Nursing students' lived experience of a clinical placement in prison healthcare: A systematic review

Aim: A systematic review of the literature to explore nursing students ’ lived experience of a clinical placement in a healthcare setting in a prison, to identify how and if their needs were met to enable an optimal learning environment Background: There is an increasing demand for clinical placements to support undergraduate/prelicense nurse education, especially within primary and community healthcare settings. A clinical placement in a prison has the potential to provide multiple learning opportunities for nursing students due to the unique requirements of prisoners. However, there remains a need to understand nursing students ’ experiences of a clinical placement in a prison. Methods: The updated PRISMA guidelines for reporting systematic reviews guided the development of this study. Inclusion and exclusion criteria informed the search strategy of recognised MeSH terms and Boolean operators, which were applied to search CINAHL complete, APA Psycinfo, MEDLINE, Google Scholar and Grey Open. Manual searching of the reference lists of all identified studies was completed. Standardised critical appraisal instruments were applied to each included study. Data extraction and analysis was completed by adhering to the thematic analysis process described by Thomas and Harden. Results: The electronic database and reference list search identified 81 studies published between January 2000 and December 2021 in the English language, which was reduced


Introduction
In many countries, including the United Kingdom (UK) and the United States of America (USA), there is an increasing demand for clinical placements to support undergraduate/prelicense nurse education, especially within primary and community healthcare settings (NHS Employers, 2022;van de Mortel et al., 2017).Nursing students' experience of clinical placements within primary and community healthcare supports their understanding of the role of nurses within these sectors and the delivery of healthcare in the community.Primary and community healthcare placements are also essential to support nursing students' knowledge of health literacy, health promotion, cultural safety, management of long-term conditions and the impact of social determinants on health (World Health Organization, Europe, 2015).Therefore, to address the need for further clinical placements for nursing students, non-traditional primary and community healthcare settings have been identified and clinical placements implemented, including clinical placements in healthcare services within prisons.
Primary and community healthcare provision within prisons has the potential to provide a comprehensive placement for nursing students, with multiple opportunities for learning, due to the unique requirements of prisoners.The unique and complex healthcare needs of prisoners include elements of health promotion, management of long-term conditions and supporting their mental health.Health promotion within prison includes diet and exercise, smoking cessation, support and care of communicable diseases such as HIV and Hepatitis B and C and sexually transmitted infections as well as drug and alcohol misuse (Condon et al., 2007;Fazel and Baillargeon, 2011;Recio et al., 2016).The management of long-term conditions includes supporting and caring for prisoners with cardiovascular and respiratory diseases, epilepsy and diabetes (Donahue, 2014;Gray et al., 2021;Tittensor et al., 2008;Viglianti et al., 2018).Finally, primary and community care nurses support prisoners with their mental health, which may include addressing self-harm and/or those diagnosed with personality disorders, anxiety disorders, mood disorders, post-traumatic stress disorders and/or psychotic disorders (Tyler et al., 2019).
Clinical placements for nursing students in prison were first considered in the mid-20th century, when they were identified as rich learning environments (Boyd and Mott, 1999;Ruman et al., 1999).However, gaps were identified in both the education of prison nurses and the inconsistencies and availability of healthcare offered to prisoners, which had a negative impact on the development of clinical placements (Evans, 1999).Since this time, improvements, have been made to ensure equitable access to healthcare by prisoners following the introduction of the Nelson Mandela Rules, the United Nations Standard Minimum Rules for Treatment of Prisons developed in 2015 (United Nations Office on Drugs and Crime, 2015) and guidance from the World Health Organization (2014).In April 2013, the National Health Service for England (NHS England) became responsible for the commissioning and provision of physical and mental health services for prisoners, which has further supported the development of clinical placements in prison healthcare in England.
An important element of clinical placements in healthcare services within prisons is the possibility of challenging nursing students' conscious or unconscious bias towards a population who have had different life experiences to themselves and been convicted of a crime (Ashton, 2017).A clinical placement in healthcare within a prison provides nursing students with the opportunity to challenge their biases through two processes; firstly, the development of an understanding of the complex social backgrounds of prisoners and, secondly, the adoption of a humanistic approach to provide prisoners with the best possible care within the constraints of a prison (Solell & Smith, 2009).A clinical placement in prison healthcare can also provide nursing students the opportunity to develop their practice, become socialised in their profession and develop their own identity as a registered nurse (Díaz et al., 2014).
Prior to a clinical placement in healthcare services within a prison, the need for both practical and psychological preparation of nursing students was identified by early studies (Boyd and Mott, 1999;Evans, 1999).The preparation of nursing students for all clinical placements is essential to support a positive learning environment, which can only be supported through a collaboration of Higher Education Institutes and healthcare institutions (Mbakaya et al., 2020).However, a contemporary study exploring Registered Nurses' experiences of supporting nursing students during a clinical placement in healthcare services within a prison identified many students were still unprepared and required detailed information relating to safety and security, the prison population and common healthcare conditions and medications (Needham and van de Mortel, 2020).In view of this, the preparation of nursing students is beginning to be addressed through initiatives such as the implementation of simulation and prison insight days, both of which were designed to introduce the prison environment, including safety and security, multidisciplinary collaboration and communication (Díaz et al., 2014;Hunt et al., 2020).
The need for nursing students to understand the provision of multidisciplinary care in healthcare services within a prison was also identified in early studies (Boyd and Mott, 1999;Evans, 1999), especially collaborating with prison guards/officers whose priority is security.The provision of care and control or therapy and security of prisoners requires cooperation, coordination and collaboration between nurses and prisoner officers (Foster et al., 2013).The navigation between care and control for nurses can evoke ethical issues, as the security of the prison may be prioritised over the provision of care (Sasso et al., 2018).Nursing students need preparation through education and guidance to develop their clinical practice to provide the best possible care in restrictive secure settings.Preparation of nursing students prior to a non-traditional primary care and community clinical placement, such as healthcare within a prison, will support the development of a positive learning experience.A positive experience may lead nursing students to consider healthcare within a prison as a potential work environment, supporting the recruitment of Registered Nurses.
Due to the need for non-traditional primary care and community clinical placements within nurse education and recruitment of prison nurses, alongside the changes to the commissioning and delivery of healthcare within a prison, a robust and contemporary understanding of nursing students' experiences of a clinical placement in prison is required.Therefore, the aim of this paper is to explore nursing students' lived experience of a clinical placement in a healthcare setting in a prison, to identify how and if their needs were met to enable an optimal learning environment.

Design
The design of our review was a systematic review with a metasynthesis of the qualitative data.The process of our systematic review was supported by adhering to the guidelines of Bettany-Saltikov (2012) and Wright et al., (2007).The updated Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines for reporting systematic reviews have been adhered to within this paper (Page et al., 2021).

Inclusion and exclusion criteria
The search for and selection of, studies was informed by predetermined inclusion and exclusion criteria (refer to Table 1).The term prison has been applied throughout this paper, although we have included other correctional settings, which is implied within our inclusion criteria.

Search strategy
The search strategy was broad to ensure the capture of all relevant work.The following search terms were developed and applied for each database search, with the inclusion of recognised Medical Subject Headings (MeSH) and Boolean operators of AND/OR: (student nurses or nursing students or student nurse or nursing student or undergraduate nurse) AND (prison or jail or incarceration or imprisonment or correction facilities) AND (healthcare or health care or hospital or health services or health facilities).Databases searched included: CINAHL complete, APA PsycInfo, MEDLINE.The search strategy also included a search of Google Scholar and grey literature searched through Grey Open.Finally, hand searching of prominent nurse education journals was completed and manual searching of the reference lists of all studies identified.

Critical appraisal
The methodological rigour and quality of each study was assessed independently by two of the authors (XX, XX), through the application of standardised critical appraisal instruments, which included the Critical Appraisal Skills Programme (CASP) qualitative studies checklist (CASP, 2018), the Critical Appraisal of Cross-Sectional Studies (Centre for Evidence Based Management, 2014) and the Mixed Methods Appraisal Tool (Hong et al., 2018).Following the completion of independent assessments, both authors compared completed appraisals, when a lack of consensus was identified, the third author supported a discussion to reach an agreement.This comprehensive process supported the identification of both the strengths and limitations of the studies included within this review.

Data extraction
Data extraction was completed and checked by two of the authors (XX, XX), using a data extraction table, which included the following characteristics of each study: author, publication year, country, methods, data analysis, participants, results and brief conclusions (refer to Table 2).

Data synthesis
Data synthesis was achieved by the adhering to the three stages of thematic synthesis described by Thomas and Harden (2008).The three stages were completed by two authors (XX, XX).The first stage commenced with the coding of results; each included paper was read line-by-line to identify possible codes.The first stage also involved data synthesis, as concepts were translated from one study to the next.During this stage the interpretation of the text into the development of codes was checked for consistency by the third author (XX).The second stage involved the development of descriptive themes, which commenced with the exploration of both similarities and differences between codes and the grouping of similar codes, followed by the development of titles to identify the meaning of each grouping of codes.Lastly, the generation of analytical themes by two authors (XX, XX), who inferred both positive and negative experiences of nursing students during their clinical placement and considered an explanation and justification for these experiences.This process supported the development of analytical themes, which were sufficiently abstract to describe and explain the initial descriptive themes.The generation of analytical themes supports the generation of new interpretative constructs to answer our specific research question, which is essential as the development of descriptive themes remain close to each primary study.

Study inclusion
The initial searches identified 81 studies, which were reduced to following the removal of duplicates.Another nine studies were identified through Google Scholar and hand searching of the reference lists of identified studies.Titles and abstracts were read and screened for inclusion criteria and 30 studies were excluded.The full remaining articles were retrieved for full text review.Of these, five studies met the inclusion criteria (refer to Fig. 1, which presents an overview of this process and the reasons for excluding studies).The first two authors completed this process independently and then discussed and agreed the inclusion of studies.

Critical appraisal
In three studies, a clinical placement in prison healthcare was voluntary and included an opt-in process, which may have created a bias in the results (Bouchaud et al., 2017;Hunt et al., 2020;Sutherland et al., 2021).The voluntary opt-in process supported only those nursing students who had an interest or desire to work in a prison setting to apply.Other possible biases were identified, both studies that applied qualitative methods did not describe the relationship between the researcher and the participant (Hunt et al., 2020;Terblanche and Reimer-Kirkham, 2020).Both studies that applied a cross-sectional design did not consider a power calculation (Bouchaud et al., 2017;Sutherland et al., 2021).One study did not discuss the reliability and validity of the questionnaires applied in the study (Bouchaud et al., 2017).Furthermore, one paper applied secondary analysis of nursing students' experiences of a clinical placement in a prison (Terblancheand Reimer-Kirkham, 2020).The primary analysis had included nursing students' experiences of a placement in one of several settings including parish, rural, correction, indigenous and international healthcare settings, without explicitly focusing on the prison setting, however the secondary analysis was appropriate and sufficiently in depth to support the research question of our systematic review (Terblanche and Reimer-Kirkham, 2020).An overall consideration of the limitations identified through the critical appraisal of each study needs to be acknowledged when considering the results of this systematic review.

Study characteristics
Five studies were included that explored nursing students' experiences of a clinical placement in a healthcare setting in a prison (Bouchaud et al., 2017;Hunt et al., 2020Hunt et al., , 2017;;Terblanche and Reimer-Kirkham, 2020).Studies focused on the experience of a prison-based insight day for nursing students (Hunt et al., 2020), the experience of a clinical placement in prison to develop nursing students' leadership skills (Terblanche and Reimer-Kirkham, 2020) and nursing students' perceptions and experiences following a clinical placement in prison (Bouchaud et al., 2017;Sutherland et al., 2021;van de Mortel et al., 2017).Three studies did not classify the security level of the prison where nursing students completed clinical placements (Hunt et al., 2020: Sutherland et al., 2021;Terblanche and Reimer-Kirkham, 2020), the remaining two studies identified clinical placements were completed in maximum security prisons (Bouchaud et al., 2017;van de Mortel et al., 2017).Studies were published between 2017 and 2021 and were conducted in USA (Bouchaud et al., 2017, Sutherland et al., 2021), UK (Hunt et al., 2020), Canada (Terblanche and Reimer-Kirkham, 2020) and Australia (van de Mortel et al., 2017).The designs of the studies included qualitative (Hunt, 2020;Terblanche and Reimer-Kirkham, 2020), cross-sectional (Bouchaud et al., 2017;Sutherland et al., 2021) and cross-sectional mixed-methods (van de Mortel et al., 2017).

Participants
All participants were nursing students, the gender of participants was reported in one study, which included 100 % female nursing students Prior to placement: students felt nervous, scared, and intimidated, believed the prison would be dark, and violent, and prisoners would be aggressive and disrespectful End of placement: students praised the diversity and depth of the experience, the prison was found safe, and staff were both friendly and professional Safety in prison: 87% felt safe, 98% felt safe caring for prisons, however, 2% did not feel safe when being with prisoners The prison placement informed nursing students of the context and content of prison nursing, providing them with new skills to support and provide assessment, prevention, and population-based care with professionalism and bias reduction.(Hunt et al., 2020).Sample sizes ranged from 17 to 186, with a total of 370 participants.However, one study included 137 participants, but only five of these participants had completed a clinical placement in prison (Sutherland et al., 2021).Therefore, a total of 228 nursing students had completed a clinical placement in a healthcare setting in a prison.

Review findings
Four themes were identified from the data analysis.The first theme was pre-placement anxiety, the second theme, a sense of safety, the third theme an impact on negative stereotypes and attitudes and lastly, the fourth theme, an opportunity for learning.The four themes will be explored in more depth below.

Pre-placement anxiety
Nursing students identified pre-placement anxiety when discussing their thoughts, feelings and expectations prior to commencing an insight day or a clinical placement in a prison (Hunt et al., 2020;Bouchaud et al., 2017).Nursing students identified their anxieties were due to their own negative attitudes towards prisons and prisoners, which had been influenced by their family, friends and how prisons and prisoners were portrayed in the media (Hunt et al., 2020).Anxieties included feelings of nervousness, being scared for their own safety and being intimidated by prisoners (Hunt et al., 2020;Bouchaud et al., 2017).Nursing students identified their anxieties were exacerbated by their fear of the unknown, which included uncertainty and a lack of expectations of a clinical placement in prison (Bouchaud et al., 2017).
The anxieties of nursing students escalated prior to entering the prison, which was identified as admission anxiety by Hunt et al. (2020).Admission anxiety was described as intense and escalated during the process and long wait to enter the prison, which included the experience of the intrusive nature of pat-downs.Admission anxiety escalated further when nursing students entered the prison and door after door was locked between them and the outside world.One student described their initial anxiety as: 'I did feel claustrophobic, they close all the doors and it's every door you go in is closed behind you, I did think 'Oh my god I can't get out of here' (Hunt et al., 2020;P.4).
However, it must be acknowledged some nursing students did not discuss anxieties, but were inquisitive, excited and curious to learn how nurses supported prisoners in a healthcare setting in a prison (Bouchaud et al., 2017;Hunt et al., 2020).A comprehensive understanding of the nursing students' anxiety prior to commencing a clinical placement in prison healthcare is difficult, as this was not included in studies that explored the perceptions and experiences of clinical placements completed by nursing students in prison (Sutherland et al., 2021;Terblanche and Reimer-Kirkham, 2020;van de Mortel et al., 2017).

A sense of safety
Nursing students discussed three factors that supported them to develop a sense of safety during their clinical placements in prison.The first factor was the identification of the security arrangements in each prison and the extra security measures in healthcare, which supported nursing students to develop a sense of safety, as one student suggested: '… you're actually safer nursing in a prison than you are Saturday night in A+E because you're got the guards all around you…' (Hunt et al., 2020;P.4).Another student identified '… having correctional officers all over and next to you during med pass made me feel safe' (Sutherland et al., 2021;P.1158).Safety was explicitly identified by 87 % of nursing students, who felt safe whilst in prison, which increased to 98 % of nursing students who felt safe whilst supporting prisoners in the healthcare setting in the prison (Bouchaud et al., 2017).
The second factor identified by nursing students, which supported the development of feeling safe in the prison occurred through their interactions with prisoners.These interactions challenged nursing students' underlying negative beliefs of how prisoners would behave.Nursing students discussed how prisoners were respectful of healthcare professionals and: 'were not aggressive, yelling or intimidating' (Sutherland et al., 2021;P.1158).Nursing students also expressed how prisoners were more well-mannered and intelligent than they had expected (Hunt et al., 2020).
The third factor identified by nursing students, which enabled the development of feeling safe in the prison was the support and presence of experienced Registered Nurses, who provided them with a realist insight into prison healthcare (Hunt et al., 2020;Terblanche and Reimer-Kirkham, 2020).Nursing students found nurses answered their questions in an honest and open manner, were knowledgeable and had a broad scope of practice (Hunt et al., 2020;Terblanche and Reimer-Kirkham, 2020;van de Mortel et al., 2017).Nurses in prison healthcare were praised by nursing students for their patience, respect, willingness to teach in a friendly, professional and flexible manner (Bouchaud et al., 2017;Sutherland et al., 2021;van de Mortel et al., 2017).Nursing students also discussed how the Registered Nurses were excellent professional role models and demonstrated empathy towards

Impact on negative stereotypes and attitudes
A clinical placement in a healthcare setting in a prison supported nursing students to identify, challenge and change their negative stereotypes of prisoners (Bouchaud et al., 2017;Hunt et al., 2020;Terblanche and Reimer-Kirkham, 2020).Nursing students identified they had held negative stereotypes of prisoners, which they only realised at the beginning of their clinical placement in prison, which included the stereotype of prisoners as violent, aggressive, disrespectful, with a 'street attitude' (Hunt et al., 2020;Bouchaud et al., 2017).However, these beliefs were challenged as nursing students interacted with prisoners and began to understand the real-life stories of prisoners, which had an impact on their negative opinions due to the realisation that prisoners were people, as one student described: '… it changed my mind, [their] story was sad, you kept having to rethink in your head [they're] in here for a reason.I think a lot of people's opinions would change … I think quite a lot of people would have let [them] out there and then if they could have' (Hunt et al., 2020;P.4).
The understanding of prisoners' life-stories also supported nursing students to consider and begin to understand the impact of social determinants on health.A prisoner's upbringing, poverty, education, substance misuse and undiagnosed physical and mental health conditions, supported nursing students to understand how the prisoner may have become involved in crime, as one student stated: 'We could see the cycle of mental illness and crime' (Terblanche and Reimer-Kirkham, 2020;P.41).The first-hand experience of understanding social determinants of health, supported nursing students to both identify and question their own biases and assumptions, to enable the provision of genuine empathetic care, as one nursing student expressed: 'I wanted to get my mind around the whole prisoner idea… to get over the judgemental attitude and get on toward caring.It's kind of weird… at first, it's "you did what?"But then later you realise that they're a person who's there for help… I wanted to build on that and help in any way' (Terblanche and Reimer-Kirkham, 2020;P.42).

An opportunity for learning
A clinical placement in a healthcare setting in a prison was described by nursing students as an excellent opportunity for learning, due to diverse learning experiences, which included understanding the autonomous role of the nurse, compassionate care guided by ethical principles, the balance between providing optimal care in the prison regime, as well as insight into community and mental health nursing (Bouchaud et al., 2017;Sutherland et al., 2021;Terblanche and Reimer-Kirkham, 2020;van de Mortel et al., 2017).Nursing students embraced these opportunities and described learning more during a prison healthcare placement than any of their other placements:'I don't know if I could really think of something I learned at my other settings [placements].But at the correctional facility, I can think of tons of things I learned.Such a vast, vast difference' (Terblanche and Reimer-Kirkham, 2020;P.45).
Registered nurses were recognised by nursing students as essential for learning during a clinical placement in prison, as nurses, who were allocated as a buddy, mentor, or preceptor, supported and guided nursing students through this unique placement.Registered nurses were identified as role models who demonstrated professional behaviour and empathy towards prisoners, which nursing students could follow, as one nursing student explained: '[it was]… challenging to see some men upset at coming in for the first time, so I found it hard to know what to do say to them but my buddies were great with this, so I was able to follow their examples' (van de Mortel et al., 2017: P.59).Registered nurses were also described as experienced, competent, knowledgeable and willing to teach, as a nursing student discussed: 'We had very experienced, competent, willing to share nurses, who were really eager to teach' (Terblanche and Reimer-Kirkham, 2020: P.44).Registered Nurses had an impact and influenced nursing students' clinical practice, professionalism and empowered them to advocate or their patients, as one student expressed: 'I'll take that with me wherever I go in nursing' (Terblanche and Reimer-Kirkham, 2020: P.45).
Nursing students identified the development and/or enhancement of their clinical skills during a clinical placement in prison (refer to Table 3), which included critical thinking, client interaction, health assessments and interventions, such as wound care and motivational interviewing (Bouchaud et al., 2017;Sutherland et al., 2021;Terblanche and Reimer-Kirkham, 2020;van de Mortel et al., 2017).A clinical placement in prison was described by nursing students as a 'different world', but a world that enabled the development of clinical skills and supported nursing students to continue to develop into a healthcare professional: 'I learned more, performed more procedures, than all my previous clinical placements combined' (Bouchaud et al., 2017;P.3).Nursing students also discussed how they had moved beyond developing their clinical skills and were able to perform clinical tasks autonomously and competently (van de Mortel et al., 2017) through the support of Registered Nurses: 'we had the best of both worlds.You saw the illness.You saw the intervention and had the opportunities to participate in it yourselves.(Terblanche and Reimer-Kirkham, 2020;P.44).
However, challenges of a clinical placement in prison were identified by some nursing students, which included the provision of poor care when security and safety was the priority, the use of a different forms, terminology and slang.Nursing students identified these elements as challenging when commencing their placement, but elements that could easily be addressed through preparation prior to the commencement of their placement (van de Mortel et al., 2017).2017), which explains the similarity of concepts identified.

Discussion
The review of published literature exploring the experiences of nursing students following a clinical placement in a healthcare setting in a prison identified four overarching themes.Firstly, pre-placement anxiety, which escalated prior to entering the prison and increased during their experience of progressing through security and the reality of being locked in the prison with prisoners.Secondly, nursing students identified a sense of safety when they became aware of the security measures in the prison and the respectful nature of prisoners, especially when receiving care in healthcare units.Thirdly, nursing student identified the clinical placement in prison healthcare challenged their negative stereotypes and attitudes by interacting with prisoners and understanding their life stories.Fourthly, the experience provided nursing students with an opportunity for learning and to understand the provision of care in this unique setting, the impact of social determinants on health, the role of the nurse and the development of their knowledge of diseases, medications and healthcare interventions, alongside the development of their clinical skills.

Pre-placement anxiety
The identification of pre-placement anxiety by nursing students prior to and on commencement of their clinical placement in prison was identified in this systematic review.Pre-placement anxiety of healthcare students prior to a clinical placement in prison has been previously identified (Boyd and Mott, 1999;Evans, 1999;Rohleder et al., 2006) and continues to be identified (Abbott et al., 2020;Díaz et al., 2014;Needham and van de Mortel, 2020).This is not exclusive to nursing students, for example clinical psychology students in South Africa (Rohleder et al., 2006) and medical students in Australia (Abbott et al., 2020) both experienced high levels of anxiety and fear prior to a clinical placement in prison.Pre-placement anxiety has been associated with the lack of preparation of healthcare students prior to commencing a placement in the unique and secure setting of a prison.Preparedness of nursing students prior to a clinical placement in prison has been identified by correctional nurses as essential and needs to include information on safety, rules and regulations, overview of prisoners, such as age, length of sentence and offence, as well as typical health conditions and medication (Needham and van de Mortel, 2020).
Initiatives to support the preparation of healthcare students, especially nursing students, prior to the commencement of their clinical placement in prison healthcare have begun to be developed and implemented, such as preparing students through simulation (Díaz et al., 2014) and an insight day (Hunt et al., 2020).Simulation allows for an interactive environment for nursing students to experience realistic scenarios similar to those they will encounter in a clinical placement in prison (Díaz et al., 2014).An insight day was developed to provide second year nursing students the opportunity to make an informed decision to complete a clinical placement in prison.The one-day experience in healthcare in a prison involved meeting both healthcare and prison staff and prisoners, as well as understanding the security checks, a tour of the healthcare facilities and question and answer sessions with nurses (Hunt et al., 2020).Both initiatives supported an understanding of prison healthcare supporting the preparation of nursing students and reducing pre-placement anxiety.The development of a standardised approach to prepare healthcare students prior to a clinical placement in a healthcare setting in a prison is still required.

A sense of safety
Nursing students identified a sense of safety, which developed during their clinical placements in prison due to understanding the security, interactions with prisoners and the support of their mentors.The identification of a sense of safety or safety being less problematic than expected has also been identified by medical students due to security processes and although security measures did have an impact on the care they provided, the presence of prison guards provided them with the opportunity to provide professional and medically competent care (Brooker et al., 2018).However, nurses in the USA have identified the potential risk to both their physical and psychological well-being when caring for prisoners, which affects their behaviours when caring and has an impact on the quality of the care provided (Dhaliwal and Hirst, 2016), although this was not identified in our review of nursing students' experience of providing care in prison.
Mentors supporting nursing students have also recognised the need for students to understand the clinical environment in prison is not "a place that they should be afraid of", however it is an environment where they need to be "watching their backs at the same time" (Needham and van de Mortel, 2020: P.383).The need for nurses to 'watch their backs' has been identified as an element of how nurses provide care in prison healthcare and this has been described as firm, fair and consistent (Solell and Smith, 2019).This approach to care in prison involves the provision of care without hesitation, whilst considering and maintaining a safe environment for prisoners, prison staff, nurses and other healthcare professionals.Therefore, there remains the need for nursing students and other healthcare professionals working in prison healthcare to remain aware of the prison environment when providing care and not to be complacent regarding their and others' safety.

Impact on negative stereotypes and attitudes
Our systematic review identified nursing students recognised their own negative stereotypes and attitudes towards prisoners and the prison environment, which were challenged during their clinical placement in prison healthcare.Negative stereotypes and attitudes held by nursing students or nurses need to be challenged, as the Nursing and Midwifery Council (NMC), the regulatory body in the UK, State Registered Nurses are obliged to ensure "…those receiving care are treated with respect, that their rights are upheld and that any discriminatory attitudes and behaviours towards those receiving care are challenged" (NMC, 2018; P.6).This is reinforced by the International Council of Nurses (ICN), which further states nurses need to "…provide people focused, culturally appropriate, care that respects human rights and is sensitive to the values, customs and beliefs of people without prejudice or unjust discrimination" (ICN, 2021; P.8).Therefore, it is essential nursing students are supported through their undergraduate/prelicense education to be able to understand individuals in their care and how to provide culturally competent care in a community setting, which may also include within the constraints of a prison.However, it is also essential nursing students are supported to identify and challenge any discriminatory attitudes or beliefs they may hold, which may have an impact on the care they provide through unjust or unacknowledged discrimination, including the care and support of individuals who have or are serving a prison sentence.
Nursing students' negative stereotypes and attitudes towards prisoners, were challenged during their clinical placement in prison, through positive interactions with prisoners and understanding their life stories.Clinical placements in prison have also supported medical students' awareness of their preconceived misconceptions and judgments of prisoners and the prison environment and developed and fostered the ability to provide non-judgemental care and support for prisoners (Brooker et al., 2018;Filek et al., 2013).Healthcare placements in a prison have also been identified to provide medical students the opportunity to engage in positive interactions with prisoners, providing insight and understanding of diverse marginalised populations (Brooker et al., 2018;Filek et al., 2013).This process supported medical students to build therapeutic relationships with prisoners and decreased their negative preconceptions, enabling them to provide empathic and non-emotional care and treatment (Brooker et al., 2018;Filek et al., 2013).Clinical placements in prison provide an opportunity for all healthcare students, including nursing students to engage with a diverse and marginalised population, which supports the development of a humanistic approach to caring, through understanding the individual in their care and removing the application of negative stereotypes.

An opportunity for learning
Our systematic review identified clinical placements in prison provided nursing students an excellent opportunity for learning, which included a breadth of experiences and supported the development of their clinical skills.Opportunities for learning has also been identified by nursing students in blogs reporting their experience of a clinical placement in prison healthcare, which included acute care through responding to trauma calls, which involved overdoses, self-harm and chest pain (Parkhouse, 2020).Other nursing students have identified the opportunity to practice clinical skills, such as ECGs, aseptic dressings, injections, suture removal, vital observations, medications and mental health assessments in a clinical placement in prison (Golightly, 2017).The opportunity to treat prisoners with complex health needs, which were explicitly linked to social determinants of health, has also supported medical students to develop both their knowledge and skills and their understanding of ethical and social justice (Abbott et al., 2020).The learning opportunity also had a positive impact on medical students' confidence when working with prisoners or patients with a history of incarceration outside of the prison setting (Brooker et al., 2018).
The learning opportunity of a clinical placement in prison was supported and enhanced through the supportive and enabling characteristics of Registered Nurses who were allocated as buddies or mentors.Healthcare professionals in the prison healthcare have also identified the value of nursing students, as they provided the opportunity to consider new ideas and engage in beneficial projects to support the development of prison healthcare (Needham and van de Mortel, 2020).Other healthcare students, such as medical students, have identified the lack of direct teaching sessions in a placement in prison, which had an impact on and limited their learning (Abbott et al., 2020).However, the combined evidence demonstrates a clinical placement in prison provides a diverse and rich learning environment for nursing and medical students.

Limitations
A limitation of this systematic review is the identification of only five contemporary studies exploring the experiences of nursing student's clinical placement in prison healthcare, with only two studies describing the level of security of the prison and where stated nursing students were all female, which may have an impact on the findings discussed.A further limitation of the study is the exploration of nursing students' experience of a clinical placement by their own institution.

Conclusions
The findings of our systematic review demonstrated the need for standardised preparation and orientation of nursing students prior to their clinical placement in a prison, provided by both their university and healthcare provider.Standardised preparation needs to comprehensively support students to understand the rules and regulations regarding security, how to interact with prisoners and address students' anxieties of entering a prison, alongside identifying the learning opportunities in this unique placement.An important element of learning identified with our systematic review was the opportunity for nursing students to identify and challenge any negative attitudes they held towards diverse and marginalised populations and the opportunity to develop clinical practice, knowledge and become socialised into the profession.However, the experience, knowledge and willingness of Registered Nurses to support nursing students in prison healthcare, with the inclusion of an understanding of the realistic risk to physical and psychological well-being, is essential to support their learning in this non-traditional clinical placement.

Table 1
Inclusion and exclusion criteria.

Table 2
Overview of included studies.

Table 3
Overview of the opportunities, registered nurses and clinical skills.
*Sutherland et al. (2021)applied the 35 items survey regarding nursing students' perceptions of their clinical experience at a prison developed by van de Mortel et al. (