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

[Types of action orientation of primary nurses in building relationships with their patients in forensic psychiatric hospitals]

Types of action orientation of primary nurses in building relationships with their patients in forensic psychiatric hospitals Abstract: Background: Building interpersonal relationships with patients is one of the most elementary tasks of mental health nurses in forensic psychiatric hospitals and should be considered as the core of their professional identity. The attitude of forensic psychiatric nurses has a substantial impact on building relationships even though this is often not immediately obvious as an implicit concept. Research question: Which types of action orientation of primary nurses characterize the building of relationships with their patients in forensic psychiatric hospitals? Methodology: To record the collective orientations of nurses, two group discussions were held with eight participants. The evaluation was carried out based on the documentary method. Results: Four types of orientations could be grouped into a generalizable basic typology. The focus is set on the relationship as a necessary precondition for successful cooperation with the patient. Honesty and mutual trust are significant features. Conversations about everyday topics facilitate relationship building. Openness and a genuine interest in the patient are equally as important as the definition and maintenance of personal boundaries. Conclusion: Implicit, action-oriented attitudes of forensic psychiatric nurses should be reflectively accessed in order to define professional relationships and maintain their boundaries. To achieve this, nurses need to have a structured framework to facilitate self-reflection and self-awareness. The goal is the systematic development of personal and interactional competences.

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.

Online video games and patient-staff power relations. A qualitative study of care and custody in forensic psychiatry

WHAT IS KNOWN ON THE SUBJECT?: Frontline forensic mental health staff often face challenges when providing recovery-orientated care, as they must balance between caring for the forensic psychiatric patient and at the same time ensuring safety and security for all other patients and staff at the ward. Research shows that balancing between care and custody in everyday clinical practice is possible, but more practical nursing studies showing ways of balancing power relations are needed to guide clinical practice. Online video games are increasingly recognized as promising new tools to promote social relations, establish competencies and re-articulate power relations in therapeutic environments. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This paper provides insights into how using online video gaming interventions may influence the establishment of social power relations of staff and forensic psychiatric patients. It adds to existing research by providing a conceptual way to study and understand how mental health nurses may balance between care and custody, delivering care to accommodate patients' needs without compromising safety and security at the ward. This study answers a call in current research by providing qualified knowledge regarding the use of online video gaming to build and sustain therapeutic relations in mental health care. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Our paper suggests that balancing between care and custody is possible by using online video gaming interventions in forensic psychiatry. It moreover provides practice-close knowledge that may inspire and guide clinical mental health nurses to further develop online video gaming interventions in mental health care for the benefit of their patients. ABSTRACT: Introduction In recovery-oriented care, forensic psychiatric nurses must engage in care relationships with forensic psychiatric patients (FPs) whilst focussing on ward security. Online video games (OVGs) may provide a platform for negotiating power and social relations. Studies showing how OVG interventions may influence power balances in forensic psychiatric care are needed to guide clinical practice. Aim Our aim was to study how power relations were articulated between FPs and staff in an OVG intervention in a Danish forensic psychiatric ward. Method Data consist of three months of observational data and interviews with three staff members and six patients. We used sociologist Pierre Bourdieu's framework of field, power and capital to analyze data. Results The OVG intervention consisted of two power fields, "in-game" and "over-game." In-game concerned the practice of gaming. Over-game described the organization of the gaming intervention. Specific logics, skills and symbolic capitals drove power in each field. Discussion Power in-game was open to FPs and staff, leading to symmetric power relations. Power over-game was open to staff only, resulting in asymmetrical power relations. Implications for practice Online video game interventions may facilitate power balancing in forensic psychiatry. These insights may guide the development of new OVG interventions for patients and nurses in mental health care.

"You Want Them Pretty, but Not Too Intelligent!": Everyday Talk and the Continuum of Men's Violence Against Women in Forensic Institutional Care

The forensic setting houses persons with offence convictions who are also in receipt of ongoing mental healthcare-a criminal justice system and healthcare meeting-point. Extant literature highlights how this context is laden with interpersonal and institutional difficulties unique to a secure context that must provide care and custody concurrently. Our central argument is that the intertwining and interdependent cultural and custodial elements of forensic healthcare environments are integral and influential to care, culture, and conduct within such institutions-including concerning misogynistic everyday talk and the continuum of men's violence against women therein. We argue that the institution is a continuation of contemporary social issues experienced within community life (e.g., misogyny), as the boundaries of such institutions are porous-polis values traverse physical brickwork. This paper analyses ethnographic data from two male wards that are situated within a UK inpatient forensic mental health hospital. Ethnographic fieldwork occurred over 300 hours-overtly participating in, exploring, and recording the daily life of the community. Five excerpts of ethnographic data are presented, which evidence the gendered ward environment and highlight a series of encounters pertaining to problematic social life, which are the upholding of heteronormative gender roles, hegemonic masculinity, and misogyny. These views are problematised within the sexual offending rehabilitative context by considering the clinical risk associated. Further, we argue that to only focus on the end of the continuum often viewed as most serious (e.g., rape) ignores a pervasive cultural landscape of the polis in wider community, beyond the institution, that facilitates the more commonly experienced end of the continuum related to misogynistic values, encounters, and talk. We evidence how social norms and habitualised gendered actions permeate the institution, which bring into question the rehabilitative efficacy of the hospital. This paper embraces a feminist lens to explore everyday social interactions and the embodied experience of the female ethnographer within a male-dominated forensic setting. We contribute to the literature by newly theorising the influences of hierarchical heterosexual gender roles, violent language in forensic settings, and misogynistic attitudes and practice, on the care for, and rehabilitation of, patients.

Conflict management: A qualitative study of mental health staff's perceptions of factors that may influence conflicts with forensic mental health inpatients

Internationally, clinical services are under pressure to reduce their use of restrictive practices. The aim was to explore how mental health nurses and nursing assistants perceive conflict and their use of restrictive practices with mental health inpatients in forensic mental health care. A total of 24 semi-structured interviews with forensic mental health staff were conducted and analysed using thematic analysis. The findings propose a dynamic model that explains how tolerance of potential conflict situations changes depending on individual staff members' perceptions of patients and colleagues, and their relationships.

Exploring the Experiences of Male Forensic Inpatients' Relationships with Staff within Low, Medium and High Security Mental Health Settings

Therapeutic relationships within psychiatric settings are highlighted as important throughout the literature. However, research from the forensic inpatient perspective is limited. We address this gap by exploring the patient-staff relationships within forensic mental health inpatient services, from the patient's perspective. Thirty adult male forensic inpatients were interviewed about their experiences on the ward and their interactions with staff. Our analysis examines inpatients experiences of respectful and reciprocal relationships, relationships that empower, a disinterest in their patients' and authoritarian relationships. This study concludes by highlighting the need to prioritise the development of reciprocal relationships within forensic services.

An integrative review exploring the experiences of service users carrying a diagnosis of personality disorder and student mental health nurses and the time they share together

OBJECTIVES

This integrative review provides a collective understanding of the experiences of student mental health nurses and service users carrying a diagnosis of personality disorder and the time they share together.

DESIGN

Published studies about the time service users and students share together were systematically selected in order to integrate their findings in a thematic analysis.

DATA SOURCES

Various databases were searched from 1984 until 2020. Specific search terms were used.

REVIEW METHODS

37 studies were included in the integrative review. The studies were from peer reviewed nursing, student, psychology and health related journals. A quality appraisal was completed using Walsh and Downe (2006) framework.

FINDINGS

Four themes emerged from a thematic analysis of the integrative review. These were; With 'Impact of time' as an overarching theme.

CONCLUSION

A positive environment which considers time and focuses on seeing the person, as an individual can lead to the development of therapeutic relationships; a core element of the Nursing and Midwifery Council standards for nursing registration in the UK (Nursing and Midwifery Council, 2018). Students attempting to build such relationships need to be mindful of service users' and their own attachment experiences and the impact these can have on experiences of transference and countertransference, particularly for service users carrying a personality disorder diagnosis. It is important for students to be aware of the supportive impact of positive environments and how doing 'everyday stuff' can make a person feel human despite residing in potentially dehumanizing places.

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

AIMS

To identify the experiences of nursing in high secure forensic mental health settings that may affect staff recruitment and retention.

BACKGROUND

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.

DESIGN

An integrative review (Whittemore and Knapfl, 2005).

DATA SOURCES

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.

REVIEW METHODS

Data extraction, quality appraisal, and convergent qualitative synthesis.

RESULTS

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.

CONCLUSION

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.

IMPACT

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.

Nurses' Perspectives of Factors That Influence Therapeutic Relationships in Secure Inpatient Forensic Hospitals

BACKGROUND

The therapeutic relationship is synonymous with mental health nursing and fundamental to the provision of nursing care, regardless of the setting in which care is provided. This literature review examines, from a nursing perspective, factors influencing the formation and maintenance of therapeutic relationships in forensic mental health settings.

METHODS

A systematic search of the literature, using a range of electronic databases, focusing on nurse-patient therapeutic relationships in forensic settings was conducted. Articles were Critical Appraisal Skills Programme quality appraised, followed by a meta-aggregative thematic approach to data analysis and synthesis to identify themes and, finally, a production of an "action" policy statement.

FINDINGS AND IMPLICATION FOR PRACTICE

Eight articles met the criteria for review inclusion. Nine themes were identified; seven were categorized as internal/interpersonal factors, and two were categorized as external/environmental factors (with some themes interconnected). Synthesis of findings resulted in the production of a policy statement encouraging forensic mental health nurses to be aware of intrapersonal influences on therapeutic relationships and the need to provide a safe and supportive clinical environment for these relationships to form.

Resilience of auxiliary nurses providing nursing care to patients with intellectual disabilities at a public mental healthcare institution

Background

Although mental health is regarded by the International Council of Nurses as a very important element of wellness, healthcare to patients with intellectual disabilities still remains neglected and under-resourced in most societies. Auxiliary nurses are crucial in providing nursing care to patients with intellectual disabilities. These nurses may not be prepared to handle challenges in providing nursing care to these patients, but their resilience can help them to manage these challenges. Limited research is available with regard to the resilience of auxiliary nurses providing nursing care to patients with intellectual disabilities.

Objectives

To explore and describe the perceptions of auxiliary nurses providing nursing care to patients with intellectual disabilities on their resilience and protective mechanisms and vulnerability factors that influence their resilience when providing nursing care to these patients.

Method

A qualitative, descriptive inquiry approach was used. The population comprised approximately 220 auxiliary nurses providing nursing care to patients with intellectual disabilities at a mental healthcare institution. Auxiliary nurses were selected through purposive sampling with the assistance of a mediator. The sample size was determined by data saturation. The data were collected through four focus group interviews with altogether 32 participants.

Results

Five main themes emerged from the data. Practical wisdom was applied by the participants. They also made use of different forms of interactions, including the application of strategies such as utilising induction programmes and being willing to learn, in order to remain resilient. Protective mechanisms and vulnerability factors influence their resilience.

Conclusions

Recommendations to strengthen the resilience of auxiliary nurses caring for patients with intellectual disabilities were formulated from the research findings, including recommendations for nursing practice, education and nursing research. Informal peer support, as well as addressing ethical issues, improving nurse–patient communication, training to handle adverse working conditions, and continuing education and further research on the practical wisdom of auxiliary nurses, is recommended.

Resident and staff perceptions of the content of their relationship in supported housing facilities for people with psychiatric disabilities

Background

The work of staff in supported housing facilities for people with psychiatric disabilities has most often been studied from the perspective of one of the two groups but not from both. The staff in these facilities generally come from differing professions, reflecting either the beliefs of the medical or social models of psychiatric care.

Aim

The aim of the present study was thus to investigate the perceptions of residents and staff of the frequency and the importance of verbal and social interactions in supported housing facilities for people with psychiatric disabilities and to compare these perceptions. A further aim was to investigate whether differences in education background and other sociodemographic factors are reflected in the staff perceptions of these interactions.

Methods

One hundred and eleven residents living in supported housing facilities in Sweden and 223 staff completed the Verbal and Social Interaction Supported Housing questionnaire.

Results

The results revealed significant differences between the perceptions of the residents and staff on all six categories of interactions, where the staff rated the frequency and importance higher than the residents, but also some similarities in terms of the relative order of the frequency of the categories of interactions. Both the residents and staff perceived that “To build a relationship with a supportive quality” as the most frequently occurring and most important category. The mean levels of importance for all the categories were higher than for the frequency according to both groups. No differences were found between the staff with a medical or social educational background. Similarly, no differences were found in staff perceptions between those with short experience and those with long experience.

Conclusion

This study is the first survey of its kind and the results indicate the need for reducing the gap between the staff intentions and the residents’ preferences, which could form the basis for in-house training activities.

'First and foremost a human being…': user perspectives on mental health services from 50 mentally disordered offenders

BACKGROUND

This is the first study of this kind in a Danish context. Knowledge and research on user perspectives is rather limited in Danish as well as Nordic psychiatry.

AIMS

The aim of the study was to create new knowledge on patient and user perspectives and how mentally disordered offenders perceive their hopes and expectancies as well as their interactions with staff in mental health services. Furthermore, the aim was to establish what constitutes helpful care and treatment seen from a user perspective, and how the users themselves look at and perceive their sentences and how, according to them, the overall aim to prevent future crime can be fulfilled.

METHOD

The study is based on 50 semi-structured qualitative research interviews. Main themes and patterns were condensed and synthesized in a qualitative analysis.

RESULTS

The study has provided useful knowledge of service users' experiences with nursing, treatment and rehabilitation practices. As part of the interviews, patients were asked to contribute with advice on how to improve practices within mental health services. There are remarkable similarities between the answers, and central points were reiterated from interview to interview: The importance of mental health staff acting with respect and empathy in their interaction with patients, improved communication between patients and professionals involved in clinical pathways, responsiveness and shared decision-making when adjusting medical treatment as well as a greater variety of activities offered within inpatient units.

CONCLUSION

When asked what it is like to be a forensic patient, the informants underline that despite severe mental illness, social marginalization as well as various criminal records they are still, first and foremost, human beings. However, they often feel dehumanized and monstrous.

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

Patients in forensic psychiatric clinics are a vulnerable and exposed patient group due to suffering from a severe mental disorder, having committed a crime and being cared for against their will in an institutional environment with a high level of security. The art of understanding in forensic psychiatric care is discussed from a caring science perspective, based on a lifeworld approach. The aim is to contribute knowledge that can support staff, who daily meet patients on forensic psychiatric wards, in applying a caring attitude.

Forensic mental health clinician's experiences with and assessment of alliance regarding the patient's readiness to be released from mechanical restraint

One of the main reasons for prolonged duration of mechanical restraint is patient behaviour in relation to the clinician-patient alliance. This article reports on the forensic mental health clinicians experiences of the clinician-patient alliance during mechanical restraint, and their assessment of parameters of alliance regarding the patient's readiness to be released from restraint. We used a qualitative, descriptive approach and conducted focus group interviews with nurses, nurse assistants and social and healthcare assistants. The results show that a pre-established personal clinician-patient alliance formed the basis for entering into, and weighing the quality of, the alliance during mechanical restraint. In consideration of the patient's psychiatric condition, the clinicians observed and assessed two quality parameters for the alliance: 'the patient's insight into or understanding of present situation' (e.g. the reasons for mechanical restraint and the behaviour required of the patient to discontinue restraint) and 'the patient's ability to have good and stable contact and cooperation with and across clinicians. These assessments were included, as a total picture of the quality of the alliance with the patient', in the overall team assessment of the patient's readiness to be released from mechanical restraint. The results contribute to inform the development of a short-term risk assessment instrument, with the aim of reducing the duration of mechanical restraint.

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.

"Treat me with respect". A systematic review and thematic analysis of psychiatric patients' reported perceptions of the situations associated with the process of coercion

WHAT IS KNOWN ON THE SUBJECT?: Psychiatric patients have generally negative experiences of being exposed to coercive measures. Existing research has generally not investigated coercion as a process; that is, it does not address issues that arise before, during and after exposure to coercion. A part of existing research within the area does not clarify and define the type of coercive measure(s) investigated. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Patients place great significance on the link between the positive and negative perceived impact of a coercive situation and the professionals' ability and willingness to interact and communicate respectfully. Psychiatric patients associate the use of seclusion, physical restraint/holding, mechanical restraint and forced medication with strong negative perceptions and wish to be treated with respect by professionals, rather than being subjected to the professionals' control. What patients perceive as moderating factors in regard to the use of coercive measures is currently under-researched. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Increased sensitivity to the patient's views of the situation at each point in the coercive process would help professionals to respond to the patients' individual needs. Professionals need to articulate concern and empathy towards patients and to improve communication skills before, during and after a coercive incident. Greater emphasis should be placed on de-escalation and the use of non-coercive strategies or coping skills before the initiation of coercive measures.

ABSTRACT

Introduction There is a lack of research into psychiatric patients' perceptions of coercion that discriminates between different types of coercive measures, while also investigating patients' perceptions of undergoing coercion as a process. This knowledge is required to improve our understanding and provide a foundation for improving clinical practice. Aims To review existing research literature in order to investigate adult psychiatric patients' reported perceptions of situations before, during and after specific and defined types of coercive measures, and to investigate what patients perceive as moderating factors, in regard to the use of these coercive measures. Method A systematic review and thematic analysis of 26 peer-reviewed studies was undertaken. Results The analysis identified six themes and additional subthemes, where "interactions with professionals" and "communication" were predominant themes across the timeline of coercion. Altogether, themes were associated with either "positive or negative patient-perceived impact." Implications for practice Increased sensitivity to patients' views of the situation at each point in the process is desirable in order to respond to the patients' individual needs. Professionals also need to articulate concern and empathy towards the patient and to improve communication skills before, during and after a coercive incident. Use of de-escalation and noncoercive strategies is required. Relevance statement Coercion within psychiatric/mental health care remains controversial, and repeated international calls have recommended a reduction of their use. This review indicates that greater attention to how patients perceive the use of coercive measures (before, during, and after incidents) needs to be considered in order to improve the evidence-based and clinical practice.

Supporting the Sexual Intimacy Needs of Patients in a Longer Stay Inpatient Forensic Setting

PURPOSE

To explore perceptions of nurses and patients regarding sexual intimacy in a long-term mental health unit.

DESIGN AND METHODS

Qualitative exploratory design including in-depth semi-structured individual interviews with 12 registered nurses and 10 long-term patients of a forensic mental health hospital.

FINDINGS

The theme of supporting sexual intimacy was identified and described in this paper and included the following subthemes for nurses: It depends on the setting, need for guidelines and consent, and for patients-it depends on the setting; and need for support.

PRACTICE IMPLICATIONS

The findings suggest that current guidelines regarding sexual intimacy in acute inpatient settings may not be appropriate in long-term facilities, with a need for guidelines to specifically address this setting. Furthermore, support for sexual intimacy needs of patients was identified as a strong need for patients and they believed not currently met. Nurses have an important role to play as part of their holistic approach to care and barriers to providing this aspect of care must be overcome to ensure patients' rights are respected.

Humor: Power Conveying Social Structures Inside Forensic Mental Health Nursing

According to research literature, humor inside the staff-patient interaction seems to be significant in the area of forensic mental healthcare. However, existing literature on the subject is limited. Therefore, the aim of this study was to explore the characteristics of the use humor by forensic mental health staff members in interactions with forensic mental health inpatients. The study included 32 forensic mental health staff members, used 307 hours of participant observations, 48 informal interviews, and seven formal semistructured interviews. Outcomes identify four themes concerning the conveyance of power to, from, and between forensic mental health staff and patients as they interact: (a) "the informal use: the human-to-human approach," characterized by an informal use of humor and without any reference to mental health issues; (b) the "formal use of humor: the staff-patient approach," characterized as formal with a view on the patient as mentally ill, unable to understand humor, and with the aim of using humor to prevent conflicts or negative behavior; (c) "protest against requested care: the human-patient approach," characterized by the use of humor as a protest against requested care; and the use of (d) "inadequacy humor: the staff-human approach," characterized by the use of inadequacy-humor referring to, for example, patients' physical features. Recommendations and clinical implications are discussed.

Mental Health Nursing, Mechanical Restraint Measures and Patients' Legal Rights

Coercive mechanical restraint (MR) in psychiatry constitutes the perhaps most extensive exception from the common health law requirement for involving patients in health care decisions and achieving their informed consent prior to treatment. Coercive measures and particularly MR seriously collide with patient autonomy principles, pose a particular challenge to psychiatric patients' legal rights, and put intensified demands on health professional performance. Legal rights principles require rationale for coercive measure use be thoroughly considered and rigorously documented. This article presents an in-principle Danish Psychiatric Complaint Board decision concerning MR use initiated by untrained staff. The case illustrates that, judicially, weight must be put on the patient perspective on course of happenings and especially when health professional documentation is scant, patients' rights call for taking notice of patient evaluations. Consequently, if it comes out that psychiatric staff failed to pay appropriate consideration for the patient's mental state, perspective, and expressions, patient response deviations are to be judicially interpreted in this light potentially rendering MR use illegitimated. While specification of law criteria might possibly improve law use and promote patients' rights, education of psychiatry professionals must address the need for, as far as possible, paying due regard to meeting patient perspectives and participation principles as well as formal law and documentation requirements.

Getting to know the person behind the illness - the significance of interacting with patients hospitalised in forensic psychiatric settings

AIMS AND OBJECTIVES

To describe what nurses want to accomplish in relationships with patients who are hospitalised in forensic psychiatric settings.

BACKGROUND

Relationships between staff and patients in forensic psychiatric settings should be grounded in trust and confidence, and the patients need opportunities for emotional reconciliation. However, relationships can be challenging for nurses, who sometimes distance themselves from patients' expressions of suffering. The role of forensic mental health nurses is nebulous, as are the prescriptives and the implementation of nursing practices.

DESIGN

Qualitative descriptive design.

METHODS

In-depth interviews with five nurses who all work in forensic psychiatric settings.

RESULTS

We present a descriptive analysis of what nurses want to accomplish in relationships with patients who are hospitalised in forensic psychiatric settings. The results are presented in two main categories: (1) getting to know the person behind the illness and (2) making a difference.

CONCLUSION

Care in forensic psychiatry needs to shift towards a more long-term view of the role of nursing, focusing less on the traditional and stereotypical identity of the productive nurse and more on the care given when nurses slow down and take the time to see the patients as individuals. Establishing trusting relationships with patients in forensic psychiatric settings is viewed as a less oppressive way to control patients and guide them in directions that are preferable for the nurses and for the society.

RELEVANCE TO CLINICAL PRACTICE

Nurses may use simple strategies in their daily practice such as sitting on the sofa with patients to establish trust. We stress that nurses should abandon policing roles and custodial activities in favour of guiding principles that promote individual recovery, treatment and health-promoting care.

Umbrella review of the evidence: what factors influence the caring relationship between a nurse and patient?

AIMS

The aim of this study was to describe the nurse-patient relationships and to study how caring behaviours were described. The review question was: What factors influence the caring relationship between a nurse and patient?

BACKGROUND

There is a growing perception that nurses fail to provide compassionate and competent care. Policy documents prescribe compassion as an essential aspect of care; however, the evidence drawn on remains unclear and without clear applications to practice.

DESIGN

Umbrella review methodology, informed by the Joanna Briggs Institute guidelines, was employed and adapted to enable the inclusion of systematic reviews that were of sufficient methodological quality.

DATA SOURCES

An extensive PsychInfo, Pubmed, CINAHL, Scopus, WoS and Embase search was conducted for literature published from January 2000-March 2014. Key words included 'nurse', 'patient' and 'relationship' in combination with index terms to find literature published from 2000 onward.

REVIEW METHODS

Critical appraisal, data extraction and synthesis were carried out according to existing guidelines for undertaking umbrella reviews.

RESULTS

Twelve reviews (representing over 290 studies) were included following critical appraisal. Forty-seven findings were extracted, resulting in 14 categories and six synthesized findings; 'Expectations of the relationships' 'Values', 'Knowledge and skills', 'Communication', 'Context and environment' and 'The impact of the relationship'.

CONCLUSIONS

A substantial body of evidence demonstrates that both patients and nurses have expectations about the nature and importance of the caring relationship. Nurses should be mindful that their behaviours and attitudes need to align with what patients value about the relationship. Context shapes the relationship in positive and negative ways.

Reducing or increasing violence in forensic care: a qualitative study of inpatient experiences

Semi-structured interviews with 13 forensic psychiatric inpatients that had decreased their assessed risk of violence were analyzed using interpretive description. The main contribution from this study is a detailed description of patients' own strategies to avoid violence. Participants described having an ongoing inner dialog in which they encouraged themselves, thereby increasing their self-esteem and trying to accept their current situation. An unsafe and overcrowded ward with uninterested and nonchalant staff increased the risk of aggressive behavior. In the process of decreasing violence, the patients and the forensic psychiatric nursing staff interacted to create and maintain a safe environment.

Engaging with Families Is a Challenge: Beliefs among Healthcare Professionals in Forensic Psychiatric Care

Being healthcare professionals in the complex field of forensic psychiatry care (FPC) seems particularly challenging. Historically, families have almost been invisible in FPC. The aim of this study was to uncover beliefs among healthcare professionals concerning families of patients admitted for FPC. Using a hermeneutical approach inspired by Gadamer's philosophy, group interviews with healthcare professionals in four Swedish forensic psychiatric clinics were analyzed. Analysis resulted in seven key beliefs. There were three beliefs about families: family belongingness is a resource for the patient; most families are broken and not possible to trust; and most families get in the way of the patient's care. Four beliefs concerned encounters with families: it is important to achieve a balance and control over the family; it is essential to set aside one's own values and morals; family-oriented work is an impossible mission; and family oriented work requires welcoming the families. Despite ethical dilemmas of working with families in FPC, healthcare professionals showed a willingness and desire to work in a more family-oriented manner. More knowledge, understanding, and caring tools are needed in order to meet the needs of the family as well as support the family's resources.

Caring Science and the Development of Forensic Psychiatric Caring

PURPOSE

This study aimed to discuss how caring science can contribute and provide a theoretical foundation for the development of caring within forensic psychiatric care.

CONCLUSIONS

It is not only a challenge but also a great opportunity to use caring science theory within forensic psychiatric care when caring for the patients and supporting their health processes.

PRACTICE IMPLICATIONS

There is a need for more knowledge about, understanding of, and willingness to care for patients within forensic psychiatric settings in a "true caring" way. In order to achieve this, a caring culture is required, one that supports carers and provides them with opportunities to further develop a caring attitude.

Caring potentials in the shadows of power, correction, and discipline - Forensic psychiatric care in the light of the work of Michel Foucault

The aim of this article is to shed light on contemporary forensic psychiatric care through a philosophical examination of the empirical results from two lifeworld phenomenological studies from the perspective of patients and carers, by using the French philosopher Michel Foucault's historical-philosophical work. Both empirical studies were conducted in a forensic psychiatric setting. The essential results of the two empirical studies were reexamined in a phenomenological meaning analysis to form a new general structure in accordance with the methodological principles of Reflective Lifeworld Research. This general structure shows how the caring on the forensic psychiatric wards appears to be contradictory, in that it is characterized by an unreflective (non-)caring attitude and contributes to an inconsistent and insecure existence. The caring appears to have a corrective approach and thus lacks a clear caring structure, a basic caring approach that patients in forensic psychiatric services have a great need of. To gain a greater understanding of forensic psychiatric caring, the new empirical results were further examined in the light of Foucault's historical-philosophical work. The philosophical examination is presented in terms of the three meaning constituents: Caring as correction and discipline, The existence of power, and Structures and culture in care. The philosophical examination illustrates new meaning nuances of the corrective and disciplinary nature of forensic psychiatric care, its power, and how this is materialized in caring, and what this does to the patients. The examination reveals embedded difficulties in forensic psychiatric care and highlights a need to revisit the aim of such care.

Consumer sexual relationships in a forensic mental health hospital: perceptions of nurses and consumers

The management of consumer-related risk is paramount in a secure forensic mental health facility. However, the consequent risk aversion presents a major barrier to consumers forming sexual relationships in a manner that is open and accepted. Investigation of the views of nurses working in forensic mental health settings on this topic is limited, and even more so for consumers of services. This qualitative exploratory study was undertaken to elicit the views of consumers and nurses about forming sexual relationships within this long-term and secure setting. Individual in-depth interviews were conducted with 12 nurses and 10 consumers. The benefits of, and barriers to, sexual relationships was identified as a major theme, and these findings are the focus of this paper. Nurse responses included the subthemes 'supportive factors' and 'potential dangers', reflecting their qualified support. Consumer responses included the subthemes 'therapeutic', 'feeling normal', 'restrictions and barriers', and 'lack of support and secrecy'. The importance of sexual relationships was clearly articulated, as was the difficulties in forming and maintaining them within the forensic setting. More open discussion about this commonly-avoided issue and the education of nurses and other health professionals is required.

New graduate nurses in transition: a review of transition programmes and transition experiences within mental health care

Research on experiences of transition into mental health-care roles seems sparse, but it is vital in order to produce a comprehensive understanding of the transition into mental health-care roles and to serve as a foundation for future research and development. The aim of the present study was to review existing research literature, and in doing so, investigate transition programmes for new graduate nurses (NGN) into mental health care, and their experiences of role transition and evaluations of participation in transition programmes. The literature review spans literature published after the year 2000. The literature search was conducted using the following databases: CINAHL, Psychology and Behavioral Sciences Collection, PsycINFO, and Pubmed. Search results consisting of 14 articles were analysed using thematic analysis. Results from the analysis showed four overall themes: nursing education, transition programmes and evaluations, working environment, and the NGN role. We conclude that it is not possible to produce a comprehensive understanding specifically concerning the transition programmes for NGN into mental health care, and that further research is necessary due to the limitations of this review.

A cross sectional survey examining the association between therapeutic relationships and service user satisfaction in forensic mental health settings

BACKGROUND

This small-scale study examines an often neglected patient group (service users in forensic mental health settings). The research investigates their therapeutic relationship with staff and which therapeutic relationship factors are associated with their level of satisfaction with services.

METHODS

A cross sectional survey was undertaken in two medium secure units in the UK with seventy seven participants completing self-report measures examining service user satisfaction with services and their therapeutic relationship with staff. Multiple regression analysis was used to identify the main predictor variables associated with satisfaction with the service provided.

RESULTS

The respondents had a generally positive view of services and also of their therapeutic relationships with staff. However, the therapeutic relationship scores were lower than those recorded in community samples. One predictor variable was significantly associated with service user satisfaction; feeling respected and well regarded.

CONCLUSIONS

The therapeutic relationship domain of being respected and well regarded by staff was identified as the most significant factor among the therapeutic relationship domains when examining the association with satisfaction with services. The important role mental health clinicians play in enabling service users to recognize they are being treated respectfully is noted as service users judge the degree of honesty, caring and interest that staff show in them. Staff also need to be available and accessible while having good listening and information giving skills. The importance of having both positive therapeutic relationships and service user satisfaction in forensic settings is also discussed.

To be strategically struggling against resignation: the lived experience of being cared for in forensic psychiatric care

To be referred to care in forensic psychiatric services can be seen as one of the most comprehensive encroachments society can impose upon a person's life, as it entails a limitation of the individual's freedom with no time limit. This study focuses upon patients' experiences of their life situation in forensic psychiatric wards. Using a Reflective Lifeworld Research approach founded in phenomenology, we analysed 11 qualitative interviews with patients cared for on a maximum security unit in a Swedish forensic psychiatric service. Results show how forensic psychiatric care can be non-caring with only moments of good care, from the patient's perspective. By using different strategies, the patients attempt to adapt to the demands of the caregivers in order to gain privileges. At the same time the patients are lacking meaningful and close relationships and long to get away from the system of forensic care. Being cared for entails struggling against an approaching overwhelming sense of resignation.

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

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

Reconstructing normality: characteristics of staff interactions with forensic mental health inpatients

Forensic psychiatry is an area of priority for the Danish Government. As the field expands, this calls for increased knowledge about mental health nursing practice, as this is part of the forensic psychiatry treatment offered. However, only sparse research exists in this area. The aim of this study was to investigate the characteristics of forensic mental health nursing staff interaction with forensic mental health inpatients and to explore how staff give meaning to these interactions. The project included 32 forensic mental health staff members, with over 307 hours of participant observations, 48 informal interviews, and seven semistructured interviews. The findings show that staff interaction is typified by the use of trust and relationship-enabling care, which is characterized by the establishment and maintenance of an informal, trusting relationship through a repeated reconstruction of normality. The intention is to establish a trusting relationship to form behaviour and perceptual-corrective care, which is characterized by staff's endeavours to change, halt, or support the patient's behaviour or perception in relation to staff's perception of normality. The intention is to support and teach the patient normal behaviour by correcting their behaviour, and at the same time, maintaining control and security by staying abreast of potential conflicts.

Nurse-patient interaction in acute adult inpatient mental health units: a review and synthesis of qualitative studies

Mental health nurses work with acutely unwell patients, and the busy setting is characterised by unpredictable events. This paper is a report of a review conducted to identify, analyse and synthesize research in adult acute inpatient mental health units, which focused on nurse-patient interaction. Several electronic databases were searched using relevant keywords to identify studies published from 1999-present. Qualitative studies published in English were included if they specifically investigated nurse-patient interaction in acute inpatient care in adult settings. Eighteen studies were included (23 papers). Findings were grouped into the following six categories: 1) sophisticated communication; 2) subtle discriminations; 3) managing security parameters; 4) ordinary communication; 5) reliance on colleagues; and 6) personal characteristics. These studies of acute inpatient mental health units reveal that nurse communication involves interpersonal approaches and modalities that exemplify highly developed communication and personal skills designed specifically for this challenging setting. Further quality research should focus on the conditions that enable the development of therapeutic interactional skills and the relationship of these skills to the nuanced context in which they are practiced.