Secure Forensic Settings Research Articles

Conducting mixed methods research with women in a forensic mental health setting: A reflexive account from a nurse as researcher.

To describe a reflexive account of a mental health nurse as researcher undertaking a mixed methods study as part of a doctoral degree, with women in a secure forensic hospital. A discursive paper that draws upon the primary author's experience of dual roles as a mental health nurse and a novice researcher, and relevant literature pertaining to positionality and reflexivity in the context of conducting mixed methods research. A mixed methods study was conducted within a secure forensic hospital in Australia, to identify factors associated with the frequency and duration of seclusion for women and, to explore their experiences of seclusion. Notes and a reflective diary were used to demonstrate the reflexive approach and strategies used throughout the study design and data collection stages of the research. Women in the secure forensic hospital setting often have complex histories and experiences and are considered a vulnerable group, which can add additional challenges when undertaking research with this population. As a doctoral student with clinical experience in mental health undertaking research in the forensic hospital setting with women, positionality and the connection with reflexivity requires exploration to understand self and the influence on research. This understanding along with identified strategies to enhance reflexivity, supports the management of the dual nurse as researcher roles to enhance all stages of the research process. Doctoral nursing candidates undertaking clinical research in their area of clinical practice and at the location of previous employment, may experience challenges in relation to identity and the dichotomy of roles. Further challenges can be posed when research involves complex populations and/or controversial practices. Support to balance role conflict and maintain reflexivity is critical to understanding the role of self in research and to enhance credibility. Women are a complex, yet minority population in forensic mental health settings, however the numbers of women being admitted to services is increasing. Future research may consider the use of the strategies explored here to enhance the reflexive process, and support future researchers in this field to conduct research that aims to support an often-misheard population to better support health outcomes. There was no patient or public contribution to this paper, however the study in which this paper is based on, is grounded in the experience of patients (women).

The Role of Nurses in the Implementation of Positive Behavior Support in a Secure Forensic Setting

ABSTRACT Positive Behavior Support (PBS) is a framework that attempts to help reduce challenging behaviors displayed by service users however, little is known about the role of nurses and their perceptions of PBS. This qualitative study aimed to explore nurses’ perceptions and their roles in the PBS implementation in two forensic learning disabilities units in London. 19 nursing staff with experience implementing PBS were interviewed. Six themes were derived from thematic analysis, with findings in line with previous research. Recommendations highlighted introducing protected time for nursing staff to discuss PBS on the ward and providing more structured training and informed supervision.

Trauma-Informed Care Practices in a Forensic Setting: Exploring Health Care Professionals’ Perceptions and Experiences

The prevalence of trauma within secure forensic populations is widely acknowledged, yet the implementation of trauma-informed care (TIC) in secure forensic settings (SFS) remains in its infancy. This qualitative study delves into the perceptions and experiences of healthcare professionals (HCPs) adopting a TIC framework in SFS, examining associated barriers and facilitators. 15 participants engaged in semi-structured interviews, and results underwent thematic analysis, yielding five overarching themes and 15 sub-themes. Themes identified include: 1) understanding the TIC experience in SFS, 2) organizational and personal barriers in TIC implementation, 3) facilitators and reflections on TIC benefits, 4) barriers to specific TIC practices, and 5) practical recommendations. Participants emphasized the prevalent nature of trauma in SFS and underscored the perceived advantages of creating spaces for reflection and emotional well-being. Interviewees explored the impact of organizational culture, the demands of frontline roles and training accessibility. Practice implications highlight the need to involve key stakeholders (staff and SUs) in decision making and in assessing the feasibility of implementing TIC. SFS should prioritize TIC by addressing training needs, allocating time for TIC in supervision, providing specialist support for trauma-informed clinical work, and ensuring dedicated spaces for reflection. While the study highlights the power of incorporating HCP perspectives, limitations arise from findings drawn from a single forensic service, emphasizing the importance of further replication. This research contributes valuable insights into advancing trauma-informed care practices within secure forensic settings.

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.

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.

Psychiatric rehabilitation in secure forensic settings in NSW: Measuring outcomes.

To quantify outcomes for patients of forensic psychiatric rehabilitation in NSW. Data on 245 conditionally released forensic patients was extracted from the Mental Health Review Tribunal (MHRT) files and matched to several state-wide datasets. Descriptive statistics were generated to establish the cohort characteristics, rates of reoffending and social and clinical outcomes. At conditional release, social circumstances for the majority of patients were improved. Clinically, the cohort was more stable, though many did not remain stable over time. Only one-fifth of the sample received a further criminal charge. Preliminary evidence suggests that forensic rehabilitation services in NSW are effective.

Obesity in secure hospital settings: Changes in BMI over time among a complete national cohort of forensic in-patients in Dundrum Hospital, Ireland

IntroductionThere are high rates of treatment resistant psychoses and medical complexity among patients in secure forensic hospitals (Basrak et al., BJPsych Open (2021) 7, e31,1-7). Patients with schizophrenia in secure settings have a lower life expectancy compared to community peers of approximately 16 years. Evidence suggests patients in secure settings often gain significant amounts of body weight during their in-patient stays, many of whom develop complex obesity presentations.ObjectivesTo ascertain changes in Body Mass Index (BMI) among patients in a secure forensic hospital setting over a 3.5 year period.MethodsA prospective longitudinal study of repeated measures of BMI for all (n=91) patients in a National Forensic Mental Health Service (CMH Dundrum, Dublin, Ireland). BMI was measured six-monthly, giving up to seven time points for each patient. Generalized Estimating Equations (GEE) analysis was conducted to ascertain changes in BMI over time. This study formed part of the DUNDRUM Forensic Redevelopment Evaluation Study (D-FOREST) (Davoren et al., BMJ Open (2022) 12(7): e058581).ResultsA total of 91 patients were included in the study, mean age 33.46 years (SD 9.23). Mean length of stay was 8.09 years (SD 9.23). The most common diagnosis was schizophrenia (67%), followed by schizoaffective disorder (17.5%) and Autistic spectrum disorder (6.2%). Using GEE with BMI as the dependent variable, for the complete patient cohort, BMI changed significantly with diagnosis (Wald X2=5817.58, df=7, p<0.001). Those with severe mental illnesses (psychoses) had the highest BMI of the group, and BMI tended to increase over time (p=0.109). Among patients who were in the secure hospital for four years or less, their weight gain was significant over time (Wald X2 =10.0, df=1, p=0.002).ConclusionsWe have shown high rates of obesity particularly in patients with psychoses and we have shown weight gain is significant during the first four years after admission to a national forensic service. This is a significant health concern and an area of unmet treatment need which is likely generalizable across secure hospitals in the EU.Disclosure of InterestNone Declared

Attributions of aggressive behaviour in people with mild intellectual disabilities to borderline intellectual functioning in a secure forensic setting

ABSTRACT Aggressive behaviour is often displayed by people with intellectual disabilities (ID) in forensic healthcare settings. Research on the causal beliefs (i.e. attributions) of aggressive behaviour are commonly studied from the perspective of support staff. As aggressive behaviour is mostly a product of interaction between the person showing it and their environment, it is valuable to include the perspective of people with ID as well. Four group interviews, consisting of a total of 20 people with mild ID or borderline intellectual functioning and forensic and/or psychiatric problems, were held to explore incidents of aggressive behaviour. The attributions were analysed using the Leeds Attributional Coding System. Clients almost equally distributed the causes of aggressive behaviour to themselves (intrapersonal domain; 48.0%) and to other persons (interpersonal domain; 45.7%). There is a distinction related to the attributions given between the client as agent (intrapersonal domain), being uncontrollable (72.1%) and global (68.9%), versus other persons as agent (interpersonal domain), being controllable (86.2%) and specific (56.9%). This analysis of attributions regarding aggressive behaviour given by clients resulted in information on causal beliefs of aggressive behaviour from the perspective of clients. Incorporating their views will possibly increase involvement and commitment in support and treatment.

Decision-making capacity regarding healthcare, welfare and finances in a secure forensic setting

IntroductionImpairment in decision-making capacity is a serious consequence of executive dysfunction secondary to serious mental disorders like schizophrenia. Functional mental capacity (FMC) refers to an individual’s ability to make and communicate legally competent decisions autonomously. Studies have shown that FMC is dependent on severity of psychosis and can improve with treatment.ObjectivesTo ascertain the correlation between the scores on a structured judgement tool, namely the Dundrum Capacity Ladders (DCL) with level of acuity of treatment setting and length of stay in a secure forensic hospital.MethodsSixty-two patients were interviewed using the DCL across three domains – healthcare, welfare and finances. Correlation between DCL scores, length of hospital stay and level of acuity of treatment setting was assessed.ResultsAs patients moved from higher to lower dependency wards, mean DCL score increased, indicating a higher level of capacity. Patients in high dependency wards were most impaired while those in the low dependency wards performed significantly better (rs=0.472, p<0.001). The longer the patients stayed in the hospital, up until five years, the higher the mean welfare domain score (rs=0.402, p=0.011) and mean DCL score (rs=0.376, p=0.018). Beyond five years of hospital stay, those who had lower DCL scores and did not improve had longer length of stay.ConclusionsPatients’ FMC improve as they progress from high to low level of acuity of treatment setting. However, this is dependent on the length of hospital stay. FMC may be a measure of recovery in the forensic setting.DisclosureNo significant relationships.

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.

Quality of Life, Risk and Recovery in a National Forensic Mental Health Service: A D-FOREST study from DUNDRUM Hospital

IntroductionSecure forensic mental health services have a dual role, to treat mental disorder and reduce violent recidivism. Quality of life is a method of assessing an individual patients’ perception of their own life and is linked to personal recovery. Placement in secure forensic hospital settings should not be a barrier to achieving meaningful quality of life. The WHO-QuOL measure is a self-rated tool, internationally validated used to measure patients own perception of their quality of life.ObjectivesThis aim of this study was to assess self-reported quality of life in a complete National cohort of forensic in-patients, and ascertain the associations between quality of life and measures of violence risk, recovery and functioning.Methods This is a cross sectional study, set in Dundrum Hospital, the site of Ireland’s National Forensic Mental Health Service. It therefore includes a complete national cohort of forensic in-patients. The WHO-QuOL was offered to all 95 in-patients in Dundrum Hospital during December 2020 – January 2021, as was PANSS (Positive and Negative Symptoms for Schizophrenia Scale). During the study period the researchers collated the scores from HCR-20 (violence risk), therapeutic programme completion (DUNDRUM-3) and recovery (DUNDRUM-4). Data was gathered as part of the Dundrum Forensic Redevelopment Evaluation Study (D-FOREST).ResultsLower scores on dynamic violence risk, better recovery and functioning scores were associated with higher self-rated quality of life.ConclusionsThe quality of life scale was meaningful in a secure forensic hospital setting. Further analysis will test relationships between symptoms, risk and protective factors and global function.DisclosureNo significant relationships.

Systematic review of physical activity interventions assessing physical and mental health outcomes on patients with severe mental illness (SMI) within secure forensic settings.

Accessible SummaryWhat is known on the subject? Individuals with a severe mental illness (SMI) are less physically active and have a lower life expectancy than the general population due to increased risks of cardiometabolic diseases (obesity, diabetes and respiratory diseases) and other health risks.Physical activity has been used as an adjunct therapy for individuals with SMI yielding improvements in cognitive functioning, quality of life and a reduction in psychiatric symptoms.Individuals with SMI residing within a secure forensic setting have reduced physical activity opportunities, possibly due to a number of factors including low motivation and restricted access to exercise facilities combined with a lack of knowledge and/or confidence in staff members to assist in physical activity programmes. What the paper adds to existing knowledge? This review demonstrates that little is known around the effects of physical activity for people with SMI who reside in secure forensic settings, with little to no long‐term effects reported.Physical activity interventions have shown some positive results through decreasing weight and waist circumference as well as a reduction in negative symptom scores in an exercise group compared with the “no treatment” control group post‐intervention. What are the implications for practice? Service users’ reluctance to engage in physical activity may be overcome by improving staff commitment, creating a motivational atmosphere and promoting service user decision making. IntroductionParticipating in physical activity has many benefits, yet those with severe mental illness (SMI) living in forensic settings are less likely to be active, and more likely to experience ill‐health. The aim of this study was to systematically review the effectiveness of physical activity programmes on mental and physical health and specifically on reducing symptoms of SMI in forensic settings.MethodA systematic search of six databases was conducted, in addition to a grey literature search. Studies were included if they had participants with SMI; were based in a forensic setting; involved a physical activity programme and reported physical and mental health outcomes.ResultsA total of 112 participants were included in four studies. One study showed a significant improvement in negative symptom scores in the exercise group compared with a treatment as usual group. Two studies reported improvements in psychiatric symptoms with no significant difference between groups; however, statistically significant changes in weight and waist circumference were evident (p < .001). No adverse effects were reported.ConclusionOnly a small number of studies were included and of limited design and quality, with no follow‐up assessments; therefore, more research is needed to determine the true effects of physical activity for improving SMI symptoms in a forensic setting.This review highlights the need for further studies exploring the barriers and facilitators of physical activity in secure forensic settings. Studies are required that include a more thorough research design. Furthermore, interventions if designed with patients and caring staff in mind may lead to lowered psychiatric symptoms and increased physical health benefits for all in forensic settings.

The use of recovery model in forensic psychiatric settings: A Foucauldian critique.

Recovery, a model of care aimed at patient-led nursing practice emphasizing autonomy, hope and self-determination, has in recent years been adapted for the secure forensic psychiatric setting. Often referred to as 'secure recovery', this model suggests the aims of recovery are achievable even in highly restrictive settings. This paper will adopt a Foucauldian perspective to offer a critical analysis of recovery in forensic settings. In providing recovery-oriented care, nurses utilize pastoral power in guiding patients to institutionally preferred outcomes. Akin to Christian religious conversion, nurses engage in a neo-religious conversion of patients to a neoliberal subjectivity of homo-economicus. This path of recovery is grounded in an ethos of personal responsibility and self-government, inseparable from the greater context of neoliberal governmentality. Despite attempts at transforming forensic nursing practice into more egalitarian directions, recovery remains a coercive practice, and fails to meet the overall goals of this paradigm in secure settings.

Exploring the Experience of a Strengths-Based Approach within a Forensic Service

ABSTRACT As part of an NHS England pilot scheme, Specialist Community Forensic Teams were developed aiming to support service users’ transition of care from secure forensic inpatient settings to living in the community. This study explored the experiences of service users, carers, health professionals and specialist residential accommodation providers in relation to one of these teams. The Good Lives Model was adapted by the team to inform formulation and intervention. Nineteen participants completed a mixed-methods survey. Data were processed using descriptive statistics and thematic analysis. Findings indicate that the use of a strengths-based model within a forensic setting was perceived by stakeholders as providing an experience of relational security and hopefulness. Most stakeholders surveyed endorsed survey items indicative of a positive experience of the service. The findings from this study suggest that GLM is an acceptable model to stakeholders for formulating the needs and strengths of service users in planning their transition from residing in secure settings to living in the community.

Predictors associated with readmission in low secure forensic settings in the UK: an exploratory investigation and survival analysis

ABSTRACT Readmission from secure forensic services has significant implications for individuals and providers. Whilst there is research on readmission for forensic services internationally and for medium secure services in the UK, little is known about rates of readmission to low secure services, and there is no research examining predictors of readmission in low secure services specifically. This study aimed to examine rates and predictors of readmission of 94 individuals discharged from UK-based low secure services. A retrospective quantitative design was employed to assess the rate of readmission. Treatment, demographic, clinical and forensic factors were considered to compare readmitted and non-readmitted groups and examined as possible predictors of readmission. In total, 34% patients were readmitted with an average time to readmission of 524 days. Readmitted patients differed significantly from non-readmitted on prescribed antipsychotic medication, previous forensic admissions, psychology intervention and group psychology intervention. Previous secure forensic admissions, scoring present on HCR-20 historical problems with violence and employability were significantly associated with a shorter time to readmission. Deterioration in mental state was the most common reason for readmission. Time to readmission post-discharge from low secure services can be predicted by several factors that are readily available to clinical teams. This novel exploratory investigation is imperative in furthering understanding of factors associated with readmission to LSFS.

Educational Needs among Women Admitted to High Secure Forensic Psychiatric Care

ABSTRACT Forensic psychiatric patients’ low educational attainment is a strong predictor for recidivism. However, there is a lack of studies on the educational background among women admitted to forensic psychiatric care. The study aimed to investigate the educational background among women within a high secure forensic psychiatric setting. A mixed-method design was applied. Data were collected from registers, including medical records, forensic psychiatric investigations, and verdicts (n = 93), and by conducting interviews (n = 61) with women admitted to forensic psychiatric care in Sweden. The women’s education length varied between 5 and 18 years. According to interviews and registers, more than 70% of the women were found to have some school-related problems. In the interviews, some women associated school with conflicts, loneliness, and learning difficulties. Others explained how their disadvantageous home environment and many school changes affected their learning and problems developing and maintaining social relationships. Women with a neurodevelopmental disorder were to a higher degree documented with school-related problems than women without such disorders (97% vs. 63%). The educational attainment varied among the women, and consequently, their educational needs were heterogeneous. Therefore, they should be offered tailored education and vocational support to have an increased prerequisite for adjusting to and participating in society.

The use of antipsychotic polypharmacy at Ravenswood House Medium Secure Unit: the extent of use and reporting of outcomes

AimsTo evaluate the use of antipsychotic polypharmacy in Ravenswood House Medium Secure Hospital. We also aimed to review the reporting of the outcomes of their use.BackgroundThe use of antipsychotic polypharmacy (APP) continues to be practised within forensic psychiatric inpatient settings yet there is a lack of robust evidence for the benefits of doing so. The practice is also associated with the use of higher total antipsychotic doses beyond the recommended BNF maximum. Such prescribing is associated with an increased side effect burden. Doctors have a duty to justify the ongoing use of antipsychotic polypharmacy and to avoid potentially ineffective and/or harmful use.MethodA cross-sectional review of the medication cards for 51 in-patients at Ravenswood House Hospital was completed. Demographic data and data pertaining to diagnoses and medication was also gathered from the electronic patient records.Result23 patients (45%) in Ravenswood House Hospital were prescribed antipsychotic polypharmacy. 87% of those prescribed antipsychotic polypharmacy had a primary diagnosis of either schizophrenia or schizoaffective disorder. 19 patients (37%) had two regular antipsychotics prescribed. 74% of these prescriptions were above the recommended BNF maximum. 62% were also prescribed a regular benzodiazepine. The vast majority of indications documented for APP were chronic behavioural disturbance and treatment resistant schizophrenia. The majority of these patients were on a T3. There was a significant under reporting of the rationale of prescribing APP. It could be surmised that at least 11 combinations were in part to mitigate side effects, but only 3 had this documented. There was also a lack of documentation or use of rating scales regarding the clinical outcomes and side effects of APP.ConclusionPrescription of antipsychotic polypharmacy is an important issue in secure forensic hospital settings. The lack of clear documentation of clinical effectiveness and side effect burden remains a concern. Wider study is required to establish the benefits of such prescribing to justify its ongoing use.

Validation of the Booth Evaluation of Absconding Tool for Assessment of Absconding Risk.

Although absconsion from secure forensic settings is uncommon, it can have serious consequences for the patient, the hospital, and the public. To assess risk of absconding in this population, using empirically based literature and clinical expertise, the authors designed a 28-item structured professional judgment measure, the Booth Evaluation of Absconding Tool (BEAT). To evaluate the psychometric properties of the BEAT, we completed a blinded, case-matched, retrospective study of absconders (n = 57) and non-absconders (n = 26) between 2009 and 2017. Together, the absconders accounted for 120 absconding incidents over the study period. The incidents had similar characteristics as previously published descriptive studies of absconding behavior. The BEAT demonstrated solid internal consistency (α = 0.78), promising inter-rater reliability across many items, and good accuracy in differentiating absconders from controls (area under the curve = 0.77). Considering the limitations associated with a retrospective chart review study, these results show promising reliability and validity for the BEAT and suggest that the BEAT could be a useful tool in assessing and managing absconding in forensic patients.

How do forensic inpatients’ interpersonal sensitivity to dominance and perceptions of staff coercion impact upon anger and rates of aggression?

PurposeCoercive practices – which are used as means to manage violent/aggressive behaviour in secure forensic settings – have come under scrutiny in recent years due to their paradoxical effects on provoking further service user aggression and violence. Previous research has found relationships between increased service user aggression with both service users’ interpersonal styles and perceptions of staff coercion (i.e. staff limit setting). This paper aims to investigate whether forensic service users’ levels of interpersonal sensitivity to dominance increase levels of self-reported anger and rates of aggression towards staff through perceptions of staff coercion.Design/methodology/approachIn a cross-sectional quantitative study design, 70 service users were recruited from one high and two medium secure forensic hospitals. Standardised measures were completed by service users and recorded incident data was collected within the past year. Correlation and mediation analyses were run to investigate the relationship between study variables.FindingsA significant relationship was found between service users’ interpersonal sensitivity to dominance and self-reported rates of anger, where forensic service users’ who had higher levels of interpersonal sensitivity to others’ dominance were likely to report higher rates of anger. No significant relationships were found between all other study variables.Practical implicationsThe findings from this study contradict previous research where coercive practices may not necessarily increase rates of aggression towards staff but, in the context of service users’ interpersonal sensitivities to dominance, it may be more useful to consider the way in which coercive practices are implemented.Originality/valueThere is a gap in the literature, which looks at the way in which forensic service users perceive coercive practices in relation to their interpersonal sensitivities and whether this too has an impact upon service user aggression.

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.