Forensic Psychiatric Nursing Research Articles

Expanding our understanding of sovereign power: on the creation of zones of exception in forensic psychiatry

The purpose of this paper is to engage with the readers in a theoretical reflection on nursing practices in forensic psychiatric settings. In this paper, we argue that practices of exclusion in forensic psychiatric settings share some common ground with Agamben's description of sovereign power and, consequently, the possible creation of zones of exception in this environment. The concept of exception is, therefore, purposely used to shift our thinking, highlight the political forces surrounding exclusionary practices in forensic psychiatric nursing, and explore the ethical tensions that arise for nurses who become entangled in the control of these zones of exception. We argue that ethical and political discussions regarding this phenomenon are necessary if we wish to further understand the complexities of this field of practice and promote constructive change.

The rhetoric of therapy in forensic psychiatric nursing

The objective of this paper is to present the results obtained from a qualitative research study conducted in a forensic psychiatric setting and to explore the dual role associated with being both "agents of care and agents of social control." Following the narratives provided by nurses working in this field, the analysis that follows will problematize the rhetoric of therapy in forensic psychiatric nursing. In order to support the analysis, this article comprises four sections. The first section will briefly review the study's methodological considerations. Using a combination of Foucault and Goffman's work, the second section provides an empirical contextualization of correctional environments and their effects on nursing care. The third section explains the effects of having a contradictory mandate of care and custody from Festinger's (1957) theory of cognitive dissonance. Lastly, the fourth section provides a critique of disciplinary interventions in forensic psychiatric nursing, as it is explained by the participants.

An exploratory study investigating the impact of the procedures used to manage patient substance misuse on nurse–patient relationships in a medium secure forensic unit

The role conflict experienced by forensic psychiatric nurses between their therapeutic responsibilities and their responsibility to operationalize security procedures is well established in the literature. There has been less investigation into how this role conflict is played out specifically in the management of inpatient substance misuse in forensic units. This study, therefore, aimed to explore the views of nurses working in one medium secure unit of the impact of the procedures used to manage substance misuse (partial strip searching, room searching, canine searching, 'pat' (or 'rubdown') searching, urine drug screening) on their relationships with patients. Ten interviews of registered mental health nurses working in a medium secure unit in the Northwest were carried out. The interview data were transcribed verbatim and framework analysis used to identify emergent themes. The impact of the procedures on nurse-patient relationships was reported as largely negative by the participants. They reported that the intrusion of the procedures had a detrimental effect on their relationships with patients. The relative degree of intrusion posed by each of the procedures was an important factor in determining the extent and duration of damage to nurse-patient relationships, as was the communication skills of the nurse conducting the procedure.

The culture of fear: expanding the concept of risk in forensic psychiatric nursing

The purpose of this article is to present, in part, the results of a nursing research that aimed at describing how fear influences nurse-patient interactions in a forensic psychiatric setting. Guided by an inductive research design (grounded theory), the analysis of data revealed that nurses incorporate a risk discourse into their practice. As a result, our data show that cultural narratives of risk affect the experience of nursing care and nurses’ day-to-day management of potential threats embodied by the patients. Furthermore, we assert that risk management is enmeshed in a cultural script that justifies the deployment of precautionary actions.

Experiences of psychiatric nurses exposed to hostility from patients in a forensic ward

Hostile behaviour is becoming a way of life in South Africa. Hostility prevails at all settings, including in the health sector. In a forensic ward psychiatric nurses are subjected to hostile behaviour by the patients. The aim of the present study was to explore and describe the psychiatric nurses' experiences of hostile behaviour by patients in a forensic ward and make recommendations for nurse managers to empower these psychiatric nurses to cope with the patients' aggression. Qualitative, in-depth, phenomenological interviews were conducted with nine psychiatric nurses exposed to hostility from patients in a forensic ward. Recommendations were derived from the results from nurse managers to assist psychiatric nurses. It became apparent from the findings that psychiatric nurses in a forensic ward work in a stressful environment. Hostile behaviour in the forensic ward is consistently experienced by the psychiatric nurses as hindering therapeutic relationships. The psychiatric nurses experienced being disempowered. Psychiatric nurses experience hostile behaviour by patients in a forensic ward as disempowering. IMPLICATIONS FOR NURSE MANAGEMENT: Nurse managers can facilitate psychiatric nurses' empowerment by providing them access to: information, support, resources, opportunity and growth.

Constructing mentally ill inmates: nurses’ discursive practices in corrections

The concepts of discourse, subjectivity and power allow for innovative explorations in nursing research. Discourse take many different forms and may be maintained, transmitted, even imposed, in various ways. Nursing practice makes possible many discursive spaces where discourses intersect. Using a Foucauldian perspective, were explored the ways in which forensic psychiatric nurses construct the subjectivity of mentally ill inmates. Progress notes and individual interviews constitute discursive spaces within which nurses construct patients' subjectivities. Progress notes provide a written (and permanent) form of discourse, while interviews set the space for a more fluid and contextual form of discourse. We identified five types of subjectivities - the (in)visible patient, the patient as risk, the deviant patient, the disturbed patient and the disciplined patient. These subjectivities were rooted in various types of discourses circulating in the selected setting. Despite the multiple discursive dimensions of forensic psychiatric nursing, progress notes remain the main formal source of information regarding nursing care even though it is not representative of the care provided nor is it representative of nurses' complex discursive practices in corrections.

Forensic Psychiatric/Mental Health Nursing: Behind Closed Doors

Incidents like the shootings in Arizona earlier this year bring to public attention the fact that there are members of our society who are mentally disturbed and who also may commit sometimes serious crimes. Although most of the debate centers on how to prevent these crimes, the fact that these perpetrators have to be cared for remains. Forensic psychiatric nurses care for clients who have broken the law, sometimes through committing crimes that are heinous and grab the public’s attention. When public interest has waned, these clients still need psychiatric treatment, often for very long periods, and sometimes for the remainder of their lives. Once high-profile offenders are imprisoned or placed in forensic inpatient settings, any remaining public attention is typically on victims and on prevention strategies—How can we recognize “disturbed” individuals before they commit such atrocities? What went wrong? Relative to the incarcerated offender, the public breathes a collective sigh of relief—out of sight, out of mind. On the other end of the public attention spectrum, perpetrators of crimes known only to the victims and the legal system are considered criminals first, mentally ill

Respect in forensic psychiatric nurse-patient relationships: A practical compromise

The context of forensic psychiatric nursing is distinct from other psychiatric settings as, it involves placement of patients in secure environments with restrictions determined by the courts. Previous literature has identified that nurses morally struggle with respecting patients who have committed heinous offences, which can lead to the patient being depersonalized and dehumanized. Although respect is fundamental to ethical nursing practice, it has not been adequately explored conceptually or empirically. As a result, little knowledge exists that identifies how nurses develop, maintain, and express respect for patients. The purpose of this study is to analyze the concept of respect systematically, from a forensic psychiatric nurse's perspective using the qualitative methodology of focused ethnography. Forensic psychiatric nurses were recruited from two medium secure forensic rehabilitation units. In the first interview, 13 registered nurses (RNs) and two registered practical nurses (RPNs) participated, and although all informants were invited to the second interview, six RNs were lost to follow-up. Despite this loss, saturation was achieved and the data were interpreted through a feminist philosophical lens. Respect was influenced by factors categorized into four themes: (1) emotive-cognitive reactions, (2) nonjudgmental approach, (3) social identity and power, and (4) context. The data from the themes indicate that forensic psychiatric nurses strike a practical compromise, in their understanding and enactment of respect in therapeutic relationships with forensic psychiatric patients.

Interrelationship between core interventions and core competencies of forensic psychiatric nursing in Finland

The importance of core competencies (CC) and their relationship to core interventions in clinical practice guidelines on schizophrenia (CPGS), and the abilities to master these competencies were studied among registered nurses (RN) and practical mental nurses (PMN) in a forensic psychiatric setting. Data were collected from RNs, PMNs, and managers of all five forensic psychiatric facilities in Finland. The research material was obtained by using a 360-degree feedback method. The response rate was 68% (N = 428). The differences between the nurse groups were statistically significant (p ≤ 0.05) regarding the importance of and ability to master the following CCs: (1) pharmacotherapy, (2) knowledge in forensic psychiatry and violent behavior, (3) the treatment of violent patients, (4) processing patient's and own emotion, and (5) need-adapted treatment of the patient. Overall, RNs exceeded PMNs in mastering the CCs, however the principles of the CPGS were not achieved within the current resources in Finland. In summary, RNs, rather than PMNs, should be recruited for work in forensic psychiatric nursing, although a considerable amount of specific training would still be required to achieve competence. Implications of our research indicate that all nurses working in this area need to receive further education in forensic psychiatry and in forensic psychiatric nursing.

Forensic psychiatric nursing: a description of the role of the psychiatric nurse in a high secure psychiatric facility in Ireland

The Central Mental Hospital is one of the oldest high secure mental health services in Europe dating back to 1845 but has been one of the last to introduce (forensic) psychiatric nurses. This paper describes the role of psychiatric nurses working in this high secure psychiatric facility in Ireland. The United Kingdom Central Council competency framework was considered to be a prudent starting point for beginning to understand this role in an Irish context. The study received a response rate of 74% and found that the Irish Forensic Mental Health Nurse experiences many of the same challenges as their international colleagues. A high proportion of nursing practice is focused on assessment, communication and creating a therapeutic environment based very much in keeping with the mainstream role in mental health nursing. Skills in specialist assessments and addressing offending behaviour were considered important but deficient at that time. The importance of recovery and human rights were considered paramount but challenged by the need for risk management and security.

A Springtime Wish for Psychiatric and Mental Health Nursing

The learning curve associated with serving as editor of JAPNA has been steep. Most surprising however, among the many things that I have learned is what it takes to write an editorial. Unlike the other scholarly writing that I do, editorial writing is both unpredictable and spontaneous. It is not possible to schedule an editorial writing day. Nor is it possible to fit editorial writing into a planned series of deadlines. Rather for me, ideas for an editorial percolate quietly below the surface of conscious thought. A recent conversation, a news story, other unplanned, even incidental exchanges of ideas with colleagues or friends, mix with long-standing values, problems, and questions. For me, topics for my editorial emerge at their own pace, in their own time. My ideas for this editorial emerged in exactly the same way. Challenges encountered at my work mixed, perhaps scrambled with various conversations, long-standing personal values and the freshness, hope, and optimism of spring. And perhaps most surprisingly, the passing of yet another birthday! As I walked across campus to an end of semester event, enjoying the sunshine and blooming flowers, the idea of optimism and hope emerged like a spring bud. Why not write about my hope for the future of our discipline? That’s right, why not capitalize on and be carried forward by the freshness and optimism of spring. Oh yea, a birthday wish for the discipline of nursing. It is my birthday after all! So for this editorial I have decided to indulge myself in writing about what I wish for the discipline of nursing and the specialty of psychiatric and mental health nursing! My wish it not totally a new one. You have heard me talk about it before. But if I had one wish to dedicate to nursing, it would be that all constituents of our discipline would see themselves as important members of a single unified team working together to improve the quality of health and well-being in the persons whom we treat. Frankly, I am tired of struggles among us and the energy wasted arguing practical, real world versus research, too much research or too little research; who really understands the patient’s circumstances, who does and does not do real research, who is and is not valued and respected. In my dream world of nursing, the struggling and competing would be long over. Rather, we would all be deeply engaged in working together to deliver the highest quality nursing care that is continuously changing, evolving and improving. We would all view ourselves as essential members of a single team committed to working together, helping each other, and teaching each other. Teams of nurses comprising RN-PMH, APPN (practitioners and CNS), PhD and DNS would be purposively constructed at the worksite and spontaneously develop within APNA and other professional organizations. Teams would be formed in response to health problems or issues and members would work together to continuously improve the care for the targeted population. We have some examples of this type of organization in the Forensic Psychiatric Nurses and the Tobacco Dependence Councils of APNA. Similarly, treatment delivery organizations might organize groups around issues such as psychotic disorders in adolescents and young adults or older adults and depression. However, even more important than the topical foci is the nature of the roles and interactions among team members. Exactly how would RN-PMHs, APPNs, PhDs, and DNSs work together to improve and strengthen quality of care? That part, I believe is easy, given that each constituent brings an important knowledge base, skill set and perspective that are important to whole. First and foremost, RN-PMH nurses are intimately aware of the issues of hands-on acute care, the patient and family perspectives, the effects of financial and community constraints and limited resources. They know what works in patient management, planning, and prevention. Furthermore, they know the problems, the gaps still unresolved and issues yet to be addressed and appropriately resolved. APPNs similar have critical skills sets related to patient and family treatment, management, and health promotion. Could both RN-PMH nurses and APPNs evolve, learn more,

Forensic psychiatric nursing: a literature review and thematic analysis of staff-patient interaction

In Denmark the increasing number of forensic mental health patients has led to prioritized services, including the area of nursing; however, this field is subject to sparse research. The aim of this study was to review existing research literature and in doing so investigate what characterizes forensic mental health staff interaction with forensic mental health inpatients and furthermore to investigate what significance these staff characteristics have for the inpatients. The literature review spans the period September 1997 to January 2009 and was based on a systematic keyword combination search in the following databases: CINAHL, CSB, PsycINFO, Scopus, Pubmed, MEDLINE and Sociological Abstracts. The articles were categorized using a literature matrix and analysed using content analysis. Seventeen quantitative and qualitative research studies were analysed. The results show that the interaction between forensic staff and forensic inpatients is characterized by two overriding themes: parentalistic & behaviour-changing care and relational & personal quality-dependent care. Only a few of the findings represent a clear account of how the interactional characteristics impact on the forensic inpatient. The conclusion is that no clear account of the patient impact issue can be reached at this point and that further investigation needs to take place.

Forensic nurses' perceptions of labels of mental illness and personality disorder: clinical versus management issues

Anecdotally, forensic psychiatric nurses generally have a more negative perception of people diagnosed with a personality disorder and this negativity is focused more towards managing the behaviours rather than on treatment efficacy and clinical outcomes. This study reports on research carried out across the High, Medium and Low secure psychiatric services in the UK. One thousand two hundred questionnaires were distributed with a response rate of 34.6%. The results indicated a statistically significant difference across High (z = 9.69; P < or = 0.01), Medium (z = 11.06; P < or = 0.01) and Low (z= 9.57; P= 0.01) security with a focus on the management of people with a personality disorder using the Wilcoxon paired samples test. There was also a statistically significant difference in relation to a more clinical/treatment focus for those with a diagnosis of mental illness in Medium (z = 9.69; P < or = 0.01) and Low (z = 9.57; P < or = 0.01) security but not in the High security services. Finally, the results showed significant differences between High, Medium and Low security on each of the four scales of Personality Disorder Clinical-Personality Disorder Management and Mental Illness Clinical-Mental Illness Management. This raises issues of stigma, prejudice and discrimination and suggests a refocus on skills development, acquisition and application for those with a label of personality disorder.

Nursing so-called monsters

Forensic psychiatric nurses work with individuals who may evoke feelings of empathy as well as feelings of disgust, repulsion, and fear. The main objective of this theoretical paper is to engage the readers in a theoretical reflection regarding the concepts of abjection and fear since they both apply to the experiences of caring for mentally ill individuals in forensic psychiatric settings. Our contention is with the potential impact of feelings such as disgust, repulsion, and fear on the therapeutic relationship and, more particularly, with the boundaries imposed on this relationship when these feelings are unrecognized by nurses. Acknowledging that patients may evoke feelings of disgust, repulsion, and fear is essential if nurses wish to understand the implications of these emotions in the therapeutic process. In forensic psychiatric settings, caring for so-called "monsters" in the face of abjection and fear is not an easy task to achieve given the lack of theoretical understanding regarding both concepts. Given the actual state of knowledge in forensic nursing, we argue that theoretical (conceptual) analyses, as well as ethical and political discussions, are paramount if we wish to understand the specificities of this complex field of nursing practice.

Binary construct analysis of forensic psychiatric nursing in the UK: High, medium, and low security services

The aim of this study was to identify if differences in perceptions of the role of forensic psychiatric nurses exist across the three levels of secure psychiatric provision: high, medium, and low. Any differences may reflect the type of clinical conditions found in different levels of security provision. An information-gathering schedule containing a validated 7-point Likert scale was distributed to 1200 forensic psychiatric nurses across the UK in 2005. A response rate of 34.6 was achieved, with 122 from high-security, 159 from medium-security, and 135 from low-security services. Differences in perceptions regarding role constructs were found across all three levels, with numerous differences being statistically significant using analysis of variance. The main implications are in relation to the development of skills and competencies, which should target specific clinical conditions in relation to effective interventions, the development of a specialist education and training curriculum focused on treatment outcomes, and the need for further research to draw together theory and practice. Finally, creative policy initiatives should be developed to cross-fertilize the levels of security provision in order that staff may acquire and deliver experiences in high-, medium-, and low-security psychiatric services.

Clinical Coaching in Forensic Psychiatry: An Innovative Program to Recruit and Retain Nurses

Ontario is currently experiencing a nursing shortage crisis. Recruitment and retention of nursing staff are critical issues. In response, retention strategies have been developed by the Ontario Ministry of Health and Long-Term Care. The Late Career Nurse Initiative is one such strategy. This innovative program encourages nurses age 55 and older to remain in the workforce by providing opportunities to use their nursing experience in less physically demanding alternate roles for a portion of their time. The Royal Ottawa Health Care Group has developed a clinical coach program in forensics that matches these veteran nurses with new graduates or nurses new to forensic psychiatric nursing. The program has resulted in retention rates of more than 91% after 1 year. This article provides background about the program and highlights its outcomes.

Binary constructs of forensic psychiatric nursing: a pilot study

The aim was to develop an Information Gathering Schedule (IGS) relevant to forensic psychiatric nursing in order to establish the perceived differences in the three levels of security, high, medium and low. Perceived differences in the role constructs of forensic psychiatric nursing is said to exist but the evidence is qualitative or anecdotal. This paper sets out a pilot study beginning in 2004 relating to the development of two rating scales for inclusion into an IGS to acquire data on the role constructs of nurses working in these environments. Following a thematic analysis from the literature two sets of binary frameworks were constructed and a number of questions/statements relating to them were tested. The Thurstone Scaling test was applied to compute medians resulting in a reduction to 48 and 20 items for each respective framework. Two 7-point Likert scales were constructed and test-retest procedures were applied on a sample population of forensic psychiatric nurses. Student's t-test was conducted on the data and the results suggest that the IGS is now suitable for application on a larger study. The IGS was piloted on a small sample of forensic psychiatric nurses. The two scales were validated to coefficient values ranging from 0.7 to 0.9. Amendments were made and the IGS was considered acceptable.

Humanism in forensic psychiatry: the use of the tidal nursing model

The humanist school of thought, which finds resonance in many conceptual models and theories designed to guide nursing practice, needs to be understood in the context of the total institution, where the individual is subjected to a mortification of the self, and denied autonomy. This article will engage in a critical reflection on how humanism has influenced nursing theorists and the subsequent production of conceptual models and theories, especially as they relate to the field of forensic psychiatric nursing. Although humanism provides optimism for nurse-patient relations, this article explores the incapability of such a philosophy to acknowledge the power relationships between individuals and its inability to explain the day-to-day realities experienced in forensic nursing, where the possibility of interpersonal violence reshapes nursing care. The tidal model will be discussed in detail as an example of a recently developed humanistic nursing model. Viewed from this perspective, it is clear that humanistic philosophy and its subsequent models of care are in discordance with the highly specialized field of forensic nursing.

Respect for Patient Autonomy in Forensic Psychiatric Nursing

A fundamental issue that forensic psychiatric nurses struggle with is respect for patient autonomy, as the two liberal prerequisites for autonomy, liberty and rationality, are either absent or compromised in forensic psychiatric settings. In this paper, a contemporary feminist perspective of autonomy, relational autonomy, will be advanced as an alternative approach to the traditional liberalist, Kantian, perspective of autonomy. The concepts of autonomy, paternalism, and justice will be discussed in relation to forensic psychiatric nursing.

Dangerous Severe Personality Disorder in the United Kingdom

For years, the UK government has struggled to find the best way to manage people with severe personality disorder. The debate continues and includes concerns by the forensic psychiatric nurses who work with these patients.