Joe Bugher started his career with the Oregon Department of Corrections (DOC) as a correctional officer. After several years in that role, followed by seven years as a correctional counselor, he was promoted to positions in mental health and management within the department. Recently he visited Norway through the Correctional Leaders Immersion Program. This article summarizes his observations during that visit and what he views as next steps in implementation in his work as a leader for the Oregon Way model.
The purpose of the visit to Norway was to expose the correctional leaders from Oregon, California, and North Dakota—50% of whom were health care leaders—to correctional practices in Norway. Within Oregon DOC, it was an opportunity to examine the policies and practices that are influencing the Oregon Way. Much of the change effort in Oregon is a grassroots effort. This type of visit, then, is intended to train leaders to be able to help those initial efforts grow through sustainable support, policies, and funding.
From an organizational perspective, the Oregon Way is focused on normalization. Viewing normalization firsthand in Norwegian prisons helped the leaders to better understand how correctional environments in the United States are transactional, rather than relational within a normalized environment. Joe observed safe and secure facilities through dynamic security, where you know enough about the persons in custody that you connect with them at a human level.
Within healthcare, Joe noted that they have often operated in a similar transactional model. And, just as that doesn’t work for security within prisons, it doesn’t work optimally within correctional health care. He and his team are now working to remove the transactional model from their delivery of services and import a community health model. One of the significant benefits of this change is the residents’ perspective on healthcare.
A second observation made by Bugher was the degree to which residents within Norway’s prisons have a voice in their care. He is now developing a process that elevates residents’ voices in Oregon DOC. Some of the examples he noted where this would be beneficial are:
- Suicide prevention utilizing “Indigenous Mental Health Standards.”
- Bringing awareness of sense of time, because U.S. systems are currently built on the dominant perspective of time (e.g., “count time”).
- Pulling together adults to review policies and rules, while engaging adults in custody to inform policies and procedures.
- Asking adults in custody what they would change in healthcare—recent responses were more time with providers, better mattresses, and better pillows.
As Joe Bugher returned to Oregon DOC from Norway, he was reminded that if he can support security in normalizing the environment that it will fundamentally change both the security and healthcare environments. One example of this is that families often worry that security can impede access to care. Security is the front-line to care. When there is a normalized environment, access to care is an important part of it.
The healthcare team members that have visited Norway are continuing to meet to consider how the environment in Norway's model impacts how they provide care and the perception of that care, as well as of safety, for adults in custody and for staff. One of the policy developments they are working on is intended to increase the healthcare literacy of adults in custody. This will have a positive impact on their release so they can advocate for themselves and also be better able to determine what healthcare they need (and when) in the community. This is a step away from transactional care toward a provider-focused delivery of healthcare. Two additional examples are: 1) increasing skills to be more resilient in terms of mental health and 2) personal responsibility for monitoring blood sugar.
In Norway, they have a Contact Officer who is an individual’s counselor during their entire prison stay. The counselor is focused on wellness and preventive interventions. They have bachelor’s degrees, as well as additional training. In Halden Prison, the motto is “Punishment that works; Change that lasts.” They plan for release from the very beginning and focus on health and wellbeing. Front-line staff guide individuals through the process.
In terms of mental health and significant physical health challenges, Joe Bugher observed that adults in custody in Norway appear to be healthier in their environment than their counterparts in U.S. prisons. He did not observe individuals who appeared to be geriatric or people with more intense healthcare problems. The mental health treatment unit was very different from what he had observed in the U.S., because patients were out and about and issues seemed to be handled in a fundamentally different way.
The use of isolation is applied in a very different way. Based on his observations, Mr. Bugher said that he realized he needed to advocate to eliminate isolation for mental health patients in Oregon DOC. He observed that building appropriate relationships with patients has an interconnectedness with security. In Norway, staff are utilized to avoid isolation. The staffing ratio is much higher, and the use of disciplinary separations are instead utilizing more staff to increase observation rather than requiring isolation.
While the architecture of prisons in Norway all support humanization and normalization, there are still lessons to be learned from their operations. Those that Joe Bugher shares with us follow:
- Our environments impact how we provide care and how our patients perceive us.
- We must be advocates for our patients and not accept things as they are; especially those policies, procedures, and practices that impact the mental and physical health of our patients.
- We need to continually be asking how we can help security be more dynamic and how we can normalize how we provide care.
- We need to prepare individuals to engage in their care in the community.
Mr. Bugher shared that even though staff are burned out after their experiences with the COVID-19 pandemic, everyone who gets exposed to the Norway model and to the Oregon Way gets more energized about the work and the opportunities. As leaders, they are reinforcing this energy by:
- sharing education and training along with their reflections;
- meeting monthly to reinforce the positive applications and to work through challenges; and
- sharing journals to keep themselves emotionally aligned with the changes.
To ensure that the changes that are being made are lasting and meaningful in the system is one of Joe’s goals. Overall, his goal is to have the healthcare provided within Oregon DOC seen as an extension of public health, rather than as prison health. His specific change objectives are:
- To develop mentor programs for patients.
- To increase literacy on policy, rules, and statutes so patients are better able to engage in civic engagement.
- To listen to and engage those with lived experience and families of adults in custody.
As every leader experiences, there are many competing priorities for daily care and change leadership. He views it as his responsibility to manage his time and to intentionally engage in the above objectives as equal priorities.
For additional information on the Correctional Leaders Immersion Program and AMEND at the University of California San Francisco go to this link.
