Secure Forensic Mental Health Research Articles

What influences the use of seclusion? A cross-sectional study of forensic mental health nurses in a UK high secure hospital

PurposeIncidents of violence and aggression are a regular occurrence within adult forensic mental health inpatient settings and often lead to the use of restrictive practices such as seclusion. Such events are frequently attributed to the complexity of the patients. Research commonly focuses on patient’s characteristics and their association with seclusion use. Less attention has been centred on forensic mental health nurses’ attitudes to seclusion and the association of nursing staff characteristics.Design/methodology/approachA cross-sectional survey was undertaken using a standardised questionnaire, “Survey of Nurses’ Attitudes to Seclusion”. Responses were received from n = 147 nurses at a high secure forensic mental health hospital in the UK.FindingsKey findings indicate that most participants believed seclusion should remain part of clinical practice. A correlation was identified between forensic mental health nurses’ attitudes to seclusion use and their characteristics: gender, age range, educational level and experience.Practical implicationsThis paper presents novel information on seclusion reduction opportunities through modifiable workforce factors such as gender-sensitive rostering and staff training and development. Furthermore, recruitment and retention strategies should be prioritised so forensic mental health is perceived as an attractive career and a safe workplace.Originality/valueThe paucity of research in this area has prompted calls for further research to explore nursing staff characteristics and seclusion use. This is particularly important now due to the current global difficulty in the recruitment and retention of mental health nurses.

‘You Still Need to Care for the patient’. Experiences of Forensic Mental Health Professionals with Inpatient Aggression

Forensic mental health professionals are frequently exposed to inpatient aggression, which may negatively affect their physical and mental health. Current studies offer limited insight into how this may affect staff-patient interactions in the aftermath of aggression. A qualitative study was conducted to explore professionals’ experiences with exposure to aggression. Thirteen semi-structured interviews and three focus groups were conducted with 25 professionals working in a high secure forensic mental health unit. A thematic analysis was conducted in consensus among three researchers. Five main themes were generated in the analysis: exposure to different forms of aggression, factors that shape the impact of aggression, emotional reactions, managing emotional reactions, and managing relationships with patients. These themes form a complex interplay. Feelings of anger and fear, intrusive memories, and avoidant or agitated behavior toward patients are frequently reported, affecting both the personal and professional lives of participants. Interpersonal relationships between team members can promote or hinder adequate management of feelings that arise after exposure to aggressive incidents. The tremendous impact that exposure to inpatient aggression may have on professionals, and the way that they care for their patients requires more attention.

IT’S ALL IN THE ACTION

CASE SETTING The prevalence of metabolic syndrome in patients with serious mental illness is almost double the prevalence reported for the general population of Australia. Cardiometabolic disease and mental illness are overrepresented in adult prison populations, with people in custody significantly more likely to have cardiovascular disease and Type 2 diabetes. The Forensic Hospital, is a mental health facility with 140 beds that sits within Justice Health NSW. It is specifically designed for people who have mental illness and have been involved with the criminal justice system, as well as those who are considered to be at high risk in the community. The Ministry of Health and Justice Health NSW have several documents that make reference to the importance of screening for Metabolic Syndrome however barriers exist at the patient, staff, and organisational level to implementing the recommended physical health guidelines in a high secure forensic mental health setting. TREATMENT It’s All In The Action is a Quality Improvement project led by the Forensic Hospital’s Senior Exercise Physiologist and Rehabilitation Coordinator. The initiative focused on embedding physical health intervention for Forensic Hospital patients at risk of or diagnosed with metabolic syndrome through the establishment of the Metabolic Care Team. RESULTS A defined physical health pathway to intervention within the Forensic Hospital in the form of a physical health MDT, atypical in the Forensic Mental Health setting. REFLECTIONS/LEARNINGS The presentation will outline the steps taken in a ground up approach to address the growing concern of systemic neglect and achieve service level change. It will demonstrate translation of best practice research as well as State and National policy and guidelines into tangible action for a significantly marginalised population group. Finally, it will reflect on the sustainability of this initiative, the integration of partnerships, and recommendations for prospective next steps.

Risk and protective factors in risk assessment: Predicting inpatient aggression in adult males detained in a forensic mental health setting.

Structured clinical risk assessments represent a preferred means of assessing levels of aggression risk at different times and in different individuals. Increasing attention has been given to capturing protective factors, with sound risk assessment critical to high-secure forensic mental health care. The aim was to assess the predictive value of the HCR-20v3 for aggression risk and the long-term care pilot version of the SAPROF (the SAPROF-LC-pilot) in a high-secure forensic mental health inpatient population and to determine the incremental value of protective over risk factors.Participants were adult males detained in a high secure forensic mental health service, with a primary diagnosis of schizophrenia and/or personality disorder. The focus was on examining hospital based aggression (self- and other-directed) at two time points; up to 6 months (T1) and between 7 and 12 months (T2).The HCR-20V3 and SAPROF-LC-pilot demonstrated good predictive validity but with variability across subscales and aggression types/periods. Historical factors of the HCR-20V3 and External factors of the SAPROF-LC-pilot failed to predict, aside from a medium effect at T1 for verbal aggression and self-harm, for Historical factors. There was evidence for protective factors adding to prediction over risk factors alone, with the integration of protective and risk factors into a risk judgement particularly helpful in improving prediction accuracy.Protective factors contributed to risk estimates and particularly if integrated with risk factors. Combining risk and protective factors has clear predictive advantages, ensuring that protective factors are not supplementary but important to the aggression assessment process.

Secure patient-therapist attachment following therapy for personality disorder in a forensic mental health setting

ABSTRACT Therapy for personality disorder can be understood as a process of enhancing attachment security. This study tests the theory that individuals in a secure forensic mental health setting with a diagnosis of personality disorder who have undertaken psychological therapy will report secure patterns of attachment in their relationship with their therapist. It uses a novel pattern matching approach that assesses the behavioural, cognitive and affective markers of attachment security in a group of patients undergoing therapy. Eight behavioural, cognitive and affective characteristics of secure attachment were identified. Ten patients completed a semi-structured interview about their experiences in therapy and key relationships, and their responses were reviewed for evidence of these eight characteristics. Nine out of ten participants were judged to have demonstrated a pattern of six or more of the eight characteristics of secure attachment. This study supports the theory that treatment for this group of patients works by developing patient-therapist attachments. A focus on attachment issues should, therefore, be a core aspect of therapy.

Testing a recovery-oriented nursing communication framework to encourage collaboration and discussion about aggression prevention: A mixed methods study.

Recovery-oriented practice is essential in healthcare, yet research exploring methods for integrating recovery-oriented principles in forensic mental health settings is limited. This study involved the co-development, with mental health care nurses and a lived experience expert, and testing of a recovery-oriented script for forensic mental health nurses to use when communicating with consumers at high-risk of imminent aggression. The aim was to examine whether nurses perceived the script as more empathic when the script included specific references to empathy, compared to an equivalent script that did not include empathic statements, and to explore nurses' perspectives on whether the script could help prevent aggression. Nurses (n = 54) working in a secure forensic mental health hospital were randomly allocated to read a script containing statements representing nine recovery-oriented principles that also included empathic statements, or an equivalent script that did not include empathic statements. After reading the script, the participants completed a questionnaire involving a recovery-oriented practice scale developed by the authors, measuring the extent to which the scripts reflected recovery-oriented principles, and open-ended questions about the script's potential to prevent aggression. Results revealed no significant difference in nurse perceptions of empathy between the two scripts. Content analysis indicated that nurses perceived the scripts could help prevent aggression.

Motiv8: a study protocol for a cluster-randomised feasibility trial of a weight management intervention for adults with severe mental illness in secure forensic services

IntroductionPeople with severe mental illness have physical comorbidities which result in significant reductions in quality of life and premature mortality. Effective interventions are required that are suitable for people in secure forensic mental health services. We conducted pilot work of a multidisciplinary weight management intervention (Motiv8) which showed improvements in physical and mental health and high levels of satisfaction. We aim to test the feasibility of Motiv8 under cluster randomised conditions, with an aim to investigate the acceptability, feasibility and potential effectiveness of this intervention to supplement standard secure care.Methods and analysisA randomised waitlist-controlled feasibility trial of a lifestyle intervention (Motiv8) + TAU compared with TAU (+ Motiv8 waitlist) for adults on secure mental health units will be conducted. Thirty-two people (4 cohorts) will be recruited from secure services in Greater Manchester Mental Health NHS Foundation Trust. Participants will be randomly allocated to Motiv8 or TAU + Motiv8 waitlist. All participants will receive Motiv8 during the trial. Assessor-blinded physical/mental health and lifestyle assessments will be conducted at baseline, 10 weeks (post-intervention/waitlist), and after 12 weeks (post-waitlist intervention/follow-up). Motiv8 is a multidisciplinary intervention including exercise sessions, cooking/nutrition classes, physical health education, psychology sessions, sleep hygiene, peer support and medication review by pharmacy. A nested qualitative study will be conducted with a subsample of participants (n = 10) to explore their experiences of taking part. The analysis will focus on feasibility outcomes and tabulated success indicators of the study (e.g. Recruitment rates, retention rates, follow-up retention and response rates, attendance at sessions, the experience of involvement in the trial and delivery of the intervention, assessment of safety, development of a manualised intervention). Thematic analysis will be conducted through qualitative interviews. The analysis will aim to inform the development of a definitive trial.Ethics and disseminationThe trial has been granted ethical approval from the NHS Health Research Authority and adopted onto the UK Clinical Research Network Portfolio. Findings will be disseminated via peer-reviewed publications, professional and public networks, conferences and clinical services.Trial registrationISRCTN13539285.

The Digital Bytes Project: Digital Storytelling as a Tool for Challenging Stigma and Making Connections in a Forensic Mental Health Setting.

This article reports on the findings of a study that explores the utility of digital storytelling as a narrative practice and learning tool for social work in an Australian secure forensic mental health hospital. The short digital stories, or Digital Bytes Project, centered on capturing the lived experience, hopes and perspectives of the hospital's service users by giving voice to their experiences through digital technology. The project was collaboratively designed and co-delivered with social work students, hospital staff, and service users. It aimed to not only destigmatize people with lived experiences of mental distress and criminal justice system involvement but also to give staff and students further insights into understanding who they are working with. Through a series of 11 semi-structured, one on one interviews, this research aims to explore social work student and forensic mental health staff experiences and perceptions in relation to the utility and impact of these digital bytes, reflecting on how the prototype bytes may have impacted their learnings, or practice, including how they then interact with service users. This research investigates how these digital bytes could be used further within forensic mental health organisations and contexts. The research findings demonstrate the overall value of digital bytes in challenging different kinds of stigma, shifting power dynamics and staff perspectives; strengthening rapport and understanding through enhancing engagement and sharing power between students, staff, and consumers; as well as providing insight into the utility of digital bytes for learning and making connections between theory and practice. The preliminary findings from this research suggest the need for greater accessibility, integration, and consideration of these digital tools, with their potential to be translated across multiple human service sectors.

Frailty in Secure Forensic Mental Health Settings: A Study from Dundrum Hospital, Ireland

IntroductionFrailty is defined as a clinical syndrome that encompasses a combination of decreased physiological reserve and low resistance to stressors. There is an association between mental illness and frailty among elderly cohorts. Frailty is also associated with obesity and smoking. There are high rates of treatment resistant schizophrenia among patients in secure forensic services. Patients with schizophrenia have high rates of morbidity and early mortality.ObjectivesThe primary aim of this study was to examine the rates of frailty present in a complete cohort of forensic in-patients.MethodsAn assessment using Fried Frailty criteria was offered to all in-patients (n=95) in Ireland’s National Forensic Service, which included measures of walking speed, grip strength, low physical activity and exhaustion. Demographic details and details pertaining to diagnoses and medications were also gathered.ResultsOf the 95 in-patients, 92 patients agreed to participate. The majority were male (89%). The most common diagnosis was schizophrenia (71.7%). Mean age was 44.7 years (SD 11.42), and 58.2% met criteria for obesity. Of the total group, 47 patients met criteria for ‘pre-frail’ and 10 met criteria for ‘frail’ using Fried criteria.ConclusionsThis is the first study examining frailty in a cohort of patients in secure forensic settings. We found high rates of patients meeting frailty criteria at very young ages. Rates of frailty in this group were comparable to those found amongst elders in community settings. We consider this demonstrates significant medical vulnerability in this patient group.DisclosureNo significant relationships.

De-escalation of conflict in forensic mental health inpatient settings: a Theoretical Domains Framework-informed qualitative investigation of staff and patient perspectives

BackgroundViolence and other harms that result from conflict in forensic inpatient mental health settings are an international problem. De-escalation approaches for reducing conflict are recommended, yet the evidence-base for their use is limited. For the first time, the present study uses implementation science and behaviour change approaches to identify the specific organisational and individual behaviour change targets for enhanced de-escalation in low and medium secure forensic inpatient settings. The primary objective of this study was to identify and describe individual professional, cultural and system-level barriers and enablers to the implementation of de-escalation in forensic mental health inpatient settings. The secondary objective was to identify the changes in capabilities, opportunities and motivations required to enhance de-escalation behaviours in these settings.MethodsQualitative design with data collection and analysis informed by the Theoretical Domains Framework (TDF). Two medium secure forensic mental health inpatient wards and one low secure mental health inpatient ward participated. 12 inpatients and 18 staff participated across five focus groups and one individual interview (at participant preference) guided by a semi-structured interview schedule informed by the TDF domains. Data were analysed via Framework Analysis, organised into the 14 TDF domains then coded inductively within each domain.ResultsThe capabilities required to enhance de-escalation comprised relationship-building, emotional regulation and improved understanding of patients. Staff opportunities for de-escalation are limited by shared beliefs within nursing teams stigmatising therapeutic intimacy in nurse-patient relationships and emotional vulnerability in staff. These beliefs may be modified by ward manager role-modelling. Increased opportunity for de-escalation may be created by increasing service user involvement in antipsychotic prescribing and modifications to the physical environment (sensory rooms and limiting restrictions on patient access to ward spaces). Staff motivation to engage in de-escalation may be increased through reducing perceptions of patient dangerousness via post-incident debriefing and advanced de-escalation planning.ConclusionsInterventions to enhance de-escalation in forensic mental health settings should enhance ward staff’s understanding of patients and modify beliefs about therapeutic boundaries which limit the quality of staff-patient relationships. The complex interactions within the capabilities-opportunities-motivation configuration our novel analysis generated, indicates that de-escalation behaviour is unlikely to be changed through knowledge and skills-based training alone. De-escalation training should be implemented with adjunct interventions targeting: collaborative antipsychotic prescribing; debriefing and de-escalation planning; modifications to the physical environment; and ward manager role-modelling of emotional vulnerability and therapeutic intimacy in nurse-patient relationships.

Enhanced Observation: How Therapeutic Are They Within A Medium Secure Forensic Mental Health Setting?

ABSTRACT Enhanced observations (EO) have been integral to mental health nursing care for decades. However, research examining patient’s experiences of EO within forensic mental health settings is limited. This study explored patients’ lived experiences of EO within a medium secure hospital as part of a service review. Four patients and one staff member completed semi-structured interviews. The data were analysed using Interpretive Phenomenological Analysis (IPA). The four themes that emerged were: 1) The importance of the therapeutic relationship; 2) Focus on staff’s interpersonal qualities; 3) EO experienced as loss; and 4) Factors to improve the therapeutic experience. Staff awareness training and development of guidelines (embedded within service policy) were suggested recommendations; with the aim of enhancing patient focused practice and altering a ritualistic task to become a recovery orientated therapeutic experience.

Genesis of change: Substance use treatment for forensic patients with mental health concerns.

Substance use disorders are highly prevalent among forensic patients. They are associated with many challenges for patients with these problems, including their ability to rehabilitate and successfully move through secure forensic mental health services, as well as increasing risk for recidivism. Traditionally, forensic services have been more adept at focusing on and treating the primary mental health diagnosis alone and have been less likely to prioritise this co-occurring patient need. Opportunities exist to foster effective treatment strategies for substance use disorders, and past research has produced positive outcomes among forensic patients in studies in both Australia and the UK to navigate a new course for patients with these problems. By providing empirically validated, co-produced and culturally competent treatment responses, forensic patients living with substance use disorders will have the opportunity to significantly improve their wellbeing and progress through the system. They will also be more prepared and equipped to face challenges upon discharge into the community, including increased availability of alcohol and other drugs, social stigma and barriers to employment. Moreover, by prioritising effective substance use treatment programs during inpatient rehabilitation, services can reduce the levels of post-discharge recidivism.

Handcuff use on forensic psychiatry wards

AimsThis project aimed to assess the use of handcuffs in a secure forensic mental health hospital.BackgroundHandcuffs are used by secure forensic psychiatric wards where patients need to leave the ward and require added restrictive measures for their own or other's safety. The decision to use handcuffs is made by the multi-disciplinary team, with the input of the unit's clinical security team and is assessed based on individual risk and need. This study investigated the frequency, duration and purpose of handcuff use in one secure forensic mental health unit, encompassing 8 male medium secure wards, 5 male low secure wards, 1 adolescent secure ward,1 female low secure ward and 5 female medium secure wards.MethodHandcuff use was recorded contemporaneously by ward staff in a specialised handcuff proforma. This data were then compiled to assess the number of instances of use, the mental health section applicable to the patient, the reason the patient needed to leave the unit, and the duration of use (including the time period for which the handcuffs were removed during the visit, if applicable.) Data from these forms over an 18 month period were analysed.ResultOver the 18 months, there were a total of 347 uses of handcuffs, with an average of 18.3 occurrences per month. In 55 cases, the patients were detained under a civil section, with the remaining instances occurring in patients detained under forensic section. 47% were unsentenced prisoners.The most common destination for patients was the general medical hospital, which accounted for 49% of all visits. Court was the second most common destination, with 39% of uses.The average duration spent in handcuffs was 3.3 hours. The average time that the handcuffs were taken off during the transfer was 1.2 hours.ConclusionThrough ongoing education and supervision by the clinical security team, handcuff use in this forensic service was limited to essential situations, most often to allow treatment of physical health issues off-site. A large proportion of instances involved unsentenced prisoners and court attendances, where the risk of absconsion might be particularly high. Duration spent in handcuffs was kept to a minimum, with cuffs being removed where possible. The service strives to continue such good practices and to identify further ways to reduce handcuff use, such as using video-conferencing as an alternative court attendance.

A quality improvement project to improve the physical health of people with intellectual disability & severe mental illness in a forensic inpatient ward

AimsReview physical health risk factors of service users Co-produce personalised care plans for service users Improve health knowledge and confidence in self-management of health problems Support reduction in risk by improving physical activity levels and supporting healthy dietary choices.BackgroundPeople with intellectual disability have poorer physical health outcomes than those without intellectual disability; there is higher prevalence of obesity, constipation and diabetes in this group of the population, and consistent evidence of premature mortality. Excess mortality in persons with severe mental illness has also been established.Empowering patients to take an active role in their care, is good practice and encouraged as part of the NHS Long Term Plan.Quality Improvement methodology was used to design and deliver a multi-disciplinary team (MDT) intervention, on a forensic mental health ward for persons with intellectual disability, to improve physical health in this patient group.MethodCardiovascular risk was assessed for 13 patients on a low secure forensic mental health ward. Measures of weight, BMI, blood pressure, resting heart rate, smoking status & status regarding prescription of psychotropic medications were collected.Together with individual comorbidities and activity levels, a personalised care plan was co-produced by MDT members and patients. Motivational interviewing techniques were adapted to support patients to set personal goals.Education sessions were designed in 'easy-read' format and delivered by MDT members in a group format. Focus groups were held with service users and with staff members to explore barriers to change. Based on these, specific ideas to increase physical activity and support healthy dietary changes were introduced.The Patient Activation Measure (PAM) questionnaire was modified and used to assess confidence and knowledge in preventing or reducing health problems, and maintaining changes.ResultCardiovascular risk and activity levels were assessed for 13 inpatients. 85% of patients had a BMI in the overweight or obese range. 62% were regular cigarette smokers. 92% were prescribed psychotropic medications. On review of 2 months of opportunities for activity, all patients were categorised as 'inactive'. Patients engaged to varying degrees to co-produce personalised care plans and to engage in group education and physical activity. Of these patients, all showed improvement in measures of Patient Activation and activity level.ConclusionAn individualised approach is required in exploring physical health problems, considering modifiable risk factors and addressing barriers to change. Co-production, and active participation of MDT members in role-modelling 'healthy habits' was positively reported by patients to facilitate self-management.

A Clinical Decision Support System to Prevent Aggression and Reduce Restrictive Practices in a Forensic Mental Health Service.

Preventing aggression and reducing restrictive practices in mental health units rely on routine, accurate risk assessment accompanied by appropriate and timely intervention. The authors studied the use of an electronic clinical decision support system that combines two elements, the Dynamic Appraisal of Situational Aggression instrument and an aggression prevention protocol (eDASA+APP), in acute forensic mental health units for men. The authors conducted a cluster-randomized controlled trial incorporating a crossover design with baseline, intervention, and washout periods in a statewide, secure forensic mental health service. The study included 36 mental health nurses (13 men and 23 women, ages 20-65 years) with direct patient care responsibility and 77 male patients (ages 21-77 years) admitted to one of two acute mental health units during the baseline and intervention periods. eDASA+APP implementation was associated with a significant reduction in the odds of an aggressive incident (OR=0.56, 95% confidence interval [95% CI]=0.45-0.70, p<0.001) and a significant decrease in the odds of administration of as-needed medication (OR=0.64, 95% CI=0.50-0.83, p<0.001). Physical aggression was too infrequent for statistical significance of any effects of eDASA+APP to be determined; however, incidents of physical aggression tended to be fewer during the eDASA+APP phase. These results support the use of the eDASA+APP to help reduce incidents of aggression and restrictive practices in mental health units.

Factors affecting high secure forensic mental health nursing workforce sustainability: Perspectives from frontline nurses and stakeholders.

WHAT IS KNOWN ON THE SUBJECT?: There are insufficient nurses to meet current demand for mental health care. This is an international concern. Within England, the impact of staff shortages on the quality of patient care in forensic high secure settings has been highlighted by the national regulatory body for hospitals. Forensic hospital nursing is a distinct specialism within mental health. Forensic nurses must negotiate the therapeutic, ethical and practical challenges of caring for high-risk patients in a locked environment. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: There has been no previous study to ask frontline high secure forensic nurses, union representatives, senior nurses and workforce leads about what factors may be affecting recruitment and retention in their setting. As well as the specialized and challenging nature of the work, participants identified that workforce sustainability was affected by unequal working terms and conditions, the hospital locations and wider national factors, such as changes to how nurse training was funded. They also identified that some strategies that were employed to address workforce shortages, such as day-to-day movement of staff within the hospital and incentive packages for new recruits could be demotivating for established staff. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Forensic high secure nursing workforce strategies should include training, development and career pathways that are specific to the specialism and extend beyond preceptorship for newly qualified staff. There should be clear and equitable employment terms and conditions with remuneration packages that are consistent within and between organizations. Hospital managers should address the effect that movement of staff between wards may have on nurses' morale, therapeutic relationships and safety culture. ABSTRACT: Introduction There has been no previous study of stakeholders' views on recruitment and retention concerns in high secure forensic settings. Aim To identify factors affecting recruitment and retention in high secure hospitals, from the perspectives of stakeholders with experience in forensic mental health nursing. Method Framework analysis of data from fifteen interviews and three focus groups with frontline nurses, nurse leaders, recruitment leads and union representatives from three high secure hospitals in England. Results Six themes emerged from the data: (a) the unique nature of high secure nursing; (b) the impact of short staffing; (c) wider factors affecting the high secure nursing workforce; (d) the location; (e) staff being on different terms and conditions of work; (f) recruitment strategies. Discussion Multiple factors are likely to simultaneously affect high secure hospital recruitment and retention. Findings on the unique nature of high secure work reflect previous qualitative research. The themes of location, working terms and condition and recruitment strategies have not been previously identified in forensic nursing research. Implications for practice Employers should ensure that employment terms and conditions are equitable and consistent. Furthermore, hospital managers should address the effect that movement of staff between wards may have on morale and therapeutic relationships.

Predicting and understanding seasonal influenza vaccination behaviour among forensic mental health inpatients

Objectives This study aimed to identify demographic and psychological predictors of seasonal influenza vaccination intentions and behaviour among a sample of inpatients in a secure forensic mental health service. It also sought to explore patient experiences about being offered the vaccine. Design This study used a mixed-methods design. The quantitative element employed a prospective design using a questionnaire; both cross-sectional and prospective findings are reported. For the qualitative part of the study, semi-structured interviews were conducted and analysed using Interpretative Phenomenological Analysis (IPA). Main outcome measures Seasonal influenza vaccination intentions and behaviour Results Past behaviour, vaccine knowledge and cues to action were predictors of vaccination intention (N = 57). Cues to action remained as the only statistical predictor of vaccination behaviour (N = 55). Nine interviews were conducted with four vaccinated and five unvaccinated participants. Three main themes were formed in the IPA analysis; these were ‘Managing Decisional Conflict’, ‘Interaction with Immune Function’ and ‘The Role of Others’. Conclusions The results highlighted the integral role of health professionals in shaping patient’s vaccination behaviour within a secure mental health setting. Recommendations for vaccination promotion strategies were offered.

An integrative review of nursing staff experiences in high secure forensic mental health settings: Implications for recruitment and retention strategies.

To identify the experiences of nursing in high secure forensic mental health settings that may affect staff recruitment and retention. Recruitment and retention of Registered Nurses is a vital international concern in the field of mental health. The high secure forensic setting presents unique challenges for the nurse. Studies of nurse's experiences in this setting have not previously been reviewed in the context of workforce sustainability pressures. An integrative review (Whittemore and Knapfl, 2005). A systematic search of data sources: MEDLINE (PubMed), PsycINFO, EMBASE, CINAHL, International Bibliography of the Social Sciences, Applied Social Sciences Index and Abstracts (ASSIA), Social Services Abstracts, ProQuest Social Sciences Premium collection (IBSS, PAIS, and Sociological Abstracts), and Web of Science from inception to December 2019. Data extraction, quality appraisal, and convergent qualitative synthesis. Fifteen papers were selected for inclusion in the review, describing 13 studies. Six studies were quantitative, all cross-sectional surveys. There were seven qualitative studies, using a variety of methodologies. Four themes were identified: engagement with the patient group, the ward social environment, impact on the nurse, and implications for practice. When policymakers address workforce shortages in high secure forensic nursing they must take account of the unique features of the setting and patient group. Nurses must be adequately prepared and supported to function in an ethically and emotionally challenging environment. This study identified factors affecting workforce pressures in the speciality of forensic mental health nursing. Findings are of interest to national nursing policymakers and workforce leads in mental health service provider organizations, seeking to promote forensic nursing as a career option and retain nursing staff.

An exploration of perceived coercion into psychological assessment and treatment within a low secure forensic mental health service

Psychologists working within forensic mental health (FMH) services face challenges around supporting clients’ informed consent when engaging in psychological assessment and treatment. Given that there is little research in this area, this qualitative study interviewed ten forensic inpatients from a low secure FMH service, to determine the impact of any perceived coercion to engage with psychologists. Interviews were transcribed and subject to Thematic Analysis. Three over-arching themes emerged from the analysis: ‘Awareness of Coercive Power’, ‘Experiencing and Responding to Coercion’ and ‘Psychological Treatment is Helpful, But…’. Participants perceived coercion to engage with psychologists. Perceived coercion led to psychological distress, wanting to resist, and superficial engagement. Despite this, therapeutic alliance was established with the psychologist but the quality of the therapeutic alliance was compromised. The findings have implications for psychologists working in FMH services. Suggestions for reducing perceived coercion and future directions for research are discussed.

Capabilities, Opportunities, Resources and Environments (CORE): Using the CORE approach for inclusive, occupation-centred practice.

Occupational participation is often claimed as a human right and determinant of health by occupational science and therapy scholars. Yet, maintaining occupation at the centre of practice is a challenge. The Capabilities, Opportunities, Resources and Environments (CORE) approach provides a mechanism for occupational therapists to address this challenge by viewing their practice through an inclusive lens, and enacting inclusive, occupation-centred occupational therapy. This paper presents applications of the CORE approach via three case narratives. The aim is to increase occupational therapists' understanding of how to apply the CORE approach and to facilitate research-to-practice knowledge translation. The CORE approach is introduced and applied through three case narratives, each highlighting one of the CORE elements within the context of the broader approach. The narratives contain critical reflective case narratives on the application of the CORE approach in the context of three different practice settings in Australia based on the authors' experiences. Practice settings include working within the National Disability Insurance Scheme, in a secure forensic mental health facility, and in rural community health. The forensic health case narrative documents findings from the authors' research which applied the CORE approach as an analytical tool, providing an additional layer of analysis of the identified themes from the original study. This paper provides occupational therapists with a practical understanding of how to apply the CORE approach through diverse case narrative examples. The practical "how to" questions that guided the development of the case narratives can be used by occupational therapists and occupational therapy students in individual or group critical reflection to support development and application of socially inclusive and occupation-centred praxis. If occupational therapists are to claim expertise in enabling occupation and social inclusion, then using the CORE approach is vital to designing and implementing inclusive, occupation-centred interventions.