Working with people who have killed: the experience and attitudes of forensic mental health clinicians working with forensic patients

Vicarious Trauma and Health Outcomes in Forensic Mental Health Nurses

BACKGROUND

Nurses working in forensic mental health settings are at risk of vicarious trauma because of their exposure to traumatized patients and distressing material such as the aversive details of patient crimes.

AIM

The aim of this study was to determine the incidence of vicarious trauma and explore its impact on health and absence from work.

METHODS

A cross-sectional descriptive correlational study was undertaken. All 205 forensic mental health nurses working in a high-security inpatient facility were invited to participate. An online survey included the Vicarious Trauma Scale and the SF-36v2 to measure mental and physical health. Absence from work was also explored.

RESULTS

Sixty-seven respondents completed the survey. Almost half of respondents had a moderate level of vicarious trauma, and only over one-quarter experienced high levels. Higher levels of vicarious trauma were associated with poorer mental health ( r = -0.59, p < 0.000) and absence from work ( r = 0.27, p < 0.010).

CONCLUSIONS

Forensic mental health nurses are at a greater risk of vicarious trauma than nurses working in mainstream mental health services, given their exposure to aversive details of patients' violent crimes. Adverse mental health consequences of vicarious trauma, and other forms of workplace trauma experienced by forensic mental health nurses, are likely to include trauma-related symptoms, depression, and anxiety. Forensic mental health nurses experiencing vicarious trauma may use sick leave as time away from work to care for their own mental health or a coping mechanism for workplace-induced psychological distress.

Using a trauma-informed care framework to explore social climate and borderline personality disorder in forensic inpatient settings

Tensions between therapeutic and security needs on forensic wards can create a social climate which is challenging for both mental health nurses and patients. Social climate refers to the physical, social and emotional conditions of a forensic ward which influence how these environments are experienced. For patients with borderline personality disorder (BPD), previous trauma means that the social climate of forensic settings may be experienced as retraumatising, negatively impacting the outcomes and wellbeing of both patients and mental health nurses. Trauma-informed care (TIC) has been offered as a contemporary framework for mental health nursing in inpatient units which aims to create a therapeutic social climate. In this critical review, we drew widely on literatures examining the social climate in forensic settings, the relationships between patients with BPD and staff (including mental health nurses), and the experiences of patients with BPD in forensic and inpatient settings to draw out the implications of scrutinising these literatures through the lens of TIC. Attending to the physical, social and emotional conditions of social climate in secure settings highlights how forensic wards can mirror trauma experiences for patients with BPD. Implementing TIC in these contexts has the potential to evoke positive shifts in the social climate, thus reducing the risk of retraumatisation and leading to improved outcomes for patients and staff.

Forensic Mental Health Nurses' Experiences of Clinical Supervision

BACKGROUND

Clinical supervision may support forensic mental health nurses with personal and professional growth in a work environment characterized by therapeutic, ethical, and practical challenges.

AIM

The aim of this study was to describe the experiences of forensic mental health nurses participating in a clinical supervision program.

METHODS

Seven forensic mental health nurses and two allied health professionals, working in a high-security forensic mental health hospital, were interviewed regarding their experiences of participating in a clinical supervision program.

FINDINGS

Participants expressed a need for clinical supervision and were motivated to participate in the program. Benefits of clinical supervision experienced by participants included improved communication with their colleagues, being supported in their career development, and developing habits and techniques to reflect on practice issues. Participants described being able to connect with their supervisor, enabled by both trust and confidence in the supervisor's expertise.

CONCLUSION

Staff showed engagement in the clinical supervision process and expressed experiencing positive outcomes related to personal and professional growth and development.

IMPLICATIONS FOR CLINICAL FORENSIC NURSING PRACTICE

To support nurses with the forensic mental health context-specific challenges they face, organizations should enable and promote access to clinical supervision. Considerations for forensic mental health organizations to increase uptake and effectiveness of clinical supervision include use of externally based clinical supervisors with adequate skills and experience with providing clinical supervision to clinical staff who work in a secure environment.

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.

Nursing staff composition and its influence on seclusion in an adult forensic mental health inpatient setting: The truth about numbers

INTRODUCTION

Research on the influence of nursing staff composition and use of seclusion in the forensic mental health inpatient settings is sparse. Nursing staff composition refers to staffing levels, roles, gender ratio and skill mix of the ward teams. Internationally, the rates of seclusion in some forensic mental health inpatient settings have increased over the past 10 years despite global efforts to reduce and eliminate its use.

AIM

To examine whether the use of seclusion in a forensic mental health inpatient setting can be attributed to staffing composition or to contextual factors such as day of the week, month or other clinical factors.

METHOD

Retrospective data collection was conducted using seclusion data, daily ward reports and staff rosters. Data were collected for all shifts in the hospital over a six-month period.

RESULTS

Three staffing variables were identified as having an influence on the use of seclusion: the number of registered nurses on duty, the presence of the shift coordinator and having a lead nurse on shift.

DISCUSSION

Senior nurse oversight and guidance are important factors in assisting staff to identify clinical deterioration and intervene early which may assist services reduce the use of seclusion.

IMPLICATIONS FOR PRACTICE

As staffing levels and composition are modifiable, the results of this study may assist nurse leaders to consider workforce improvements to reduce seclusion use.

The Clean and Proper Self: The Relevance of Kristeva's Concept of Abjection for Nursing

Nurses regularly encounter feelings of disgust in practice, from bodily fluids and wounds to the criminal histories of patients. Though these experiences are widespread in nursing practice, there exists a culture in which they are regularly and intentionally ignored by nurses, and have received little attention in the literature. French-Bulgarian philosopher Julie Kristeva described these feelings of disgust within her psychoanalytic concepts of abjection and the clean and proper self. When nurses experience abjection, they work to protect and maintain the boundaries of the clean and proper self. This paper will employ a conceptual analysis to explore the implications of abjection and the maintenance of the clean and proper in nursing practice, with a specific focus on forensic nursing. A literature review of scientific articles and monographs addressing issues of disgust and abjection was conducted. The work of Kristeva provides the theoretical framework for this analysis. The analysis illustrates that nurses erect boundaries between themselves and patients, with significant consequences for patient care. An enactment of rituals to avoid the uncomfortable feelings of abjection and an effort to maintain the clean and proper self is widespread in nursing practice. Acknowledging the presence of abjection in nursing practice, recommendations are given on how to both embrace and overcome this experience.

Extreme Stress Events in a Forensic Hospital Setting: Prevalence, Impact, and Protective Factors in Staff

The current research explored the prevalence of stressful events in a forensic hospital setting, and their impact on staff. A systematic review of the literature on responses following exposure to extreme stress comprised 46 articles. This was followed by a Delphi study of professionals based in a forensic hospital (n = 43) to explore views on the factors that affect responses to extreme stress. This comprised three rounds to build consensus. Finally, a study of forensic hospital staff was conducted (n = 153, 47% male) to capture current trauma symptoms. The systematic review indicated three superordinate themes: outcomes adversely impacting staff and patients; personal characteristics moderating the impact of events; and organisational and interpersonal support moderating the impact of events. The Delphi supported these themes and noted the importance of factors external to the workplace and internal factors, such as self-blame. The final study demonstrated how a fifth of the workforce showed at least some trauma symptomology. Those who experienced less burnout reported lower trauma symptoms, while staff who experienced higher levels of secondary trauma at work reported higher levels of trauma symptoms. A higher level of resilience was related to lower levels of trauma symptomology. Findings are discussed in relation to the importance of recognising trauma in staff and implementing strategies to reduce and/or buffer the impact of stress on wellbeing. In doing so, the research presents a new model for consideration and development, the Impact and Amelioration of extreme stress events Model (IA-Model).

Vicarious trauma and nursing: An integrative review

Nursing requires empathic engagement, within therapeutic relationships, to ensure the delivery of compassionate care. Empathic engagement with people who have experienced trauma is known to potentially lead to experiences of vicarious trauma occurring in the caregiver. However, relatively little is known about the implications of vicarious trauma for nurses. This integrative review aimed to explore what is known about vicarious trauma and consider its implications for nursing. Twenty-two articles were included in the review, with findings considering how vicarious trauma is conceptualized and applied to nursing in the literature, what implications of vicarious trauma, specific to nursing, are identified in the literature, and what vicarious trauma interventions are identified to apply to nursing. The findings highlight clear articulation of the concept of vicarious trauma and its relevance to nursing, including its pervasive and significant personal and professional effects. Vicarious trauma was identified to be a workplace hazard for nurses working across settings, which also impacts upon organizations. The review highlighted that at individual, team, organizational, and social levels, awareness and preventative approaches are recommended. These approaches require systemic supports that foster individual coping mechanisms, self-care and support networks for nurses, education about vicarious trauma, screening for vicarious trauma, and formalized access to clinical supervision and peer support for all nurses. With increasing awareness of trauma across health care settings, and a move towards the delivery of 'trauma informed care', recognition of vicarious trauma amongst nurses as a likely 'cost' of the delivery of compassionate care to trauma survivors, is essential.

Strategies Employed by Forensic Community Mental Health Nurses to Resolve Difficulties in Supporting Offenders With Mental Disorders Under the Medical Treatment and Supervision Act in Japan

OBJECTIVE

This study aimed to identify the strategies used by forensic community mental health nurses to resolve difficulties in supporting offenders with mental disorders under the Medical Treatment and Supervision Act in Japan.

METHOD

Interviews were conducted with 13 nurses, and the data were analyzed using content analysis.

RESULTS

The study identified the strategies for difficulties in (a) assessing and managing risk potential of forensic service patients, (b) addressing offending behavior, (c) managing the transition of patients, (d) supporting patients to understand the impact of justice processes and applying knowledge of legislation to nursing, and (e) promoting the role of forensic community mental health nurses within the multidisciplinary team.

CONCLUSIONS

The findings can benefit and support forensic community mental health nurses' practices. The Japanese forensic community mental health nurses experiencing difficulties and providing home visits to patients can utilize the identified strategies.

What characterizes a good mental health professional in court-mandated treatment settings?: Findings from a qualitative study with older patients and mental health care professionals

BACKGROUND

Therapist-related activities and characteristics such as empathy and genuineness are factors that significantly contribute to psychotherapy outcome. As they play a role in psychotherapy more generally, it can be expected that they are equally important in the treatment of court-mandated patients more specifically. At the same time, these treatment settings come with specific challenges-e.g. due to coercion and control-and it could thus be that some therapist-related characteristics might have a different empathy on the therapy. This interview study sought to investigate service providers' and users' perspectives on therapist-related characteristics in the context of detention.

METHODS

We conducted a qualitative interview study with 41 older incarcerated persons mandated to treatment, and 63 mental health professionals (MHP). The data analysis followed thematic analysis.

RESULTS

Patients and experts both emphasized the importance of treating patients with respect by taking a humanistic approach, that is, condemn the deeds but embrace the person and display genuine interest in supporting patients with any issue or concern that is of relevance to them. Furthermore, interviewees underscored that the coerciveness of the therapy context required to incorporate patients' wishes into treatment planning, recognize and respond to the patients' needs, and allow some choice within the given framework. Such inclusive attitude was deemed critical to engage and motivate patients to participate in treatment. In addition, it was emphasized that feedback and advice by the therapists need to be concrete, detailed and applied to each person's current situation. Lastly, patients questioned MHP's qualification when they did not progress in therapy.

DISCUSSION

Our findings indicate that some therapist-related activities and characteristics are of particular importance in court-mandated settings. These include genuine interest in the patient, a respectful and positive attitude, as well as the capacity to target sensitive issues in a directive but non-confrontational manner. Further research needs to identify specific expressions and behaviors that are linked to the aforementioned characteristics in the forensic context. Our study therefore contributes to much-needed empirical research on clinician and patient perspectives on therapist characteristics and activities in the treatment of court-mandated patients.

Exposure to workplace trauma for forensic mental health nurses: A scoping review

BACKGROUND

Forensic mental health is a challenging workplace, with nurses subject to various trauma exposures in their professional role.

OBJECTIVES

To identify the key concepts related to the nature, extent and impact of workplace trauma for forensic mental health nurses.

DESIGN

A scoping review, informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) tool.

METHODS

Sources of evidence were identified and assessed for inclusion using an explicit search strategy. Relevant information was extracted and synthesised to present a descriptive summary of existing evidence.

RESULTS

Of the 16 articles on workplace trauma for forensic mental health nurses included in the review, nine reported data related to extent (incidence and severity) and 14 described the impact. The incidence (per bed/per year) of each workplace trauma type ranged from 0.95 - 7.15 for physical violence, 0.39-5.12 for verbal abuse, 0.03-0.12 for sexual violence, and 1.47-7.9 for self-harming behaviour. The proportion of incidents at the lowest severity rating ranged from 15.1% to 84.7%, and the range for the highest severity rating was 0% to 38.7%. In the single study that examined the incidence of vicarious trauma, 14.9% reported low levels and 27.7% reported high levels. Psychological distress was the most commonly reported impact of workplace trauma, identified in eight studies. Seven studies reported limited data for physical injury from workplace trauma. The impacts of exposure to workplace trauma reported in the remaining studies included needing to access psychological support, experiencing physiological symptoms, feeling less safe at work, and requiring time off work. With the exception of two studies providing limited data related to absenteeism, the impact for organisations was not explored in existing literature.

CONCLUSIONS

While studies indicated that forensic mental health nurses are frequently exposed to various forms of workplace trauma, reports of severe assaults on staff were rare. Although limited, these findings suggest that cumulative exposure to workplace trauma over time, or exposure to more severe forms of physical violence, increase forensic mental health nurse vulnerability to experiencing detrimental impacts on their personal and professional wellbeing.

Controlling emotions-nurses' lived experiences caring for patients in forensic psychiatry

Purpose: Nurses working in forensic psychiatry often encounter offenders who have a severe mental illness, which may cause ethical challenges and influence nurses' daily work. This study was conducted to illuminate the meaning of nurses' lived experiences of encounters with patients with mental illnesses in forensic inpatient care. Methods: This qualitative study employed narrative interviews with 13 nurses. Interviews were audiotaped and transcribed verbatim and analysed following a phenomenological-hermeneutic approach. Results: Four key themes were revealed: "Being frustrated" (subthemes included "Fighting resignation" and "Being disappointed"), "Protecting oneself" (subthemes included "To shy away," "Being on your guard," and "Being disclosed"), "Being open-minded" (subthemes included "Being confirmed," "Developing trust," and "Developing compassion"), and "Striving for control" (subthemes included "Sensing mutual vulnerability" and "Regulating oneself"). Further, working in forensic psychiatry challenged nurses' identity as healthcare professionals because of being in a stressful context. Conclusions: Dealing with aggressive patients with severe mental illnesses threatens nurses' professional identity. Nurses must attempt to empathize with patients' experiences and respond accordingly. Utilizing strategies rooted in compassion such as self-reflection, emotional regulation, and distancing themselves when necessary may enable nurses to more effectively respond to patients' needs.

Clinicians' perspectives of forensic rehabilitation

Having sought 22 clinicians' views of how rehabilitation was practised in a forensic mental health service, this study explores whether or not these views are consistent with claims that forensic rehabilitation can be hampered by the lack of a coherent rehabilitation framework. Two major, mutually influencing themes emerged from the participants' narratives, the first of which delineates the culture and functioning of individuals and systems in a forensic service and the underlying philosophies and beliefs guiding professional behaviour. The second theme outlines the participants' views of the ways in which client needs are assessed and how clients are subsequently provided with the skills and opportunities required for their rehabilitation. The results indicate that while the participants perceived that there were positive aspects to the forensic mental health care that was provided; they also stated that systematicity in the formulation and provision of forensic mental health clients' needs was lacking. These findings reinforce previous claims that there needs to be a theoretically sound means of embedding and systematising effective rehabilitation practice in forensic services.

Promoting positive and safe care in forensic mental health inpatient settings: Evaluating critical factors that assist nurses to reduce the use of restrictive practices

Reducing and eliminating the use of restrictive practices, such as seclusion and restraint, is a national priority for Australia's mental health services. Whilst legislation, organization and practice changes have all contributed to a reduction in these practices, forensic mental health services continue to report high rates. This paper details the findings of research that examined the experiences of nurses working in the inpatient forensic mental health setting. The research aimed to (i) document the experiences of nurses working in the forensic mental health setting, (ii) articulate their perceived unique skill set to manage challenging patient behaviours, and (iii) determine how their experiences and skill set can inform practice changes to reduce the use of restrictive practices. Thirty-two nurses were recruited from one Australian forensic mental health service. Data were collected using semi-structured interviews and analysed using inductive content analysis. Four categories were identified that influenced practice experiences: (i) working in a challenging but interesting environment, (ii) specialty expertize, (iii) exposure to aggression and resilience as a protective factor, and (iv) the importance of effective teamwork and leadership. Forensic mental health care is complex, highly specialized, and often delivered in an unpredictable environment. Whilst high rates of restrictive practices may be linked to the unique characteristics of forensic patients, training, teamwork, and leadership are critical factors influencing their use in this setting. Nurses working in this area need to be educated and supported to work confidently and safely with this high-risk patient cohort.

Mental health services in Nigerian prisons: Lessons from a four-year review and the literature

Forensic and correctional mental health services may constitute an important "safety net" for the mentally ill and can ensure a degree of public protection. The increasing prison populations and shift towards humane care of the mentally ill that encompasses promotion of human rights, community re-integration, utilitarian safety and operation of internationally comparable mental health legislations underscore the need to appraise correctional psychiatry services, especially in resource-restricted settings. We present findings from a review of the literature and from mental health services provided to 179 inmates in two Nigerian urban prisons. The mental health services spanned four years and allowed a focus on important issues deserving urgent attention. The mean age of participants was 33.10 years (SD = 9.91) and majority (86.6%) were males. The common clinical diagnoses among participants were schizophrenia (49.3%) and mood disorders (29.6%), while approximately half (46.5%) used psychoactive substances. About one-fifth was evaluated as having high risk for violence-dangerousness based solely on clinical evaluation. The majority (88.4%) presented with a first episode of mental illness, and 14% had a prior correctional history. Gender, marital status and hallucinatory experiences were associated with a high risk of dangerousness (p < 0.05), while gender, use of psychoactive substances, previous history of mental disorders and depot medication indexed participants more likely to have a previous forensic history (p < 0.05). Considering the current findings, we advocate for inclusion of validated tools in risk assessments, multipronged intervention strategy to address the unmet needs of prisoners and improved attention to forensic and correctional mental health in relevant policy-law, service-planning, research and training.

The experience of clinical supervision for nurses and healthcare assistants in a secure adolescent service: Affecting service improvement

WHAT IS KNOWN ON THE SUBJECT?: Regular and effective clinical supervision for mental health nurses and healthcare assistants (HCAs) is an important tool in helping to reduce stress and burnout, and in ensuring safe, effective and high-quality mental health care. Previous studies of clinical supervision within secure mental health environments have found both a low availability of clinical supervision, and a low level of staff acceptance of its value, particularly for HCAs. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: In previous studies, the understanding shown by HCAs and nurses around the benefits of clinical supervision may have been limited by the methods used. This study was specifically designed to help them best express their views. In contrast to previous studies, both nurses and HCAs showed a good understanding of the function and value of clinical supervision. Significant improvements in the experience of, and access to, clinical supervision for nurses and HCAs working in secure mental health services may be achieved by raising staff awareness, demonstrating organizational support and increasing monitoring of clinical supervision. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Organizations should consider reviewing their approach to supervision to include raising staff awareness, multidisciplinary supervision, group supervision, and recording and tracking of supervision rates. Organizations should be mindful of the need to provide effective clinical supervision to HCAs as well as nurses.

ABSTRACT

Introduction Studies have found a low availability and appreciation of clinical supervision, especially for healthcare assistants (HCAs). Qualitative research is needed to further understand this. Aims Increase understanding of nurses' and HCAs' experiences of, and access to, clinical supervision. Identify nurses' and HCAs' perceptions of the value and function of clinical supervision. Assess how interventions affect staff's experiences of clinical supervision. Methods In 2013, HCAs and nurses in a secure adolescent service were surveyed about clinical supervision. Forty-nine HCAs and 20 nurses responded. In 2014, interventions to facilitate supervision were introduced. In 2016, the study was repeated. Forty HCAs and 30 nurses responded. Responses were analysed using a mixed methods approach. Results Significantly more HCAs found supervision to be a positive experience in 2016, and both nurses and HCAs reported significantly fewer challenges in accessing supervision. HCAs and nurses understood the value of clinical supervision. Discussion Significant improvements in the experience of clinical supervision were achieved following increased staff awareness, multidisciplinary and group supervision, and recording supervision rates. HCAs and nurses understood the consequences of inadequate supervision. Implications for practice Organizations could adopt the interventions to facilitate clinical supervision. Supervision should not be overlooked for HCAs.

Feeling Safe and Taking on Responsibilities: Newly Graduated Nurses' Perceptions and Evaluations of Their Transition Into a Forensic Mental Health Inpatient Setting

Forensic mental health care is faced with serious problems in the recruitment and retention of newly graduated nurses (NGNs). Research into NGNs' experiences of their transition to and evaluations of transition programs in forensic care is sparse, and more studies are called for. This study aimed to investigate the characteristics of NGNs' experiences and perceptions of their transition into a forensic setting and their evaluations of the introduction period. Three focus group interviews were carried out, involving 13 NGNs, lasting 79.68 minutes on average. They were analyzed using thematic analysis. Results show two main themes: "feeling safe" and "taking on responsibilities." If NGNs felt overburdened with clinical responsibilities during their transition, their feeling of safety reduced. The converse also applied; theThe safer they felt, the greater clinical responsibility they felt capable of handling. The more difficult the NGNs perceived the informal transition, the more unsafe they felt, and the more negatively they perceived the responsibilities placed upon them. Tailored programs designed to support both the informal and formal transitions are recommended, along with preceptorship, theoretical training, and role-based support, such as a shift manager, along with early introduction to conflict management and security measures.

Understanding and Treating Offenders with Serious Mental Illness in Public Sector Mental Health

This article begins with the history of the rise and fall of the state hospitals and subsequent criminalization of persons with serious mental illness (SMI). Currently, there is a belief among many that incarceration has not been as successful as hoped in reducing crime and drug use, both for those with and those without SMI. Moreover, overcrowding in correctional facilities has become a serious problem necessitating a solution. Consequently, persons with SMI in the criminal justice system are now being released in large numbers to the community and hopefully treated by public sector mental health. The issues to consider when releasing incarcerated persons with SMI into the community are as follows: diversion and mental health courts; the expectation that the mental health system will assume responsibility; providing asylum and sanctuary; the capabilities, limitations, and realistic treatment goals of community outpatient psychiatric treatment for offenders with SMI; the need for structure; the use of involuntary commitments, including assisted outpatient treatment, conservatorship and guardianship; liaison between treatment and criminal justice personnel; appropriately structured, monitored, and supportive housing; management of violence; and 24-hour structured in-patient care. Copyright © 2017 John Wiley & Sons, Ltd.