'The Art of Understanding in Forensic Psychiatric Care' - From a Caring Science Perspective Based on a Lifeworld Approach

A Meta-Ethnographic Review of Forensic Psychiatry Inpatient Care. Nursing Staff Experiences of the Nurse-Patient Encounter

AIM

The aim of this review was to synthesise qualitative research into how nurses perceive and experience encountering patients in forensic inpatient care.

REVIEW METHOD

This review followed the steps of meta-ethnography developed by Noblit and Hare.

DATA SOURCES

Twelve studies, published from 2011 to 2021, were identified through a search of relevant databases in December 2021.

FINDINGS

The synthesis revealed three third-order and 10 second-order constructs during the translation of concepts in the studies. These are: Adopting the patient's perspective (liberation, comprehension and resistance), Action (security, trust, flexibility and predictability) and Activation (afraid or safe, involved or indifferent and boundaries). Further, a line of argument was developed which indicates that in forensic psychiatry inpatient care, nurses experience having to deal with internal and external resistance that affects their freedom of choice in the creation of a caring relationship.

CONCLUSION

The encounter is experienced as a continuous process in which the foundation is laid for the encounter (approach), the encounter unfolds and develops (action) and the nurse experiences the encounter (activation). The process is intertwined with and takes place in a context where care is influenced by the duality of the task (task), the culture of care (context), the patient's expression (patient) and the nurse's own impression of the patient's expression (oneself).

IMPLICATIONS

Professional communities should support initiatives that can strengthen nurses' self-awareness and provide opportunities for reflection on practice, which will both benefit the resilience of the nursing staff and the quality of care for patients in this setting.

Facilitating a safe and caring atmosphere in everyday life in forensic mental health wards - a qualitative study

PURPOSE

To explore healthcare professionals' experiences with facilitating a safe and caring atmosphere in patients' everyday lives in forensic mental health wards.

METHODS

This qualitative study employed interviews with 16 healthcare professionals working shifts in two forensic mental healthcare wards in Norway. Data were analysed using phenomenological hermeneutic analysis.

RESULTS

The findings are presented in terms of two themes. The first theme is "Creating a calming atmosphere" and includes the subthemes "Creating caring surroundings with safety, comfort and trust" and "Balancing everyday life activities". The second theme is "Facilitating risk assessments and care" and includes the subthemes "Acting as a team", "Becoming aware of the meaning in signs" and "Becoming aware of vulnerability and the window of tolerance".

CONCLUSIONS

Involvement in patients' history and lived lives is important both for understanding general social behaviour as well as for assessing signs, symptoms, and changes in patients' conditions; furthermore, it provides valuable information that allows healthcare professionals to become aware of the underlying meanings in signs, which can facilitate examinations and treatment. Acting as a team is essential to solve issues in a calm and safe way when signs of violence occur. In addition, our participants highlighted the need to be aware of individual patients' vulnerability and windows of tolerance to obtain a deeper understanding of patients' lived lives as a whole in the context of providing therapy and care to patients.

Forensic Mental Health Care Staff Experiences of Providing Palliative Care: A Qualitative Descriptive Case Study Approach

BACKGROUND

There is a steady increase in the number of people dying within the walls of forensic institutions across the world. This escalation is, to a large extent, because of an aging population. There is a need to explore how palliative care can be delivered in these settings where, historically, security has been the main focus.

OBJECTIVE

The aims of this study were to explore staff experiences of providing palliative care in a forensic mental health unit and to establish the subjective significance of those experiences.

METHOD

A qualitative, descriptive, case study approach was used. This study examined staff perspectives of provision of palliative care to a long-term service user who had been diagnosed with a life-limiting illness and who subsequently died. Interviews were analyzed using codebook thematic analysis.

RESULTS

There were nine in-depth interviews with staff who were involved in the service user's care. Analysis resulted in five main themes: intrinsic dignity, "It was out of our depth," "It's just the way these places are," "Hospital was the practical place," and specialist services.

CONCLUSION

If equitable access to palliative care is a human right, then it is essential that individuals in secure care with mental illness are able to access palliative care services that are responsive to their needs. Forensic mental health services need to be proactively prepared for the inevitability that people will die in their care.

Forensic psychiatric patients’ experiences of participating in administrative court proceedings concerning the continuation of forensic psychiatric care

Introduction

Previous studies show that both staff and patients describe patient participation as a challenge in forensic psychiatry. One reason may be that the forensic psychiatric process is difficult to understand and is experienced as being slow and complex. The proceedings in an administrative court are a core element in forensic psychiatric care as it constitutes the legal authority that legitimizes the deprivation of liberty. A better understanding about how patients experience these proceedings can contribute with important knowledge about how forensic psychiatric care can be understood from a patient perspective. The aim of the study was to describe patients’ lived experiences of participating in oral hearings in an administrative court concerning the continuation of their forensic psychiatric care.

Materials and methods

This is a phenomenological study performed in a Swedish context with a total of 20 interviews conducted with a Reflective Lifeworld Research (RLR) approach.

Results

The results reveal three themes; A significant, correct but meaningless formality; An imbalance of power within the hearings; and Existential and practical disorientation.

Conclusion

The findings show how these court proceedings concerning the continuation of forensic psychiatric care are often experienced as challenging. This is partly due to the care structure in forensic psychiatry and that the purpose of the hearings is difficult to comprehend and is perceived as unjust by patients. Another challenge is of a more existential dimension, where the main character in a hearing is most likely in a situation that would be stressful for anyone. However, the focus on danger can make this experience even more intense. An increased transparency on this legal process along with more discussion and education for both patients and staff is called for based on the results.

Meanings of carers’ lived experience of “regulating oneself” in forensic psychiatry

Purpose

This study aimed to illuminate the essential meanings of carers’ lived experience of regulating themselves when caring for patients with mental illnesses in forensic inpatient care.

Methods

Qualitative analysis was used to analyse data from narrative interviews with open-ended questions conducted with nine carers, which were analysed using a phenomenological-hermeneutic approach.

Results

Findings revealed three themes, “preserving oneself as a carer,” “building an alliance with the patient” and “maintaining stability in the community.” Carers not only regulated emotions related to patients but also the ward to facilitate a caring climate. For carers, encounters with patients meant facing expressions of suffering that evoked unwanted emotions. Regulating one’s emotions also meant being emotionally touched and facing one’s vulnerability.

Conclusion

Regulating oneself was a strategy used by carers to get closer to the patient and establishing a trusting relationship. Regulating oneself meant becoming aware of one’s shortcomings, not projecting them onto others, which may impair establishing relationships with patients and fulfilling the aim and caring task of forensic psychiatry. This study stresses the importance of carers being guided to manage their conflicting emotions and vulnerabilities and finding courage and an approach that allows a permissive climate of self-reflection.

"You Know Where the Boundary Is When You Cross It" - A Phenomenological Understanding of Vulnerability as Experienced by Carers in Forensic Inpatient Care

In forensic nursing, carers must balance caring and limiting actions in encounters with patients. Interpreting suffering in others raises awareness of one's own vulnerability. Hence, the aim of this study was to describe the phenomenon of vulnerability as experienced by carers in forensic inpatient care. Nine participants were recruited at a major forensic hospital, and their narratives were analysed with a reflective lifeworld approach. The findings revealed that vulnerability was both a strength and a burden. Vulnerability comprised becoming aware of one's boundaries, being genuine and protecting oneself. Dealing with vulnerability enables carers to open up to patients.

Patients' Experiences of Participation in High-Security, Forensic Psychiatric Care

The role of patient participation in forensic psychiatric care is unclear, but has been emphasised as important in recent research. This study aims to describe patients' lived experiences of participation in high-security, forensic psychiatric settings. Sixteen patient interviews were performed in this phenomenological study and analysed with a Reflective Lifeworld Research approach (RLR). Results show that participation must be understood in relation to its opposite construct, non-participation. Participation can thus be explained as situations where non-participation is less visible. Actions to develop the training of patient-staff interactions for forensic psychiatric staff to promote patient participation are called for.

"Walking Together Towards Freedom." Patients' Lived Experiences of Participation in Outpatient Forensic Care

There is a general agreement regarding the significance of patient participation in care. In forensic psychiatric care, however, this appears to be troublesome because of the paradoxical nature of having responsibility; to give person-centered, recovery-oriented psychiatric care and to protect society from potentially dangerous individuals. The aim of this study was to describe patients' lived experiences of participation in outpatient forensic psychiatric care. Data were collected by means of individual interviews with five patients. The phenomenological hermeneutical analysis shed light on patient participation as having two dimensions. The outer dimension focuses on participation as "doing" and as a means of developing the understanding and skills necessary for being discharged from forensic care, while the inner dimension is related to "being" and experiences of acceptance and inclusion in communion with other people. This emphasises the importance of supporting patients' experiences of being involved in everyday life together with others, even in periods when patients' possibilities to affect decisions regarding their care are limited.

A Qualitative Review of What Forensic Mental Health Nurses Include in Their Documentation

BACKGROUND

Documentation of mental health care is a critical component of nursing practice. Despite being identified as playing a critical role, researchers continue to question the quality of nursing documentation and missing and/or inaccurate information.

PURPOSE

Our aim is to explore the content of nursing documentation among mental health nurses providing care to forensic inpatients.

METHODS

Using a constructed semi-grounded emergent theme approach for data analysis, we reviewed the types of activities, subjects, and interactions described within nursing notes and identified themes of the content.

RESULTS

Our results demonstrate that nursing documentation could be categorized into one of seven themes: interactions, food, activities, sleep, mental health, physical health and hygiene. These areas were not consistent with the recommendations from nursing bodies in Canada, specifically the areas of assessment, planning, implementation, and evaluation. Furthermore, missing in the nursing notes is context.

CONCLUSIONS

The discussion highlights the importance of nursing documentation within the context of best practice, bias, and the impact on patient care. We also discuss missing information (context, clinical relevance, and case conceptualization), and suggest that nurses are not injecting this expertise in patient notes. Clinical implications for documentation practices are presented in relation to education and reflective practice.

'I know what I need to recover': Patients' experiences and perceptions of forensic psychiatric inpatient care

Patients find forensic psychiatric care inadequate in that they are not treated as individuals and not involved in their own care. The purpose of this study was to describe patients' experiences and perceptions of forensic psychiatric inpatient care. Semi-structured interviews were conducted with 11 inpatients. A qualitative content analysis resulted in a recurring theme, 'I know what I need to recover', and three main categories: 'A need for meaning in a meagre existence', 'A need to be a person in an impersonal context', and 'A need for empowerment in a restricted life'. Participants experienced and perceived forensic care as predominantly monotonous, predetermined, and not adapted to them as individuals, forcing them to fight and adapt to get through it and not lose themselves. Perceived needs were largely ignored or opposed by staff due to the content and structure of care. Findings suggest a need for reflective practices and patient involvement in order to develop and maintain a person-centred and recovery-oriented nursing practice. The study adds to previous research showing the importance of patients in forensic psychiatric inpatient care being listened to and involved in their care. The study is reported in accordance with the COREQ guidelines.

An Interview Study of Professional Carers' Experiences of Supporting Patient Participation in a Maximum Security Forensic Psychiatric Setting

Patient participation in forensic psychiatric settings seems to be complex by nature, and previous studies show that patients rate their participation as lower in this context compared to general psychiatric contexts. Studies on caregivers' perspective could provide a clearer picture of the components and possibilities of patient participation in forensic psychiatry. The aim of the study is to describe carers' experiences in supporting patient participation in a maximum security forensic psychiatric care setting. Twelve psychiatric caregivers were interviewed about how they support patients' participation. The result shows that a complexity of patient participation emerges as a difficult act of balancing the paradoxical role of caring for the patient's interests and development, while simultaneously representing and adhering to the rules and regulations of the system in which one is employed. In conclusion, it is suggested that participation is comprehended as an umbrella term and that focus is directed to conceptualising what caregivers can do in order to create positive patient-carer relationships, as well as what constitutes such a relationship.

Moral Dilemmas in Contact-Based Care: The Relevance of Moral Case Deliberation for Forensic Psychiatry

Currently, forensic psychiatry shows a shift from a control-based to a contact-based approach. Working from contact may, however, entail new moral questions and dilemmas. How to secure safety when focusing on contact? Does contact imply being physically close to the patient, or should one refrain from intimate relations? In order to help care professionals to deal with these moral issues, clinical ethics support can be useful. A specific approach in clinical ethics support is moral case deliberation (MCD). An MCD is a structured dialogue between professionals on a moral issue they experience in practice, structured by a conversation method and guided by a facilitator. In this article, we describe the background and procedures of MCD. Furthermore, we present a case example in which care professionals reflect on the moral question of whether provision of care in forensic psychiatry may entail physical closeness. The MCD shows that an open conversation results in a better understanding of different perspectives and creates the basis for finding a joint way to proceed in the case. We conclude that MCD can enable professionals to reflect on moral issues and develop shared values in forensic psychiatry.