health promotion program. This behavioral program was adapted to LEAD-Corrections (LEAD-C) and serves incarcerated adolescent female offenders. Results of this pilot study show that it is feasible to offer LEAD-C in a correctional setting. Positive effects were noted on session satisfaction surveys as well as formative and summative evaluations. Implementation of LEAD-C, using therapeutic expressive arts interventions, included coping strategies to help adolescents become confident and self-assured and review better choices. Adolescents were taught to utilize these learned coping strategies in their life, which may help to overcome adversity, enhance resilience, and support youth transition at the time of reentry to the community. KEY WORDS: adolescent female offenders; corrections; expressive arts; health promotion; resiliency
he aim of this article is to report the findings of a pilot study designed to test the feasibility of implementation, assess implementation barriers, and determine the effectiveness of a modified evidence-based program designed for adolescent female offenders in a women’s correctional facility in the United States. The goal of the program was to enhance resilience by strengthening coping strategies and decision-making skills for incarcerated youth.
T
Author Affiliation: School of Nursing, University of Connecticut. Funding for this study was received from the Viola Bernard Foundation and Sigma Theta Tau International Mu Chapter. The authors declare no conflict of interest. Correspondence: Denise M. Panosky, DNP, RN, CNE, CCHP, FCNS, School of Nursing, University of Connecticut, 231 Glenbrook Road, Unit 4026 Storrs, CT 06260. E-mail: [email protected]. Received March 21, 2015; accepted for publication June 20, 2015. Copyright © 2015 International Association of Forensic Nurses DOI: 10.1097/JFN.0000000000000082
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It was believed that these skills would help to overcome adversity, enhance resilience, and support youth transition at reentry to the community.
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Background and Significance
In 2011, U.S. law enforcement agencies made almost 1.5 million juvenile arrests; 29%, or 429,000, of these arrests involved female offenders (Puzzanchera, 2013). Gender differences are seen in juvenile offending and need to be recognized so that effective programming can be tailored to meet the unique needs of these adolescents. In comparison with their male counterparts, female juvenile offenders present with a higher prevalence of physical and sexual abuse, mental health challenges (Cook, Barese, & Dicataldo, 2010; Grande et al., 2012; Guthrie, Cooper, Brown, & Metzger, 2012; Palmer, Jinks, & Hatcher, 2010), and exposure to trauma (Solomon, Davis, & Luckham, 2012), which must be considered when planning effective programs Volume 11 • Number 3 • July-September 2015
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(Lederman, Dakof, Larrea, & Li 2004; Lewis, 2006; Martin, Martin, Dell, Davis, & Guerrieri, 2008). In addition, family dysfunction, substance abuse problems, high-risk sexual behaviors, school problems, and affiliation with deviant peers (Hubbard & Pratt, 2002) are seen more frequently among incarcerated women, further supporting the need for gender-sensitive programs within the legal and criminal justice systems. There are few studies that specifically target adolescent incarcerated women. Palidofsky and Stolbach (2012) described a drama therapy program used with incarcerated girls with trauma histories, to perform musicals based on their experiences, which led to therapeutic benefits for participants. In a single-case effectiveness study (N = 4), Lenz, Speciale, and Aguilar (2012) found that a nine-session relational– cultural therapy intervention helped incarcerated women to foster relational empowerment and engagement. Furthermore, gender-specific substance abuse interventions have been found to reduce problems related to social and personal functioning in incarcerated female adolescents (RobertsLewis, Welch-Brewer, Jackson, Kirk, & Pharr, 2010). Lederman et al. (2004) suggest that interventions that have been developed for assisting incarcerated adolescents have the potential to help them turn their lives around. Rew and Horner (2003) further suggest that using a resilience framework to address the needs of female adolescent offenders may be beneficial through the use of early interventions designed to reduce risky behaviors and associated negative outcomes later in adolescence. Different study outcomes have proven effectiveness for incarcerated women, but they are limited in number and may focus on only one aspect of their lives. Using a resilience framework may help focus adolescent female offenders be successful with reentry into the community with a strong foundation of resilience strategies.
Adolescent Resilience Polk’s (1997) resilience theory was the fundamental theoretical framework used for the Leadership, Education, Achievement, and Development-Corrections (LEAD-C) program. Resilience is important to this work as it has been shown that resilient adolescents are individuals who have positive outcomes in the face of adversity and may increase competence; build connections; and develop communication, academic, decision making, and extracurricular skills (Rew & Horner, 2003). Furthermore, “resilience represents the interaction between risk factors (vulnerability) and protective resources (protection)” (Rew & Horner, 2003, p. 379) and is often “viewed as an adaptive stress-resistant personal quality that permits one to thrive in spite of adversity” (Ahern, Ark, & Byers, 2008, p. 32). LEAD-C applies strategies to build resiliency. Nurses working with adolescents can use and teach strategies to help enhance resiliency to improve outcomes. Journal of Forensic Nursing
Therapeutic Arts Intervention LEAD (Shelton, 2008, 2009) is an evidence-based therapeutic expressive arts program designed for use in a community setting to reduce the risk of minority youth involvement with the juvenile justice system. In collaboration with the author of LEAD, LEAD-C was adapted for a correctional setting and pilot tested with a sample of incarcerated female adolescents. The LEAD-C program used therapeutic expressive arts and coping skills strategies to enhance resilience among the incarcerated youth who participated. It was expected that these skills would transfer to the community upon reentry. To determine the effectiveness of the therapeutic arts program, adaptations were made for LEAD-C to prevent misuse of self-disclosed personal information that would put participants at high risk for abuse or manipulation within this closed environment. Expressive arts (drawing, poetry, music, drama, and drumming) permit healing from within without verbal disclosure through the expression of self and the experience each individual has, even if no words are used (Fox, 2003). In this way, the arts provide the opportunity for communication and healing to occur on an individual basis, especially in an environment where the potential for misuse of verbal disclosures is high. Journaling, a means of private written expression, provided opportunity for guided reflection and active counseling between group leaders and individual participants in a confidential manner. Writing was completed in the group, and journals were collected and returned to participants in the next group with comments from group leaders. This provided safe keeping of the journals, as personal space was limited for participants’ personal items within their living environments in the correctional setting. Upon release, the journals were mailed to participants if wanted. This study also sought to assess the feasibility of implementing the LEAD-C program in a women’s correctional facility. Of interest were implementation issues related to the correctional environment (e.g., space, staff coordination) as well as implementation and evaluation of the effectiveness of the logistical curriculum content (which was adapted to meet safety and security of the environment), programmatic structure (e.g., length of session, instrumentation, size of group), and recording of barriers so that they could be addressed when the program was replicated. There is a lack of gender-specific programming in many correctional facilities (Albrecht, 1994), especially evidencebased treatment programs designed for correctional health settings. Many needs of young offenders are often unmet, including mental health, social, and educational needs, with few offenders having any form of intervention (Chitsabesan et al., 2006). Teaching adolescent offenders coping and problem-solving strategies to help make better choices may indeed promote confidence, positive thinking, positive www.journalforensicnursing.com
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attitudes, and self-assurance and improve reentry outcomes such as retention in school. This pilot study explored the feasibility, implementation, barriers, and effectiveness of an evidence-based therapeutic expressive arts program for adolescent offenders in a women’s correctional facility. The study sought to answer the clinical question, “Can the LEAD-C program be implemented effectively with female adolescents in a women’s correctional setting?”
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Methods Design This feasibility study utilized a repeated measures design with a 6-month follow-up to examine program satisfaction and effectiveness. Descriptive and qualitative approaches were utilized for programmatic evaluation. The setting was in a northeastern state prison facility in the United States that houses all female juvenile and adult offenders. Institutional review board approval was obtained from the University of Connecticut (Protocol No. H09-153), Duquesne University (Protocol No. 09-90), and the Connecticut Department of Correction (DOC; Protocol No. 2010CAU-72).
Criteria for Participation English-speaking adolescent female offenders aged 15–17 years, of any race or ethnicity, and who had a DOC release date (sentenced or remanded) of at least 7 weeks after the start date of the LEAD-C program were eligible to participate in the study. Because the groups took place off the living units, only youth who were behaviorally stable to obtain a pass off their unit to attend the group were eligible.
Participant Recruitment Procedures Potential participants were identified by treatment teams and asked if they wanted to participate. If they verbally agreed to participate, permission forms were mailed to their parents/guardians. Once completed permission forms were obtained, the principal investigator (PI) met with the adolescents to explain the LEAD-C program and obtain assent along with a declared commitment to participate in the program for 6 weeks. Although there were minimal risks involved with participation in the LEAD-C program, as per DOC protocol, the PI agreed to make a verbal referral to the treatment team member on duty if a participant was emotionally upset or tearful during or after a program session. At the start of the program, six female adolescent offenders agreed to participate in the pilot LEAD-C program. Five of the participants were 17 years old, and one was 16 years old (mean age = 16.8 years). One participant responded that she was White, four indicated that they were multiracial (White/Hispanic, Hispanic Black, Hispanic/ American Indian, Black/American Indian), and one chose not to answer this question. 146
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Implementation of the LEAD-C Program LEAD-C was implemented over 6 weeks; two sessions were offered twice a week after school, for 1.5 hours. These sessions were closed group sessions, implying that, once a group program began, it was closed to new participants. The number of participants was purposely kept small to allow for both individual and therapeutic group participation. Each LEAD-C session was structured with an introduction of the session’s focus, relaxation, a journaling assignment, an expressive arts activity, cleanup, and an anonymous evaluation of the program session. Topics included coping skills and tools, exploration of self (identity and uniqueness, within the family and environment), social networks, anger management, self-talk and affirmations, and role expansion. The LEAD-C curriculum was designed in a manner that allowed for a relaxation activity at the close of each session, which further provided the PI with the opportunity to observe each individual participant for signs of being upset, which would have required a referral to treatment staff. Data were collected at various intervals. Demographic data forms were completed on the first week of LEAD-C, and participants had the opportunity to evaluate each LEAD-C session. At the 6-week point (program end), a Client Satisfaction Questionnaire (CSQ; Larsen, Attkisson, Hargreaves, & Nguyen, 1979) was completed by participants. In addition, upon completion of the program, certificates were provided at a small celebration of completion. A postprogram evaluation was conducted to determine if: (a) the participant would participate in a community-based LEAD program if it was offered; and (b) arrangements were made to mail journals to the participant’s address once released from the DOC. Reincarceration rates were reviewed at 6 months after the program to see if an adolescent was sent/committed/sentenced back to prison. Feasibility, implementation, and effectiveness of the LEAD-C program were evaluated weekly throughout the 6 weeks of the program. Weekly reviews of barriers, the implementation process, program attendance, and monthly reviews at administrative meetings with the correctional facility team members were also completed.
Instruments Demographic Data Form A demographic data form was developed by the PI for use in this study. Demographic data (age, race, and ethnicity) were collected and used to describe the population. This form was filled out by each participant in Session 1.
Program Session Satisfaction Scale The Program Session Satisfaction Scale was also developed by the PI for this pilot study. The four-item analog scale, with seven numbered sad/happy faces (representing “not very satisfied” to “very satisfied”), was completed by Volume 11 • Number 3 • July-September 2015
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participants after each LEAD-C session to rate that session’s activities, specifically the session’s curriculum focus and programmatic structure, for example, the length of session, sequence of activities, assessment and satisfaction measures, and size of group (see Figure 1). Participants reported their satisfaction with the program session by
circling the faces with the numbers that corresponded to their feelings about the activities in each session, and dropped their evaluations off in a box on their way out the door. The higher numeral response was correlated to a higher satisfaction level. One open-ended question asked if there was anything else participants wanted to add. The
FIGURE 1. LEAD-C program session satisfaction. LEAD-C = Leadership, Education, Achievement and Development-Corrections. Journal of Forensic Nursing
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PI reviewed all written responses after every session and made improvements and/or changes to programming as needed. For example, if participants stated they wanted more journaling time, or more guided imagery time, this was added into the future sessions.
satisfaction; (b) the assessment of implementation barriers; and (c) the effectiveness of the modified therapeutic expressive arts program designed for young female offenders.
Client Satisfaction Questionnaire
Implementing and running a program in a correctional facility cannot be accomplished without the support from those working in the correctional facility. Adolescents needed to arrive on time and attend each LEAD-C program session. Factors that supported implementation of the LEAD-C program included tremendous support from the DOC, including the warden, custody staff, and treatment team members. Obtaining support from custody, including correctional officer supervisors and correctional officers, was necessary. Treatment team meetings were facilitated before beginning this study. Correctional officers were available, and support continued throughout the 6 weeks for all 12 LEAD-C program sessions. Before each LEAD-C session, the PI arrived early to meet with the correctional officer responsible for escorting participants to the group sessions. A list of LEAD-C participants was given to the correctional officer, who made a telephone call to the Pod (living area), for the participants to arrive on time for each session. Participants were aware of each program session and ready to attend when called. Participants were informed, during the assent process, and agreed to attend all LEAD-C sessions. A correctional officer always had a room available for the LEAD-C program. Coordination and cooperation were always accomplished, and all available participants arrived as planned to each LEAD-C session. Attendance of participants in every LEAD-C program session was recorded by the PI. The first session was attended by all six participants. The second and third sessions were attended by five participants; one participant was not allowed, by DOC staff, to attend for disciplinary reasons. Further sessions were not attended by all participants (w = 3.58, median = 3, mode = 3). The original design for the LEAD-C program was to have sessions twice a week, for 2 hours, for 6 weeks. Because of school and dinner time conflicts, an adjustment of the 2-hour time frame was necessary. The length of LEAD-C sessions was adjusted to 1.5 hours. This time was sufficient for LEAD-C sessions, especially with our small group of participants. There was enough time for program curriculum and an adequate amount of time to give each participant individual attention if needed.
This eight-item, 4-point Likert scale, structured questionnaire was used without modification. The questionnaire asked participants about the quality of services received, if it was the service wanted, the extent the program met their needs, if they would recommend the program to a friend in need, how satisfied they were with the amount of help received, if the services helped with their problem, overall satisfaction with the program and services, and whether they would participate in the program again (Larsen et al., 1979). Overall scores ranged from 8 to 32, with the higher score indicating higher satisfaction. In many studies, the reliability of the CSQ-8 has been reported with the internal consistency, as measured by coefficient alpha, ranging from 0.83 to 0.93, with values of 0.86 and 0.87 in two of the largest samples. Validity has been indicated by higher satisfaction scores among participants who completed a program as compared with participants who did not complete a program (Attkisson, 2012).
Field Notes The PI’s personal notes and observations made while implementing the program were retained for use in evaluation of the pilot data and to guide later replication of the program. These notes were compared between the PI and the research mentor for process modifications. Facilitation of the implementation process was measured by adolescent movement from living area to program room by corrections officers, program dates, times, room availability, correctional officer availability, parent or guardian permission, and participant assent obtainment. Process evaluation measures were reviewed weekly by the PI and at monthly administrative meetings with the DOC Research Advisory Committee, the DOC treatment team, and the correctional facility warden. Confidential minutes of the meetings were kept by the PI, and qualitative review of the implementation process was ongoing with improvements and/or minor changes made as necessary. Summative evaluation measures included dropout rate and loss to release from corrections into the community and were also reviewed at monthly administrative meetings.
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Results
This pilot study sought to answer the clinical question, “Can the LEAD-C program be implemented effectively with female adolescents in a women’s correctional setting?” The findings of this pilot study will be reported in three sections: (a) the feasibility of implementation and program 148
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Feasibility of Implementation and Program Satisfaction
Program Session Satisfaction Scale Results on the program satisfaction scale (7-point analog scale) included satisfaction with the following: the time length of the sessions (w2 score = 6.6), the activities completed (w2 score = 6.4), the size of the group (w2 score = 6.6), and the overall session program (w2 score = 6.6). Responses to a fifth Volume 11 • Number 3 • July-September 2015
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open-ended question asking if there was anything else participants wanted to add or let the PI know were recorded. Results from the four satisfaction questions/program areas were recorded. The average scores of participants for questions about time, group size, and overall program were between 6 and 7 constantly (w2 = 6.6), indicating a high level of satisfaction. The average scores of participants for the question about activities were between 6 and 7 for Sessions 2–12 (w2 = 6.4), with the exception of Session 1 where the average score fell slightly below 6 (w2 = 5.7). Participants’ satisfaction for the LEAD-C program shown by the overall trend lines for all LEAD-C program session satisfaction surveys increased from Sessions 1 to 12 in all four areas (w2 = 6.6, median = 6.7, mode = 6.7). Reasons for increased program satisfaction may include adolescents being comfortable with, and getting to know, the group leader and other participants in the group setting over time. Participants verbalized feelings of trust and confidentiality within LEAD-C program sessions. The group leader also recognized programming curriculum that worked well with these adolescents and what did not work well. For example, group participants wanted to spend more time writing in their journals and less time listening to guided imagery CDs. Minor changes to the LEAD-C program sessions were made, and activities focused on the needs of the group.
Client Satisfaction Questionnaire Upon completion of all sessions, the CSQ (Larsen et al., 1979) was completed by the remaining LEAD-C participants (n = 2) during the last session of the program in Week 6. Participants answered eight questions (see Figure 2). These two participants were very satisfied (mean = 4) with the quality of services received and mostly satisfied (w2 = 3) with the overall satisfaction of the program services. The lowest average score (w2 = 2.5) was for the extent the program met their needs. For all remaining five questions on the CSQ,
participants were between mostly and very satisfied (w2 = 3.5) with the LEAD-C program.
Implementation Barriers Implementation barriers included obtaining parent/guardian permission, environmental challenges, and participation availability/nonattendance. Identification of barriers is important to address so that changes can be made and improved when the LEAD-C program is replicated. Before the implementation of LEAD-C, parental/ guardian permission was necessary. A cover letter explaining the LEAD-C program and a permission form was mailed to all adolescent offenders’ parents/guardians by the PI, with the assistance of medical records staff. Signed forms were to be mailed back to the PI within 2 weeks, in a selfaddressed stamped envelope provided, to the medical records department at the correctional facility. Returned forms were difficult for the PI to find and were not received in a timely manner. Locating a returned signed parental/ guardian permission form was an unforeseen barrier. Communication between all collaborators and correctional team members was necessary. Another barrier was that parental/guardian permission was difficult to obtain. Reasons for this may have included parents/guardians not living at addresses on record and/or moving frequently; homelessness; physical, emotional, and/or mental health issues; alcohol and/or drug use/abuse; and uncaring/uninvolved parents. This problem of unobtainable parental permission forms may be difficult to resolve. The Department of Children and Families (DCF) was the guardian for three participants. Follow-up with these adolescents’ DCF case workers/guardians was completed in a treatment group administrative meeting. Signed permission forms were easily obtained at this meeting, in the mail, or by fax from adolescents’ DCF case workers.
Environmental Challenges Safety and security take precedence in a correctional setting. The correctional environment can be a difficult place to run programs because of the lack of resources including correctional officer assistance and/or room availability. With the right planning and involving appropriate individuals in the correctional setting, these potential barriers can be overcome. Security awareness and the safety of environment, personnel, and group participants were necessary at all times. Room reservations for the LEAD-C program and being flexible with unforeseen changes were crucial. Maintaining professional relationships with the correctional officers was essential.
Participation Availability/Nonattendance FIGURE 2. Client Satisfaction Questionnaire. Journal of Forensic Nursing
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and program completion included disciplinary infractions participants received that were not related to the LEAD-C program, court hearings, and/or participants being released from the DOC earlier than planned. Two participants were released from the DOC after the third session. A third participant was released from the DOC after the sixth session, and a fourth participant was released after the 11th session, only missing the last session. Four participants left before LEAD-C was completed; the remaining two participants completed the LEAD-C program.
Effectiveness of the Modified Therapeutic Expressive Arts Program Satisfaction Program session satisfaction surveys were reviewed after every session by the PI. Results were confidentially recorded on an Excel spreadsheet, which was updated weekly. Modifications were made as needed to address individual participant and group needs. The open-ended question asking if there was anything else a participant wanted to add or let the group leader know was helpful. One participant filled in a response every week. Her comments related to the expressive arts activity and the discussion and support that followed. Her responses included “I liked today’s group, it was nice,” “Thank you miss, it was very great,” “It was the best time I ever had here,” and “It was nice expressing myself.” The other participants rarely filled in responses. These responses included “Thank you for taking your time to help me and all the other YOs” (youthful offender) and “I liked the relaxation music.” Participants were very appreciative of this LEAD-C program, verbalizing it was nothing like any other group program they have attended in this correctional facility. LEAD-C program sessions ran smoothly for the most part. There were a few sessions where participants did not agree with each other, but arguments were made with civility, and group rules, which the participants set in the first program session, were followed. No referrals, for a participant being emotionally upset, needed to be made for this first pilot program of LEAD-C. Participants in the first LEAD-C program who were released from the DOC were not reincarcerated at the 6-month follow-up.
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Discussion Feasibility The LEAD-C program was feasible for a small group (N = 6) of adolescents for 6 weeks, but there were some barriers that needed to be overcome. Most barriers were easily and quickly conquered; however, there are still two barriers that need to be resolved and/or improved: parental permission because of permission forms not being returned and attendance related to participants’ disciplinary infractions, court hearings, and/or early release. 150
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A barrier that may be difficult to overcome is obtaining parental/guardian permission for this adolescent population. Making LEAD-C a regular part of correctional programming for this population would eliminate this barrier. Parental permission would not be necessary for this specific program, and adolescents would be able to attend this program. Another strategy may be to recruit adolescents at a different time when parents may still be present and available to sign a permission form for this program. This may include when adolescents are arrested or are at their court hearing. Consistent attendance was another barrier for several reasons. Participants were informed that a disciplinary infraction would most likely mean they could not attend this program and/or would miss a group session(s). This happened to one participant only once. She shared how upset she was that she had to miss a session, which opened up a discussion among all group members who then agreed to “follow all rules” so that they would not miss any future sessions. No participants had further disciplinary infractions during the time LEAD-C ran. As we want participants to attend all program sessions to reap the benefits of each session, working with DOC for alternative methods of disciplinary infractions (other than missing LEAD-C) may help. Court hearings were another reason participants missed sessions but are unavoidable, and dates are unforeseen. Finally, early release was an issue but can be addressed with additional eligibility criteria. Recruiting participants earlier, when first admitted (sentenced or remanded) into the DOC, may help retain participants for the entire program. Adding an ongoing open group design for sessions/programming, where new participants can join at any time, would be beneficial. Each open group session would need to be modified to include benefits if a participant only attends an individual session.
Implementation Implementation of the LEAD-C program for female adolescent offenders in a correctional setting was successful. Through formative and summative evaluations, the satisfaction and effectiveness of the program were measured. All six adolescents who participated in the pilot LEAD-C program responded favorably to the program as measured by the program session satisfaction questionnaire and the CSQ. Adolescents who attended actively participated in every LEAD-C activity session and showed engagement with the program content. Participants stated they looked forward to coming to LEAD-C every week and were sad to see the program end. In the last session, the remaining participants spoke about how this program “is like no other program here” (in the DOC), and one participant stated, “I have learned more about myself in the past six weeks than I ever knew” and “It was good to work through some trauma in my life; I now know that I am a good person.” Volume 11 • Number 3 • July-September 2015
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Original Article Collaboration The support and collaboration of vital correctional team members including the warden, deputy warden, lieutenant, psychologists, psychiatrists, nurses, medical records staff, adolescent treatment team members, and correctional officers was essential. Continuing involvement with all correctional treatment team members working with the adolescent population needs to be ongoing for future LEAD-C programs. Correctional facility staff were very helpful and welcomed LEAD-C as another after-school program.
Application to Other Settings This LEAD-C program was offered to adolescent female offenders in a women’s correctional facility. With the limited number of female adolescent offenders in the women’s facility, feasibility and implementation in a boys’ facility are recommended. LEAD-C may be applied and used, with little adaptation, for male adolescent offenders in boys’/men’s correctional facilities. Male adolescents usually have longer sentences in a correctional facility because of the more serious nature of crimes committed (Office of Juvenile Justice and Delinquency Prevention, 2008), which increase the probability of attending the entire 6-week program sessions of LEAD-C. LEAD-C may also help with resiliency for the male adolescent offender population. LEAD-C may also be implemented and offered to the 18- to 21-year-old population in women’s and men’s correctional facilities, and parental permission for these young adults would not be required. There is little programming for women in this age group at this correctional facility, and LEAD-C may be very valuable and beneficial for this population. The LEAD-C curriculum would need to be adjusted slightly for this population of young adults. Implementation of LEAD-C in other correctional facilities, and also into the community with newly released offenders, may prove to be very valuable and help to decrease recidivism.
Limitations A limitation of this pilot study was the small sample size of participants who completed the LEAD-C program because of attrition. Youth were released from the facility and unable to complete the program. This issue will need to be addressed for future programming. An open group design allowing adolescents to enter and leave the group as needed based on their length of stay in the DOC facility may be an option. A more rigorous design is needed to show clinical outcomes of LEAD-C. Random assignment to control treatment comparison groups and longitudinal postrelease follow-up would indicate effectiveness of the intervention. Inside–outside models are considered valuable for criminal justice populations (James, 2015) and would provide an alternative design for program delivery. Journal of Forensic Nursing
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Implications for Practice, Policy, and Future Research
There are not many nurse-led evidence-based treatment programs in correctional settings. Nurses are at the forefront of delivering healthcare in this unique setting on a daily basis. They have the knowledge, education, and leadership skills to influence practice and run programs that can make a difference for the patients they serve in correctional settings. Using a theoretical framework focusing on resilience of the female adolescent offender population and/or the effect of an evidence-based therapeutic expressive arts behavioral program is essential. Continuing the LEAD-C program in this correctional facility and placing more LEAD-C programs in other correctional facilities may obtain similar results as that in the community. This would be beneficial for the adolescents and also for society and the communities in which we live. Providing evidence-based programming, including LEAD-C, for female adolescent offenders and other populations in correctional settings may promote resilience in all these vulnerable populations. Nurses can make a difference for these adolescent offenders and for society as a whole. Based on the success of the LEAD-C program pilot, nurses should be encouraged to continue with implementation of this program in other correctional facilities. Using a resilience framework, including sociocultural context, individual risk factors, and protective resources, can strengthen resiliency and protective resources for youth (Rew & Horner, 2003) and improve health outcomes for adolescents. This, in turn, may help decrease recidivism. Longitudinal follow-up in clinical practice would be needed to review adolescent offender outcomes, including residency. Community support would be necessary, including funding, and this would be another area for clinical nursing practice, policy development, community education, and research for nurses. Implementation of policies in correctional settings and/or organizations is also needed to assure that programming meets the needs of adolescent offenders. Female adolescent offenders need resources, services, and more evidence-based programming in correctional settings. Allocation of resources is needed so that adolescents may receive programming to help foster resilience. Resources include financial resources, time, and clinical nursing practice availability to implement new policy changes necessary to provide evidence-based treatment programs for adolescent offenders. Future research with continuation of the LEAD-C program for adolescent female offenders in a women’s correctional facility is recommended. Funding and/or nursing resources, specifically time, are needed to continue this program. Eligibility criteria must be reevaluated. Four adolescent offenders who were not sentenced, and who participated in this pilot program, were released from corrections earlier than planned and therefore were not able to complete the LEAD-C program. Eligibility criteria included www.journalforensicnursing.com
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participants having a release date from corrections at least 7 weeks from the start of the program; however, when the adolescents went for their court hearing, they were released early. For this reason, eligibility criteria for closed groups would remain the same, but criteria for open groups would be altered to eliminate the release date criteria of 7 weeks from the start of the program. Another option to evaluate may be to have more flexibility with the length of time/ weeks of the LEAD-C program. An alternative to explore would be to offer the same amount of LEAD-C program sessions (12) over 4 weeks by increasing program sessions to three times per week. Shortening the LEAD-C program to 4 weeks, from 6 weeks, may increase the number of participants who may be able to complete the program. The number of program sessions would remain the same. Therapeutic evaluations of adolescents would need to be completed by clinicians to test outcomes of a shortened program, as compared with the 6-week LEAD-C program, for this vulnerable population. A comparison between LEAD-C participants and nonLEAD-C participants would be beneficial. It is recommended that eligible/assenting adolescents not participating in LEAD-C programs be assigned to one of the after-school sessions offered, which is treatment as usual (TAU). TAU groups, which are considered usual and customary “standard of care,” are offered routinely for adolescents in the DOC and may consist of different programs throughout the year. In contrast to LEAD-C, the TAU after-school programs are highly structured and may include Girls Circle, yoga, exercise programs, addiction services, and anger management. None of the programs combine the aspects of LEAD-C, and none of the programs utilize them with the therapeutic emphasis designed in the LEAD-C curriculum. Comparison analysis of adolescent offenders who participate in the therapeutic expressive arts LEAD-C program may be evaluated for increased self-esteem, resilience, and behavioral control and if participants are able to address issues of interpersonal/domestic violence and/or stress when compared with the TAU group. The LEAD-C program can enhance resiliency, help to overcome adversity, improve outcomes, and positively influence the lives of adolescent female offenders in a women’s correctional facility. The six adolescents participating in LEAD-C were taught coping strategies, through the use of therapeutic expressive arts, to begin the healing process to foster resilience. Nurses have an important leadership role and must be actively involved in future planning and implementation of new policy, programs, and research for all patients, especially for the vulnerable adolescent female offender population.
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Acknowledgments
The authors would like to thank the Department of Correction facility Warden, treatment team members, 152
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correctional officers, and all others who helped in many essential ways for their collaboration and support implementing this pilot study in a correctional setting. The authors would also like to thank all participants of the first LEAD-C program who made this possible.
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