Working under threat: fear and nurse-patient interactions in a forensic psychiatric setting

Poststructuralism and the construction of subjectivities in forensic mental health: Opportunities for resistance

Nurses working in correctional and forensic mental health settings face unique challenges in the provision of care to patients within custodial settings. The subjectivities of both patients and nurses are subject to the power relations, discourses and abjection encountered within these practice milieus. Using a poststructuralist approach using the work of Foucault, Kristeva, and Deleuze and Guattari, this paper explores how both patient and nurse subjectivities are produced within the carceral logic of this apparatus of capture. Recognizing that subjectivities are fluid and dynamic, and capable of change, Deleuze and Guattari's concept of deterritorialization will illustrate opportunities for resistance, where nurses can begin to practice outside the dominant carceral logic (and restrictions) of the system.

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.

The Forensic Psychiatric Network of Observation and Documentation: At the Intersection of Review Board Hearings and Nursing Practice

Forensic psychiatric nursing is a specialty at the junction of two well-researched intersecting systems with two mandates: criminal justice and health care. Nurses' involvement at one of the systems' points of juncture, review board (RB) hearings, has largely been left unexplored. At RB hearings, a panel of legal and healthcare professionals determines if persons unfit to stand trial (UST) or not criminally responsible on account of mental disorder (NCR) represent significant threats to the safety of the public and orders conditions aimed at keeping the community safe. The aim of this article is to present the results of a critical ethnography that explored how psychiatric and public safety discourses construct the identity of persons UST or NCR during RB hearings as well as nurses' contribution to such identity construction. The main finding is that the forensic psychiatric structure leverages nursing interventions and documentation as evidence of deviancy, so that persons UST or NCR can be objectified and produced as dangerous. Structures sustaining the forensic psychiatric system inscribe nursing care within a disciplinary scheme, rendering the care-and-custody dichotomy insufficient to explain the complex processes at play in forensic psychiatry. These findings have implications for the practice of nurses working in forensic psychiatric settings and for that of other nurses who practice on the medicolegal borderland.

Violence and unsafety in Italian hospitals: Experience and perceptions of nursing students

BACKGROUND: Assessment of workplace violence towards healthcare workers represents a challenge for healthcare organizations worldwide. Workers’ experience and perceived risk of violence may have a serious impact on job satisfaction and retention of workers. To date, no studies have been conducted on nursing students. OBJECTIVES: To assess the prevalence of physical and non-physical violence among nursing students during their clinical experiences and to analyze the perceived risk of violence. METHODS: Multicentre, cross-sectional survey. We enrolled a convenience sample of nursing students of the bachelor’s degree in Nursing of the University of Milan (Italy). The students completed a structured questionnaire prepared in accordance with the available literature on violence in healthcare settings. RESULTS: Out of 1185 questionnaires sent, 603 were collected (50.89%). 35.1% had experience of verbal violence during the clinical internship training period, while 8.1% were victims of physical violence. 202 students (33.5%) reported unsafety, which was related to experience of physical or psychological violence, witnessed episodes of violence, gender, hospital structure and efficacy of the safety policies. CONCLUSIONS: Our findings highlight that nursing students are exposed to the risk of violence which influences their perception of risk.

A critical ethnographic perspective on risk and dangerousness in forensic psychiatry

In the Canadian forensic psychiatric context, the concepts of risk and dangerousness interact, intersect, and morph into the notion of significant threat to the safety of the public. Stemming from the results of a critical ethnography of the Ontario Review Board, this article unpacks the central role of forensic psychiatric nursing, as an example of a 'psych' discipline (e.g., psychiatry and psychology), in a system that is built to produce risky persons and to legitimize their detention and supervision. By using excerpt of interviews conducted with nurses, ethnographic observations of Review Board hearings, and other documentary artifacts, the findings illustrate how rationalizations of risk and dangerousness are contingent on space, time, and observer. Depending on the time of the assessment or on the health-care professional who performs it, different elements including, but not limited to, mental illness, interpersonal relationships, financial instability, and sexual vulnerability, are relied upon in very fluid, interchangeable, and discretionary ways to justify findings of dangerousness. Such a dynamic expands the reach of psychiatry's legitimacy at identifying risky conduct and controlling risky persons to domains very loosely associated with the notion of dangerousness. The work of Foucault and Castel provides the theoretical backdrop on which rests the discussion and the implications for nursing.

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.

"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.

Abjection and the weaponization of bodily excretions in forensic psychiatry settings: A poststructural reflection

Nurses working in forensic psychiatric settings face unique challenges in practice, where they take on a dual role of custody and caring. Patient resistance is widespread within these restrictive settings and can take many forms. Perhaps the most disturbing form of resistance entails a patient's weaponization of their bodily fluids, with nurses as their target. The tendency in assigning motive for this act is to relegate to the psychopathology of the patient. This paper will adopt a poststructuralist perspective to reexamine this phenomenon as an act of resistance through the lens of Kristeva's concept of abjection. Patients confined in these settings have little sense of control, and in resistance may resort to the only thing available: their bodily fluids. By weaponizing the abject, patients actively violate and permeate the physical and psychological boundaries of nurses-the very boundaries considered crucial to safe and professional forensic psychiatric nursing practice. By recognizing this phenomenon as an act of resistance to confinement and loss of control, nurses may reorient their approach to care in forensic psychiatric settings.

Revisiting the Concept of Othering: A Structural Analysis

The various ways in which nurses relate and interact with patients, who are considered marginal, vulnerable, and in some ways "different," tend to revolve around the concept of othering. To date, much attention has been given to the immediate situation in which othering may take place, both in terms of process (occurring within interactions) and outcomes (exclusion and marginalization). Drawing on current literature from feminist studies and critical theory, we have drawn attention to broader historical, political, cultural, and social factors that come to shape nurse-patient relationships and propose a new dimension to the concept: structural othering.

Self-confidence in conducting forensic psychiatric evaluations among general psychiatrists in Indonesia

OBJECTIVE

Several general psychiatrists experience lack of confidence when they perform forensic psychiatric evaluations that may be due to limited or insufficient training. This study aimed to determine whether structured forensic psychiatry educational modules are associated with general psychiatrists' self-confidence in conducting forensic psychiatric evaluations in Indonesia.

METHOD

A cross-sectional study was conducted with 246 general psychiatrists. A questionnaire was developed exclusively for this study by a group of experts based on relevant references and it was distributed online. Sample questions included: "How often do you perform forensic psychiatric evaluations?", "As a general psychiatrist, are you confident in conducting forensic psychiatric evaluations?", and "Do you experience any difficulties when conducting forensic psychiatric evaluations?" Data were analyzed through SPSS 20 for Windows; a p-value <0.05 indicated statistical significance.

RESULTS

Compared to general psychiatrists who did not study structured forensic psychiatry educational modules during their residency training, those exposed to such modules reported confidence in conducting forensic psychiatric evaluations in the following cases: insanity defense in cases of violence, insanity defense, fitness to stand trial, malingering, capacity to consent to treatment, risk of recidivism, guardianship, and parenting capacity. Furthermore, those with higher self-confidence were less likely to experience difficulties in conducting forensic psychiatric evaluations.

CONCLUSION

Structured forensic psychiatry educational modules during general psychiatry residency training played an important role in the development of psychiatrists' self-confidence.

Forensic Mental Health Nurses' Perceptions of Clinical Supervision: A Qualitative Descriptive Study

Mental health nursing in the forensic services is perceived as stressful as there is often a tension between therapeutic and custodial processes. Clinical supervision has been discussed as a support strategy for nurses. The aim of this paper is to explore forensic mental health nurses understanding of clinical supervision and their perception of its utility within their practice. A qualitative descriptive method was used and 10 mental health nurses were interviewed with the aid of an interview guide. Qualitative data was analysed using a thematic approach culminating in the emergence of three themes.Participants talked about the tension between caring and custodial roles within the forensic services which was stressful and created difficulties in the maintenance of a therapeutic relationship. Clinical supervision was seen as a necessary support to assist nurses working in the forensic services. The findings support the premise that there is a tension between therapeutic and custodial practices. Acknowledgement of the complexities of working within the forensic services and the provision of clinical supervision within a confidential, non-judgemental relationship may assist nurses in the provision of care and the maintenance of therapeutic relationships.

Resisting the muddy notion of the 'Inclusionary Other': A re/turn to the philosophical underpinnings of Othering's construction

The notion of 'Inclusionary Othering,' in garnering uptake within diverse nursing spheres, muddies a critical understanding of Othering by obscuring the colonial production, exploitation and perpetuation of the Other for economic and political gain. The ongoing genocide of Indigenous women and girls in Canada is a direct manifestation of the Othering process and in response to the report's Calls for Justice, it is an apt time to re-enliven the conversation of the process of Othering's philosophical construction. The purpose of this article is to re/turn to the philosophical underpinnings of the process of Othering in hopes of enlivening a new wave of resistance within nursing and elsewhere to the means by which the Other is constructed as well as to the notion of Inclusionary Othering itself. Perhaps this re/turn to the philosophy of Edward Said and Sylvia Wynter can result in further thwarting the Othering construct by highlighting its colonial construction and usher in a pragmatic shift, increasing critical engagement with the construct as well as inspiring a re/newed resistance toward Othering in nursing practice.

Working alliance among mental health nurses in Indonesia: A comparative analysis of socio-demographic characteristics

Background

Working alliance between therapist and client in psychotherapy practice has become proven to compensate for a significant difference in various psychotherapy modalities. However, few studies have investigated the structure of alliance in the context of nurses working at mental health hospitals in Indonesia.

Objective

This study aimed to compare the working alliance of mental health nurses according to socio-demographic characteristics.

Methods

A cross-sectional research was performed at the Mental Health Hospital in West Java, Indonesia, as a referral hospital in Indonesia from May to December 2019. The inclusion criteria were nurses with a minimum of one year of working experience and a Diploma III certificate in nursing. Convenience sampling was used to recruit 120 nurses who agreed to join in this study. The working alliance was measured using Working Alliance Inventory-Short Revised-Therapist (WAI-SRT).

Results

The majority of the respondents were female (77.5%), holding a Diploma III degree in nursing (49.17%), having working experience ranged from 11 to 15 years (34.17%), and working at the chronic unit (32.5%). The mean score of the working alliance was 44.46 (SD = 11.32). The domain of agreement on goals had a higher mean score (17.65 ± 3.45), followed by the task domain (16.56 ± 5.81) and bond domain (22.10 ± 7.23). There was a significant difference in working alliance according to education level and working experience (p < 0.05), while no significant differences in terms of gender and working unit.

Conclusion

Mental health nurses with higher education levels and more vast working experience had higher working alliances. Thus, nurse managers and hospital policymakers should provide Continues Nursing Education (CNE), working alliance training, and therapeutic strategies for nurses to improve their working alliances. It is also essential to cooperate with nursing schools to include working alliances as learning objectives.

(Re)construction identitaire et pratique infirmière en psychiatrie légale : réflexion critique sur les commissions d’examen

Introduction&#160;: The caritative impact of nursing care provided in forensic mental health settings is rarely questioned.Context&#160;: Caritative nursing care is indirectly regulated by the Review Board (RB), a para-judicial court which ensures public safety.Objective&#160;: This study presents a critical reflection on the political and social effects of the RB, forensic psychiatry hospitals and practices of forensic mental health nurses.Method&#160;: The reflection is centered on the concepts of biopower, degradation ceremonies, moral career and identity (re)construction.Results&#160;: &#8216;Therapeutic&#8217; nursing practices are useful for disciplinary purposes in the forensic psychiatric hospital, insofar as they permit the identification and management of dangerous persons. However, the practices also fall within the biopolitical scope of the RB, since they assist the latter in ensuring public safety.Discussion&#160;: The forensic psychiatric environment can prove problematic for nurses, requiring a double allegiance, whereby their responsibilities to patients (consent and confidentiality) and to the institution (protection of the public) can lead to tension.Conclusion&#160;: The analytical framework of the study allows for a reassessment of other presumed processes in psychiatric environments, which nonetheless constitute just as many rituals of identity (re)construction.

Intégration des droits humains dans la pratique du personnel infirmier faisant usage de coercition en santé mentale : recension systématique des écrits et méta-ethnographie

Introduction and background&#160;: The last decade has seen a steady and rising use of coercion in mental health care, as well as an increase in the number of forms it takes. The application of these measures frequently relies on the work of nurses, but few studies have analyzed the human rights issues raised by these practices.Aim&#160;: To produce a qualitative synthesis of how human rights are integrated into the practice of nurses who use coercion in mental health care.Methodology&#160;: A systematic review of qualitative scientific literature published between 2008 and 2018 was conducted and supplemented by a meta-ethnographic analysis.Results&#160;: The analysis of the forty-six selected studies revealed four distinct themes&#160;: coercion in mental health care as a socio-legal object, issues of recognition of human rights in mental health care, role conflict experienced by nurses, and the conceptualization of coercion as a necessary evil or a critical incident.Discussion and conclusion&#160;: Further research is needed to understand the specifics of the continuum of support and control that characterizes the coercive work of psychiatric nurses.

Barriers and facilitators to the effective de-escalation of conflict behaviours in forensic high-secure settings: a qualitative study

Background

Violent and aggressive incidents are common within mental health settings and are often managed using high-risk physical interventions such as restraint and seclusion. De-escalation is a first-line technique to manage conflict behaviours and prevent violence and aggression. There is limited research into the use of de-escalation in high-secure settings. This study investigated staff, patient and carer perspectives on the barriers and facilitators to using de-escalation for conflict behaviours.

Methods

Semi-structured individual interviews (n = 12) and focus groups (n = 3) were conducted with eight patients, four carers and 25 staff members in a high-secure hospital in England. Interviews and focus groups were informed by the theoretical domains framework and were digitally recorded, transcribed verbatim and analysed using framework analysis and the COM-B behaviour change model.

Results

Four themes and 15 sub-themes (barriers and facilitators) were identified. Themes related to capabilities (building relationships: knowing the patient and knowing yourself), opportunities (filling the void: challenges within the high-security environment; dynamic relationships) and motivation (keeping everyone safe). Strong staff-patient therapeutic relationships underpinned by trust, fairness, consistency and an awareness of the trauma-aggression link were considered key to successful de-escalation. Specific psychological and interpersonal skills including empathy, respect, reassurance, sincerity, genuine concern and validation of the patient perspective are needed to achieve this. Barriers related to the physical environment; organisational resources, practices and systems; staff traumatisation; hierarchical and punitive attitudes towards patient care, and an insufficient understanding of psychiatric diagnoses, especially personality disorder. It was apparent across themes that fear, which was experienced by both staff and patients, was a driver for many behaviours.

Conclusions

This work has identified organizational and behaviour change targets for interventions seeking to reduce violence and restrictive practices through the use of de-escalation in high-secure hospitals. The potential for, and occurrence of, violence in such settings is high and leads to fear in patients and staff. The factors which promote fear in each group should be addressed in de-escalation training.

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

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

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.

The long-term effects of a prevention program on the number of critical incidents and sick leave days

Background

This study explores the effectiveness of refresher training sessions of an intervention program at reducing the employees’ risk of injury due to patient violence in forensic psychiatric hospital.

Methods

The original safety intervention program that consisted of a 3 days’ workshop was conducted in the maximum—security ward of a psychiatric hospital in Israel. Ever since the original intervention, annual refreshers were conducted highlighting one of the safety elements covered in the original intervention. The study examines the effect of the intervention program along with the refreshers over a period of 10 years in four wards.

Results

Analysis of the data demonstrates that beyond the initial reduction following the original intervention, refreshers seem to have an additional positive long-term effect, reducing both the number of violent incidents and the number of actual employee injuries in forensic psychiatric hospital.

Conclusions

We conclude that such an intervention program followed by refresher training would promote employees’ wellbeing. A healthy work environment is part of management’s commitment to improve employee wellbeing at the workplace.

Mental Health Professionals' Attitudes Toward Offenders With Mental Illness (Insanity Acquittees) in Ghana

Mental health professionals' attitudes toward offenders with mental illness have significant implications for the quality of care and treatment rendered, making it imperative for these professionals to be aware of their attitudes. Yet, this topical issue has received little research attention. Consequently, the present study investigates attitudes toward offenders with mental illness (insanity acquittees) in a sample of 113 registered mental health nurses in Ghana. Using a cross-sectional survey and self-report methodology, the participants respond to measures of attitudes toward offenders with mental illness, attitudes toward mental illness, conviction proneness, and criminal blameworthiness. The results show that mental health nurses who reportedly practiced for a longer duration (6 years and above) were more likely to be unsympathetic, while the male nurses who were aged 30 years and above were more likely to hold offenders with mental illness strictly liable for their offenses. Importantly, the nurses' scores in conviction proneness and criminal blameworthiness significantly predict negative attitudes toward the offenders even after controlling for their attitudes toward mental illness. Yet, when the nurses' conviction proneness and criminal blameworthiness were held constant, their attitudes toward mental illness failed to predict attitudes toward the offenders. This initial finding implies that the nurses' views regarding criminal blameworthiness and conviction may be more influential in understanding their attitudes toward offenders with mental illness relative to their attitudes toward mental illness.

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.

Convergence and divergence: An analysis of mechanical restraints

BACKGROUND

Psychiatric nurses are regularly confronted with the uses and effects of control interventions such as mechanical restraints. Although there are evident tensions in the literature regarding the use of mechanical restraints, very little research has focused on the lived and embodied experience of their use, whether from the patient's perspective or the perspective of nursing staff responsible for their application.

RESEARCH AIMS

(1) to gain access to the bodily phenomenon of being placed in mechanical restraints; (2) to give voice to the intimate experiential understanding of this experience; and (3) through phenomenological interpretation, to understand the subjective processes and meaning-making of this experience.

RESEARCH DESIGN

For this research, we adopted a distinctly ethics-oriented application of the methodology known as interpretative phenomenological analysis, that is, the interpretive dimension of the research focused on ethical practice in mental healthcare - one that is informed by experiential accounts of the lived body.

PARTICIPANTS AND RESEARCH CONTEXT

A total of 40 in-depth semi-structured, nondirected interviews with both nurses (n = 21) and patients (n = 19) we conducted to meet the aims of this article. Participants were recruited from an inpatient psychiatric unit of a Canadian general hospital.

ETHICAL CONSIDERATIONS

The research received research ethics board clearance from both the hospital where the study took place and the University of Ottawa.

FINDINGS

The comparative analysis is presented under the following headings: (1) context of care, (2) meaning of quality of care, (3) emotional reactions and nurse-patient relationship, (4) meeting the needs and (5) need for alternatives.

DISCUSSION/CONCLUSIONS

The research findings are discussed in light of current literature and implications for practice.

"They're Really PD Today"

The therapeutic relationship is of particular importance when working with patients with antisocial personality disorder, but despite this, there is a paucity of literature exploring student nurses' perceptions of developing a therapeutic relationship with such patients. Hence, this qualitative study explored the perceptions of second-year mental health nursing students of developing a therapeutic relationship with this patient group. Student nurses from a University in the Northwest of England participated in two focus groups, to compare the perceptions of a group of student nurses who had experience in secure settings (forensic hospital) with those who had not. Four key themes emerged: diagnosis, safety, engagement, and finally environmental influences. Both groups commented on looking beyond the diagnosis and seeing the person. The student nurses cited other staff in their clinical placement areas as hugely influential in terms of the development of their perceptions of patients with antisocial personality disorder and how to relate to them.

Prison Nursing: Formation of a Stable Professional Identity

AIM

The aim of this study was to analyze how working within prison environments can influence the self-identity and professional identity of nurses.

BACKGROUND

The prison environment can be a difficult environment for nurses to deliver care within, with nurses having to carry out activities that seem to go against their professional role, while at the same time providing care to prisoners who have greater health needs than the general population. There is a lack of theoretical consideration of how prison nurses carry out their role in the face of such challenges.

METHOD

This study used a review of literature published over the last 11 years exploring nurses' beliefs, thoughts, and feelings toward delivering care within prison environment.

IMPLICATIONS FOR FORENSIC NURSING

With time, nurses working within prison environments develop specific skills to be able to deliver appropriate care to their patients. These skills include adapting to both the prison environment and the prison culture. Ultimately, adaptations lead to a change in identity allowing nurses to work effectively within prison.

CONCLUSION

Providers of prison healthcare should ensure that induction (orientation) processes for new nurses are designed to address specific challenges that nurses face including the potential for cognitive dissonance. They should ensure that nurses receive training to develop and acquire the skills highlighted in this review. Ensuring that this training is in place may increase nurse retention.

Enhancing the Safety Climate and Reducing Violence Against Staff in Closed Hospital Wards

This study examined the effectiveness of an intervention program to enhance unit safety climate and minimize employee risk of injury from patient violence. The intervention program, including a 3-day workshop, was offered to personnel on maximum security units of an Israeli psychiatric hospital. Safety climate was examined before and after the implementation of the intervention, and incidents of patient violence were investigated. Six months after the intervention, a significant improvement in employees' perceptions of management's commitment to safety as well as a marginally significant improvement in communication about safety issues were found. This study demonstrated that an intervention program to enhance safety climate was associated with a decrease in the number of aggressive incidents. The researchers concluded that this intervention program is likely to return a sense of safety to workers and reduce workplace violence.

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.

To do good might hurt bad: exploring nurses' understanding and approach to suffering in forensic psychiatric settings

Patients in forensic psychiatric settings not only have to deal with their mental illness, but also memories of criminal activities and being involuntarily hospitalized. The aim of the present study was to explore how nurses working in forensic psychiatric services understand and approach patients' experiences of suffering. Data were generated by semistructured interviews with psychiatric nurses from two different forensic psychiatric units in Sweden. Data were analysed by means of a hermeneutic approach inspired by Ricoeur's hermeneutics. The findings are reflected in four main themes: (i) ignoring suffering; (ii) explaining suffering as a natural and inevitable part of daily life in the forensic context; (iii) ascribing meaning to suffering; and, (iv) being present in suffering. To engage in alleviating suffering is a struggle that demands courage and the strength to reflect on its character and consequences. To encounter suffering means that nurses are not only confronted with patients' suffering, but also their own reactions to those patients. If suffering is not recognized or encountered, there is a risk that actions may have a negative impact on patients.

Locating the qualitative interview: reflecting on space and place in nursing research

Interview location has been widely overlooked in the nursing literature. This paper presents a discussion of interview location in the context of nursing research with particular emphasis on the concepts of space and place. It draws on six research projects that were conducted between 2008 and 2013 in Canada, and is informed by key texts on the concepts of space and place. We argue that thinking about space and place in the context of interviewing is one way to engage in reflexivity. The reflexive accounts featured in this paper support the need for nursing researchers to engage in explicit analysis of their own interview locations and to discuss the significance of space and place in their own work. These accounts suggest that location is a fundamental aspect of the interview process.

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.

Psychiatric nurses' self-rated competence

This study explored the self-rated competence of 52 Swedish psychiatric nurses in three clinical environments: forensic psychiatry, general psychiatric inpatient care, and clinical non-residential psychiatric care. A questionnaire wtih 56 statements from nine areas of expertise was completed. Forensic nurses were more skilled in safety and quality and in dealing with violence and conflicts. Non-specialist nurses appreciated their skills more so than specialist nurses in health promotion and illness prevention and conduct, information, and education. Women were inclined to invite patients' relatives for education and information. Men attended to a patients' spiritual needs; they also coped with violence and managed conflicts.