Time use of patients in a secure forensic hospital: A mixed methods study

INTRODUCTION

Forensic mental health services balance recovery-focussed therapy with risk management, which may limit opportunities for participation in meaningful occupation. Previous research describes forensic patients in secure settings participating mainly in passive leisure and sleep. This study aimed to use quantitative and qualitative evidence to investigate how patients in the sub-acute and rehabilitation units of an Australian forensic hospital perceive and use their time and to discuss how the findings compare with the previous study within the organisation, published in 2004.

METHOD

An explanatory sequential mixed methods design was used with convenience sampling of patients and purposive sampling of staff. Patients completed time use diaries followed by semi-structured interviews. Staff perceptions were obtained via survey.

RESULTS

Seven male patients with a diagnosis of schizophrenia and five staff members (three occupational therapists and two nurses) participated. Time use diaries indicated patients spent most time in personal care, passive recreation, and leisure activities. Qualitative data illustrated patient time use was influenced by the individualised meaningfulness of activities. Patients drew meaning from past roles, personal interests/needs, and their goals for recovery. While patients had some choice over how time is spent and with whom they chose to engage, external factors such as staff/program availability prevented their having full control. Staff provided additional perspectives on the links between time use and recovery, identifying enablers and barriers to meaningful time use.

CONCLUSION

Patient time use has not changed significantly when compared to past research, although perceptions of time use are more future and recovery-focussed. The amount of time recorded in activities typically associated with recovery does not necessarily capture the quality and benefit of that time use. Patient participation continues to be influenced by broader systems.

The violence profile of male mentally disordered offenders in a high secure unit in Turkiye

Our knowledge of the severity and reoffending is limited for mentally disordered offenders, and studies generally evaluate without separation between different diagnostic groups. It was aimed to determine the general profile of mentally disordered offenders who are inpatients in a high secure psychiatry unit from Turkiye and to evaluate the factors associated with violence profiles among different diagnostic groups. According to the results the schizophrenia patients committed the most severe crimes, and intellectual disability patients had some different features from schizophrenia and bipolar disorder patients. History of substance misuse in the intellectual disability group (p = 0,045) and comorbid antisocial personality disorder in the bipolar disorder group (p = 0,015) were associated with increased crime severity. Substance misuse history, history of substance use during the crime, and the existence of comorbid antisocial personality disorder were associated with increased offenses in each of the three diagnosis groups. Living alone (p = 0,004) and having a suicide history (p= 0,052) were associated with the high number of offenses in the schizophrenia group. This study is the first study that compares three diagnostic groups to involve a large patient group. We believe that clinicians must evaluate these parameters for the violence risk assessment of patients.

An examination of service user satisfaction in forensic mental health settings

High levels of service user satisfaction are viewed as a reliable indicator of a service providing good care and treatment. There has been limited research looking into levels of satisfaction in forensic mental health settings with most work focused on staff satisfaction in these settings. This study examined service users' levels of satisfaction with a forensic mental health service in the United Kingdom. The service covered two sites; one a purpose-built secure unit and the other based in an old cottage hospital. Thirty-nine in-patients completed a 60-item validated forensic satisfaction scale. The scale measured seven domains of satisfaction as well as reporting an overall satisfaction score. The results indicated the service users were reasonably satisfied with the care and treatment they received. The domains of rehabilitation, safety, staff interaction and overall care showed the highest level of satisfaction. The high rehabilitation satisfaction score demonstrated the importance of meaningful activities for users accessing forensic services and may have been influenced by the security measures on the wards. The high safety domain score indicated respondents felt safe and secure within the wards and were likely to be influenced by positive interpersonal interactions. Good staff interaction was also an important factor in helping service users feel safe on the wards. These interactions are likely to be associated with longer periods of admission in secure services allowing therapeutic relationships to develop. Financial advice/support was the one domain that recorded negative satisfaction levels. Financial literacy training may help develop money management skills.

Occupational therapy with patients in forensic solitary confinement: A qualitative study

INTRODUCTION

Occupational therapists work with forensic mental health patients in solitary confinement to counter impacts of mental illness and occupational deprivation, to promote well-being and support transition to less restricted environments. There is little literature describing occupational therapy in this context. This study aimed to explore and describe the work, context and professional reasoning of occupational therapists working in solitary confinement settings within a large forensic mental health service in Victoria, Australia.

METHODS

A qualitative design used semi-structured interviews with 11 occupational therapists and reflexive thematic analysis.

FINDINGS

Three central organising themes, it's all about risk, the work we do and why we do what we do, provided rich description of the context and work of occupational therapists in solitary confinement settings, including approaches used to engage patients in occupation and how the Model of Human Occupation and recovery principles informed their professional reasoning. Despite the setting restrictions, participants engaged in core elements of the occupational therapy practice process and described creative work that offered patients choice and meaningful occupation. They described occupational enrichment to address occupational deprivation and create opportunities for change within the highly restrictive and risk-focussed environment of solitary confinement. Assessment was mainly unstructured, and the need for better evaluation of therapy outcomes acknowledged. Goal setting often focussed on immediate needs. Working in a risk-focussed environment influenced participants' professional reasoning and work with patients, and while they advocated for occupational opportunities for patients, frustration was experienced in response to limits to occupational therapy involvement in risk assessment.

CONCLUSION

The findings address a gap in the literature about the work of occupational therapists in forensic solitary confinement. Though participants' reasoning was informed by occupational and recovery principles, and they described working in occupation-based ways, they did not always articulate explicit connections between theory and practice.

The change in occupational participation and quality of life following occupational therapy for people supervised by probation

INTRODUCTION

The probation system is a penal and enforcement system in which the completion of sentences of individuals who are incarcerated and rehabilitation processes are carried out together. This study considered the change in occupational participation and quality of life following occupational therapy for people supervised by probation.

METHODS

The research was planned as a pre-test and post-test study. Fifteen individuals participated in the study voluntarily. The participants completed the Socio-Demographic Information Form, COPM for occupational participation, and the Nottingham Health Profile (NHP) for quality of life. We implemented an intervention program consisting of, on average, 1 h once a week for 12 weeks. Post-intervention evaluations were completed, and the results were compared.

RESULTS

There was a significant difference between the pre-intervention and post-intervention measures of the total quality of life scores (p = 0.003) and the COPM scores for performance (p = 0.001) and satisfaction (p = 0.001).

CONCLUSION

Implementing a client-centred occupational therapy intervention involving personal behaviour, organisational environment, and activity change resulted in an increase in clients' activity performance, satisfaction with their performance, and quality of life.

Occupational participation, stress, anxiety and depression in workers and students from Brazilian universities during the COVID-19 pandemic

Abstract Introduction The physical, social and occupational restrictions imposed by the COVID-19 pandemic have affected the health and well-being of the world population. Objective To identify the repercussions of the pandemic on the occupational participation of students, lecturers and technicians from three public universities in Northern Brazil, to compare the changes reported by participants in occupational participation before and during the pandemic, and to identify symptoms of depression, anxiety and stress self-reported. Method This is a Cross-sectional, descriptive and comparative study with a quantitative approach. One hundred and ninety-nine (n = 199) participants (students, lecturers and technicians) responded to an online questionnaire, the “Occupational Participation Checklist” and the Anxiety, Stress and Depression Scale (DASS-21). Data analysis were descriptive and also performed by applying the Wilcoxon and Mann-Whitney tests. Results During the pandemic, an increase in occupational participation was identified for all participants in domestic activities (p <0.001) and a decrease in work and study face to face (p <0.001). Students reported more symptoms of depression, anxiety and stress when compared to lecturers (p<0.001). Most students did not organise their time to fulfil their occupations with satisfaction. Such difficulties were associated with symptoms of depression, anxiety and stress, especially among the student's group (p<0.001). Conclusion This study provided preliminary evidence about differences in occupational participation before and during the Covid-19 pandemic. The organization of time and difficulties in occupational participation were associated to levels of anxiety, depression and stress, especially in the sample of students.

Patients' experiences of place and space after a relocation to evidence-based designed forensic psychiatric hospitals

Forensic hospitals provide care for incarcerated patients who have committed a crime under the influence of serious mental illness. The care and (re)habilitation of the target group require highly competent staff and treatment strategies as well as purpose-built facilities that promote successful recovery. The aim of this study was to examine patients' experiences of place and space in new, purpose-built, evidence-based designed forensic psychiatric facilities in terms of supporting everydayness. A qualitative methodology was chosen. In total, 19 patients agreed to participate. Data were collected through photovoice (a combination of photographs and interviews) at three forensic hospitals, according to an evidence-based design and the concept of person-centred care in Sweden. The data were analysed through thematic content analysis. Four themes emerged from the data, revealing the patients' experiences of the new buildings: (i) having a private place, (ii) upholding one's sense of self, (iii) feelings of comfort and harmony, and (iv) remaining connected to one's life. The findings reveal that purpose-built environments can support everyday living and well-being and can create comfort. This is considered highly therapeutic by the patients. In conclusion, the findings of this study are of imperative importance in the design of health-promoting forensic hospitals.

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.

Stuck in separation: Liminality, graffiti arts and the forensic institution as a failed rite of passage

Forensic psychiatric institutions are tasked with both containment and transformation, with securely policing the border between institution and society and readying patients for return to the community. Forensic institutions can thus be theorised as a form of 'rite of passage', engaged in a process of transformation which both navigates and demarcates social limits. This article contributes to literature on risk and control in clinical institutions by offering a novel theoretical synthesis of features of rites of passage and liminality, as facilitated by an art project in a forensic setting. Through the prism of the Graffiti and Wellbeing Project (GWP), an arts initiative, we explore the ways in which forensic institutions thus offer or impede opportunities for transformation. The project engendered a space for the transformation of difficult emotions and histories through the medium of art creating a liminal space of transformation within the confines of a secure institution. Drawing on Douglas, Kristeva and Bahktin, we argue that forensic institutions largely attempt to manage their own transgressive, marginal status, and the abject experiences of patients, through a recourse to order, suppression and sublimation. We argue for a wider range of responses to the transgressive and marginal experiences and behaviours prevalent in forensic settings, drawing on examples from the GWP.

Doing and being occupation centred in challenging settings: reflections on implementation strategies and professional rewards

Abstract Introduction In order to centralise occupation in challenging settings, therapists need a supportive process and distinct strategies to assist them as they re-design and implement services which are truly occupation centred, based and focussed. Objectives The aim of this article is to illuminate the strategies utilised by a group of occupational therapists working to centralise occupation in a forensic mental health service in Australia. It also highlights the subsequent professional rewards they experienced from being more occupation centred in everyday practice. Method A Community of Practice Scholars was formed by participants. They then used a Practice Based Enquiry (PBE) approach – a type of action methods research - involving iterative cycles of data collection, analysis, critique and implementation of practice innovations. Results Seven major themes emerged from the study. The theme of Strategies in, and Rewards of, Occupation Centred Practice is the focus of this article, with inclusion of data from the theme of Communicating with Certainty. Additional themes are discussed through other, related publications. Conclusion This article highlights the process of moving beyond “knowing that” occupation centred practice is important, to “knowing how” to re-design an occupational therapy service to achieve this aim. Becoming more occupation centred in practice can be experienced as more professionally rewarding for occupational therapists, especially those working in challenging settings.

Patients' Views With Regard to Personal Recovery in Forensic Psychiatry in German-Speaking Switzerland-An Explorative Study

Recovery orientation (RO) is a modality of supporting patients to improve self-determination, leading a meaningful life and well-being in general. This approach is widely studied in general psychiatry, but evidence is lacking for forensic inpatient settings in Switzerland. While secure forensic clinics tend to be regarded as total institutions, which are an anathema to RO, a project to implement RO interventions in this setting was financed by the Swiss Federal Office of Justice. This explorative study investigates baseline expectations and views of patients in forensic wards in German-speaking Switzerland in the context of a recovery-oriented intervention. As such wards are non-existent in Latin-speaking Switzerland, the investigation could only be carried out in this language region. Six focus groups with 37 forensic inpatients were conducted. Thematic analysis revealed two major and several subthemes. The major theme "heteronomy" includes the subthemes "stigmatization and shame," "coercion," "lack of support," "mistrust," "waiting," and "structural impediments." The subthemes "learning to live with the disorder and working on oneself," "participation," "connectedness," "confidence," and "joie de vivre" belong to the major theme "regaining self-determination." In this way, results of prior research are extended to forensic peculiarities. Furthermore, the personal views of patients are discussed in detail regarding their possible influence on therapeutic outcomes and personal recovery. These findings should be of help to therapeutic staff in the respective setting to be better informed about, and to counter the effects of, heteronomy and long-term hospitalization. Important in this regard is the concept of procedural justice and the subjective client's perception thereof.

The experience of long stay in high and medium secure psychiatric hospitals in England: qualitative study of the patient perspective

Background

Some forensic patients in England remain in secure care for long, possibly unnecessarily prolonged, periods, raising significant ethical and resource issues. Research focused on the patients in secure care has examined quality of life and service provision but not the perspectives of patients experiencing long stays. This study explored how long stay patients experience secure care, what factors they felt influenced long stay, and its impact upon treatment engagement and motivation to progress.

Methods

Embedded within a larger epidemiological study, we conducted semi-structured interviews with a purposive sample of forty long stay patients from two high and six medium secure hospitals. Long stay was defined as a 5 years stay in medium secure care or 10 years in high secure care, or 15 years in a combination of high and medium secure. Transcripts were subject to thematic analysis, and narrative analysis at individual case level to explore the relationship between emergent themes.

Results

Four themes emerged illustrating participants' attribution, outlook, approach, and readiness for change. A typology of four long stay stances was developed (dynamic acceptance, dynamic resistance, static acceptance, static resistance). These illustrate differences in the extent to which participants believed being in secure care helped them to get better, and actively work towards progression and leaving secure care. There were considerable differences in how patients adopting these stances attributed the reasons for their long stay, they viewed their future, and their motivation to progress. Negative perceptions arose from excessive restrictions, treatment repetition and changes in therapeutic relationships, leading some patients to exhibiting tokenistic engagement and low motivation to progress.

Conclusions

Planning care for long stay patients in secure psychiatric settings should take account of the differing stances patient's adopt towards engagement and progression. Service providers should be mindful of these stances and provide patients with individualised opportunities to progress through the secure care treatment pathway, avoiding treatment repetition and maintaining continuity in key professional relationships. Refocusing on quality of life may be appropriate for some long-term patients who are unwilling or unable to move on. For some long-term patients, purpose designed long stay setting may be appropriate.

Working towards least restrictive environments in acute mental health wards in the context of locked door policy and practice

There has been a shift towards provision of mental health care in community-based settings in Australia. However, hospitals continue to care for people in acute mental health wards. An increasing proportion of the people in wards are admitted involuntarily, subject to restrictions of movement to minimize risk of harm to self and others. In response to concerns about the safety of people absconding from care, Queensland Health introduced a policy requiring all acute mental health wards in the State to be locked. In response, the Queensland Mental Health Commission funded a project to understand the impact of this policy and develop evidence-based recommendations regarding provision of least restrictive, recovery-oriented practices in acute wards. Facilitated forums were conducted with 35 purposively selected participants who identified as consumers, carers, or staff of acute mental health hospital wards, to test the acceptability, feasibility, and face validity of a set of evidence-informed recommendations for providing least restrictive, recovery-oriented practices. Participant responses were recorded, and data were analysed through an inductive, thematic approach. A recovery-oriented approach was supported by all stakeholders. Reducing boredom and increasing availability of peer support workers were considered key to achieving this. Focusing less on risk aversion was reported as central to enabling true Recovery Orientation. This project enabled recognition of the perspectives of consumers, carers, and staff in the consideration of evidence-informed recommendations that could be implemented to provide least restrictive care in the context of locked doors.

Exploring the lived experience of homelessness from an occupational perspective

BACKGROUND

Working in homelessness is a growing area of practice for occupational therapists, however, there is limited literature on the lived experiences of homelessness and occupational engagement Study aim: To explore the lived experience of homeless men in relation to how they engaged in day-to-day occupations when sleeping rough or hostel dwelling Methods: Data were gathered from five men residing in a homeless hostel in the UK. Data collection included semi-structured interviews and photographic diaries. Data were analyzed using Interpretative Phenomenological Analysis Results: Participants described their experiences of occupational engagement whilst sleeping on the streets which included engaging in survival occupations, the significance of apparently ordinary occupations and moving beyond survival occupations. The homeless hostel provided opportunities for occupational engagement that the men perceived in an idiosyncratic manner. The men described benefits of engaging in novel occupations and reengaging in known occupations. Occupational injustices were a common theme that occurred throughout participants experiences Conclusion: This study has highlighted the diversity of occupational engagement for 'roofless' or 'houseless' participants and how different individuals experience occupational adaption Significance: This study has furthered understandings of the concept of 'survival occupations' and the importance of community resources to facilitate occupational engagement whilst homeless.

A mixed-methods study exploring the characteristics and needs of long-stay patients in high and medium secure settings in England: implications for service organisation

Background

Forensic psychiatric services provide care for those with mental disorders and offending behaviour. Concerns have been expressed that patients may stay for too long in too high levels of security. The economic burden of these services is high, and they are highly restrictive for patients. There is no agreed standard for ‘long stay’; we defined a length of stay exceeding 5 years in medium secure care, 10 years in high secure care or 15 years in a combination of both settings as long stay.

Objectives

To (1) estimate the number of long-stay patients in secure settings; (2) describe patients’ characteristics, needs and care pathways and the reasons for their prolonged stay; (3) identify patients’ perceptions of their treatment and quality of life; and (4) explore stakeholders’ views on long stay.

Design

A mixed-methods approach, including a cross-sectional survey (on 1 April 2013) of all patients in participating units to identify long-stay patients [work package (WP) 1], file reviews and consultant questionnaires for long-stay patients (WP2), interviews with patients (WP3) and focus groups with other stakeholders (WP4).

Setting

All three high secure hospitals and 23 medium secure units (16 NHS and 9 independent providers) in England.

Participants

Information was gathered on all patients in participating units (WP1), from which 401 long-stay patients were identified (WP2), 40 patients (WP3), 17 international and 31 UK experts were interviewed and three focus groups were held (WP4).

Results

Approximately 23.5% of high secure patients and 18% of medium secure patients were long-stay patients. We estimated that there are currently about 730 forensic long-stay patients in England. The source of a patient’s admission and the current section of the Mental Health Act [Great Britain.Mental Health Act 1983 (as Amended by the Mental Health Act 2007). London: The Stationery Office; 2007] under which they were admitted predicted long-stay status. Long-stay patients had complex pathways, moving ‘around’ between settings rather than moving forward. They were most likely to be detained under a hospital order with restrictions (section 37/41) and to have disturbed backgrounds with previous psychiatric admissions, self-harm and significant offending histories. The most common diagnosis was schizophrenia, but 47% had been diagnosed with personality disorder. Only 50% had current formal psychological therapies. The rates of violent incidents within institutions and seclusion were high, and a large proportion had unsuccessful referrals to less secure settings. Most patients had some contact with their families. We identified five classes of patients within the long-stay sample with different characteristics. Patients differed in their attribution of reasons for long stay (internal/external), outlook (positive/negative), approach (active/passive) and readiness for change. Other countries have successfully developed specific long-stay services; however, UK experts were reluctant to accept the reality of long stay and that the medical model of ‘cure’ does not work with this group.

Limitations

We did not conduct file reviews on non-long-stay patients; therefore, we cannot say which factors differentiate between long-stay patients and non-long-stay patients.

Conclusions

The number of long-stay patients in England is high, resulting in high resource use. Significant barriers were identified in developing designated long-stay services. Without a national strategy, these issues are likely to remain.

Future work

To compare long-stay patients and non-long-stay patients. To evaluate new service models specifically designed for long-stay patients.

Study registration

The National Institute for Health Research (NIHR) Clinical Research Network Portfolio 129376.

Funding

The NIHR Health Services and Delivery Research programme.

A longitudinal study of changes in asylum seekers ability regarding activities of daily living during their stay in the asylum center

The aim was to assess change in activities of daily living (ADL) ability amongst asylum seekers and if there were any difference between tortured and non-torture following a 10 months post-arrival period, and if self-reported health and exposure to torture were factors related to change in ADL-ability. The study was a combined baseline, follow-up correlational study amongst individuals from Afghanistan, Iran and Syria, living in Danish asylum centers. Forty-three persons aged 20-50, were invited and participated in the baseline study. Twenty-two were still in asylum center at the follow-up and 17 of them participated. ADL-ability was measured using Assessment of Motor and Process Skills and questionnaires about exposure to torture, self-reported mental health and pain. ADL motor and process measures, well-being and self-rated health declined from baseline to follow-up. Measures of pain and depression increased. Exposure to physical torture and change in ADL motor (r = 0.525) measures were associated, as well as change in current pain and change in ADL process (r = 0.525) measures. Due to preponderance of torture survivors analysis of group difference was not applicable. Health care workers should be aware of ADL concerns and exposure to torture in this population to best address their needs within rehabilitation settings.

Occupation, Mental Illness and Medium Security: Exploring Time-Use in Forensic Regional Secure Units

Research investigating occupational experience among people with mental illness has highlighted their difficulties in selecting, organising, valuing, enjoying and competently performing occupations. Although occupational therapy literature consistently identifies environmental factors as key in facilitating successful and valued engagement, few authors have studied the implications of detention in secure mental health settings for this population.

This study investigated the occupational experiences of five people with schizophrenia in two forensic regional secure units. Quantitative and qualitative methodologies were used, with semi-structured interviews adding depth and subjectivity to Occupational Questionnaire (Smith et al 1986) responses. The quantitative data were analysed using non-parametric analysis, with content analysis applied to the qualitative data.

Time-use was characterised predominantly by engagement in passive leisure and rest occupations. This reflects the findings of both inpatient and community-based studies elsewhere and suggests that mental illness is a common factor influencing time-use. The participants chose occupations based on expectations of enjoyment and success, and associations with independence and normality. Significant correlations were found between perceived competence, value and enjoyment (p<0.01), and the participants were more likely to enjoy self-chosen occupations (p<0.05).

Forensic occupational therapists must use evidence to optimise resources and deliver interventions that facilitate choice and autonomy and reflect individual needs. Further research with larger samples and longitudinal methodologies will facilitate generalisation and establish temporal perspectives.

Occupational Therapy in Forensic Psychiatry: A Review of the Literature and a Call for a United and International Response

A review and critique of the literature on occupational therapy in forensic mental health settings was conducted. The results indicate that the evidence base supporting occupational therapy in a forensic mental health setting is relatively weak. Much of the literature describing the role of occupational therapy in a secure setting is over 10 years old and lacks currency, and many of the research-based articles lack methodological rigour. Research has often been conducted in isolation and over a diverse range of topics, which means that important research questions have not been studied systematically.

This paper argues that to enhance the credibility and efficacy of occupational therapy in forensic practice, a coordinated international network of therapists needs to be established. Using the strength of multi-site studies, such a group can build the evidence base for occupational therapy practice in forensic settings. In addition, better links between occupational therapy services and local universities should be formalised in order to promote ongoing research that meets rigorous research standards.

Inpatient forensic-psychiatric care: Legal frameworks and service provision in three European countries

Laws governing the detention and treatment of mentally disordered offenders (MDOs) vary widely across Europe, yet little information is available about the features of these laws and their comparative advantages and disadvantages. The purpose of this article is to compare the legal framework governing detention in forensic psychiatric care in three European countries with long-established services for MDOs, England, Germany and the Netherlands. A literature review was conducted alongside consultation with experts from each country. We found that the three countries differ in several areas, including criteria for admission, review of detention, discharge process, the concept of criminal responsibility, service provision and treatment philosophy. Our findings suggest a profound difference in how each country relates to MDOs, with each approach contributing to different pathways and potentially different outcomes for the individual. Hopefully making these comparisons will stimulate debate and knowledge exchange on an international level to aid future research and the development of best practice in managing this population.

Forensic Occupational Therapy in Canada: The Current State of Practice

Although occupational therapists have been practicing in forensic settings for many years, there is a paucity of literature regarding the nature of this practice in Canada. The purpose of this study was to describe the practices of Canadian occupational therapists in forensic mental health. An online survey was designed based on the Canadian Practice Process Framework. Following purposive and snowball sampling, responses were analysed with descriptive statistics and content analysis. Twenty-seven clinicians responded (56% response rate). Respondents indicated commonalities in workplaces, client caseloads and practice challenges. The outstanding need in Canada to demonstrate client outcomes through the use of evaluation instruments reflects those practice gaps identified internationally. Education, advocacy and research are critical areas for the development of Canadian forensic occupational therapy. Although findings heavily reflect one provincial context and may not be generalizable to nonhospital settings, a number of priority areas were identified. Future efforts should clarify the role of forensic occupational therapy to stakeholders, and validate their contributions through research that evaluates intervention efficacy and meaningful outcomes. Copyright © 2016 John Wiley & Sons, Ltd.

Using the Evaluation of Social Interaction (ESI) with men in a low secure forensic unit

Statement of context

This practice analysis explored the utility of the Evaluation of Social Interaction (ESI) in a 12-bedded male in-patient low secure forensic unit in England. The ESI is a standardised observational assessment of the person engaging in two social exchanges in naturalistic settings with real social partners.

Critical reflection on practice

The ESI helped identify specific social interaction skills that supported and skills that limited competent quality of social interaction. This enabled the men to better understand why they had social interaction problems, thus improve their motivation to engage in planning their own treatment and resulted in positive re-enforcement during the intervention.

Implications for practice

The ESI is suitable to use in forensic and mental health settings. Unexpected outcomes included a more productive team, a more settled atmosphere and reduced levels of frustration for both staff and clients.

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.

An integrative review of social and occupational factors influencing health and wellbeing

Therapeutic approaches to health and wellbeing have traditionally assumed that meaningful activity or occupation contributes to health and quality of life. Within social psychology, everyday activities and practices that fill our lives are believed to be shaped by structural and systemic factors and in turn these practices can form the basis of social identities. In occupational therapy these everyday activities are called occupations. Occupations can be understood as a contextually bound synthesis of meaningful doing, being, belonging and becoming that influence health and wellbeing. We contend that an integrative review of occupational therapy and social psychology literature will enhance our ability to understand the relationship between social structures, identity and dimensions of occupation by elucidating how they inform one another, and how taken together they augment our understanding of health and wellbeing This review incorporates theoretical and empirical works purposively sampled from databases within EBSCO including CINAHL, psychINFO, psychArticles, and Web of Science. Search terms included: occupation, therapy, social psychology, occupational science, health, wellbeing, identity, structures and combinations of these terms. In presenting this review, we argue that doing, being and belonging may act as an important link to widely acknowledged relationships between social factors and health and wellbeing, and that interventions targeting individual change may be problematic.

Looking beyond the illness: forensic service users' perceptions of rehabilitation

The aim of this qualitative study was to explore perspectives on rehabilitation of those detained in a New Zealand forensic hospital setting. Twenty forensic service users participated in individual interviews, which were audio-taped, transcribed verbatim, and subjected to thematic analysis. The analysis identified seven themes that were broadly categorized into those that concerned the rehabilitation context (external) and those that more directly reflected the forensic service user's personal experience (internal). External themes highlighted a person-centered approach, the nature of relationships with staff, consistency of care, and awareness of the rehabilitation pathway. Internal themes related to forensic service users' self-evaluations, agency, and coping strategies. These findings are discussed within the broader context in which rehabilitation took place.

A scoping review of time-use research in occupational therapy and occupational science

BACKGROUND

Time use is a defining interest within occupational therapy and occupational science. This is evident through the range of contributions to the disciplinary knowledge base. Indeed it has been suggested that time-use methods are amongst the most established research techniques used to explore aspects of human occupation. However, the extent and nature of such activity in occupational therapy and occupational science has not been examined to date.

AIM

This study sought to map the extent and nature of time-use research in occupational therapy and occupational science journals and the extent to which studies explored the relationship between time-use and health.

METHOD

A scoping review method was used.

RESULTS

Sixty-one studies were included. Scandinavian countries contributed the largest number of studies (n = 16, 26%). While time-use diaries were used most frequently (n = 30, 49%) occupational therapists and occupational scientists have developed a range of data-collection instruments. Forty-nine studies (80%) focused on time-use in clinical or defined population sub-groups. Ten studies (16%) included an empirical examination of the relationship between time-use and health.

CONCLUSION

Future research should examine time-use and health amongst well populations across the lifespan and in different parts of the world.

An appraisal of service users' structured activity requirements in an Irish forensic setting

Participating in purposeful and structured daily activities is an important factor contributing to the health and well-being of forensic service users. A survey was carried out in an Irish forensic mental health setting to identify whether service users meet the standard of 25-h weekly activities, a standard set by the Quality Network for Forensic Mental Health Services, London. The findings indicate that 57 (61%) out of 93 service users fully meet the criteria. Furthermore, service users within the medium- and low-security environments appear to be engaging to an increased number of structured activities in comparison to those in acute units.

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.

Rehabilitation between institutional and non-institutional forensic psychiatric care: important influences on the transition process

All patients cared for in forensic psychiatric care (FPC) have some kind of psychiatric disorder and most of them have committed one or more criminal acts. One part of the patient's rehabilitation is the transition from institutional to non-institutional FPC, but a number of patients do not succeed. The aim of this study was to elucidate different caregivers' experiences of aspects that influence the patients' ability to manage this rehabilitation. A qualitative approach was chosen. Data were collected by interviews in two focus groups, each group comprising of six caregivers representing both institutional and non-institutional FPC. The transcribed interviews were analysed using a qualitative content analysis. Important aspects influencing the patients' transition described were a well-planned care plan, together with a suitable non-institutional dwelling and a tailored occupation. Other important areas were having a well-functioning and trusting social network and a good relationship with a contact person/advocate. A major barrier to a successful transition was whether the patients managed their own finances or not. It was stated that it is important that the patients participate in the care and that different authorities create individual conditions and flexible solutions. All of these factors are important to focus on when caring for patients during their stay in the institutional FPC.

The Use of the Wii Fit in Forensic Mental Health: Exercise for People at Risk of Obesity

Introduction:

Side effects of psychotropic medication often lead to rapid weight gain, having detrimental effects on forensic mental health patients' health, wellbeing, occupational performance and quality of life. Virtual reality technology could provide novel environments and motivating forums for exercise, which are otherwise unavailable to patients in such secure settings. This exploratory study aimed to evaluate the use of the Nintendo Wii Fit in changing engagement in physical activity for patients at risk of obesity at a secure hospital.

Method:

Two participants used a Wii Fit for 8 weeks in individual or group sessions. A mixed methods approach was taken, because participants' use of the Wii Fit was compared with their attitudes towards it (reported during interviews) and their daily physical activity levels (measured using an accelerometer). Researcher field notes were also used to gather contextual data.

Findings:

Participants played Wii Fit up to four times a week in sessions ranging from 7 to 127 minutes. When using the Wii Fit, participants increased their overall time spent actively moving their bodies in physical activity, as measured by the accelerometer. Using the Wii Fit also changed participants' attitudes towards exercise as they realised that it could be ‘fun’ and ‘challenging’, especially if staff members also participated.

Conclusion:

The Wii Fit encouraged patients to attempt physical activities and to learn about their bodily response to exercise. It provided a meaningful occupational intervention in a secure setting and demonstrated a potential use of the technology in mental health settings.

Occupation and meaning in the lives of women with chronic pain

The aim of this study was to examine how women experience occupations as they live with chronic pain and more specifically to gain detailed knowledge regarding the meaning of important occupations in their life. The article is based on an analysis of 17 narratives based on an Occupational Performance History Interview. Participants were interviewed as part of their occupational therapy assessment at Orton Rehabilitation. The narratives were analysed in order to identify the experiences of doing occupations in everyday life. When interpreting their problems in and solution for doing occupations women in this study used four basic metaphors: (1) moving forward, (2) slowing down, (3) fighting and (4) standing still. The tone of the narratives varied from hopeful to hopeless and from fearful to frustrated. Each of these four types of narratives differed in: (a) the tone of the narrative, (b) the meaning ascribed to occupation, (c) how others are viewed in relation to one's doing, and (d) how the future is envisioned. The experience of occupation in the lives of women with chronic pain is heterogeneous and depends on the underlying meaning of the narrative used to experience and interpret occupational life.