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

Exploring the use of body worn cameras in acute mental health wards: a mixed-method evaluation of a pilot intervention

BACKGROUND

Body worn cameras (BWC) are mobile audio and video capture devices that can be secured to clothing allowing the wearer to record some of what they see and hear. This technology is being introduced in a range of healthcare settings as part of larger violence reduction strategies aimed at reducing incidents of aggression and violence on inpatient wards, however limited evidence exists to understand if this technology achieves such goals.

AIM

This study aimed to evaluate the implementation of BWCs on two inpatient mental health wards, including the impact on incidents, the acceptability to staff and patients, the sustainability of the resource use and ability to manage the use of BWCs on these wards.

METHODS

The study used a mixed-methods design comparing quantitative measures including ward activity and routinely collected incident data at three time-points before during and after the pilot implementation of BWCs on one acute ward and one psychiatric intensive care unit, alongside pre and post pilot qualitative interviews with patients and staff, analysed using a framework based on the Consolidated Framework for Implementation Research.

RESULTS

Results showed no clear relationship between the use of BWCs and rates or severity of incidents on either ward, with limited impact of using BWCs on levels of incidents. Qualitative findings noted mixed perceptions about the use of BWCs and highlighted the complexity of implementing such technology as a violence reduction method within a busy healthcare setting Furthermore, the qualitative data collected during this pilot period highlighted the potential systemic and contextual factors such as low staffing that may impact on the incident data presented.

CONCLUSION

This study sheds light on the complexities of using such BWCs as a tool for 'maximising safety' on mental health settings. The findings suggest that BWCs have a limited impact on levels of incidents on wards, something that is likely to be largely influenced by the process of implementation as well as a range of contextual factors. As a result, it is likely that while BWCs may see successes in one hospital site this is not guaranteed for another site as such factors will have a considerable impact on efficacy, acceptability, and feasibility.

Intervening factors between risk of violence and aggressive behaviours among forensic inpatients: a scoping review

BACKGROUND

Risk of violence is closely associated with aggression propensity. However, there is a lack of research to explain the mechanisms behind this association, especially among the patients of forensic secure facilities. This review aimed to identify and synthesize the available literature concerning the intervening factors (mediating or moderating factors) in the relationship between the risk of violence and aggressive behavior in forensic secure facilities.

METHODS

Two electronic academic databases were searched: Scopus and Web of Science (WoS) using specific keywords as search terms derived from the PCC framework with no specific time limit. The search strategy was developed based on the JBI Manual for Evidence Synthesis and utilised the PRISMA-ScR guidelines. Data on the risk of violence, intervening factors, and aggressive behavior were extracted from the included studies. Further analysis was performed whereby similar data were grouped and synthesised together.

RESULTS

The initial search produced 342 studies. However, only nine studies fulfilled the inclusion criteria. The nine studies included 1,068 adult forensic inpatients from various psychiatric hospitals. Only mediation studies reported significant mechanisms of influence between the risk of violence and aggressive behavior. It is postulated that the human agency factor may be the underlying factor that influences a person's functioning and the subsequent series of events between the risk of violence and aggression.

CONCLUSIONS

In light of the paucity of evidence in this area, a generalised conclusion cannot be established. More studies are warranted to address the gaps before conclusive recommendations can be proposed to the relevant stakeholders.

Medical and surgical nurses' experiences of modifying and implementing contextually suitable Safewards interventions into medical and surgical hospital wards

AIM

To explore general nurses' experiences of modifying and implementing contextually suitable Safewards interventions into medical and surgical hospital wards.

DESIGN

Qualitative action research was used working with nurses as co-researchers.

METHODS

Pre-implementation focus groups were conducted in April 2022 to understand and explore the current strategies nurses utilized to avert, respond to or decrease violence. Following this, two Safewards interventions were modified by the nurses on the wards. Post-implementation focus groups were conducted in October 2022, to explore the nurses' experience of implementing Safewards interventions and the effect on their nursing practice. Data were analysed using Braun and Clarke's framework for thematic analysis.

RESULTS

Three themes emerged from the analysis of the pre-implementation focus groups that reflected the type of violence experienced by these nurses and the context within which they occurred: 'the space is hectic'; 'it can feel like a battlefield'; and 'the aftermath'. These themes encompass the nurses' experience of violence from patients and their visitors. Following the implementation of two modified Safewards interventions, the analysis of the focus groups reflected a change in nursing skills to avert or respond to violence: 'Safewards in action'; 'empathy and self-reflection'; and 'moving forward'.

CONCLUSION

Safewards interventions can be successfully modified and used in general hospital wards and influence nursing practice to manage patient and visitor violence.

IMPLICATIONS FOR THE PROFESSION

In the interests of safety, successful interventions to reduce violence towards general hospital nurses should be a priority for managers and healthcare organizations. Averting, mitigating and managing violence can decrease the negative professional and personal effect on nurses and ultimately improve well-being, job satisfaction and retention rates. Furthermore, decreasing violence or aggressive incidents leads to a safer patient experience and decreased number of nursing errors ultimately improving patient experiences and outcomes. Understanding nurses' experiences of violence and working with them to explore and develop contextually relevant solutions increases their capacity to respond to and avert violent incidents. Contextually modified Safewards interventions offer one such solution and potentially has wider implications for healthcare settings beyond the specific wards studied.

IMPACT

This study addressed the implementation of modified Safewards strategies in medical and surgical wards to prevent violence. Three themes emerged from the analysis of the pre-implementation focus groups that reflected the type of violence experienced by these nurses and the context within which they occurred. Following the implementation of two modified Safewards interventions, the post-implementation focus groups reported positive changes to their practices using the modified resources to prevent violence from patients and their visitors. Mental health interventions, such as those used in the Safewards model can be modified and provide a tool kit of interventions that can be used by medical and surgical nurses.

REPORTING METHOD

This paper has adhered to the COREQ guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: This paper outlines and discusses the action research approach undertaken to work with general hospital nurses to modify mental health nurses' Safewards interventions into their clinical practice. This paper provides evidence of the 'real world' application of Safewards interventions by medical and surgical nurses in general hospital wards. This paper presents qualitative findings based on focus group methods to highlight the narratives of general nurses and their experiences of violence.

Development and evaluation of a de-escalation training intervention in adult acute and forensic units: the EDITION systematic review and feasibility trial

Background

Containment (e.g. physical restraint and seclusion) is used frequently in mental health inpatient settings. Containment is associated with serious psychological and physical harms. De-escalation (psychosocial techniques to manage distress without containment) is recommended to manage aggression and other unsafe behaviours, for example self-harm. All National Health Service staff are trained in de-escalation but there is little to no evidence supporting training's effectiveness.

Objectives

Objectives were to: (1) qualitatively investigate de-escalation and identify barriers and facilitators to use across the range of adult acute and forensic mental health inpatient settings; (2) co-produce with relevant stakeholders an intervention to enhance de-escalation across these settings; (3) evaluate the intervention's preliminary effect on rates of conflict (e.g. violence, self-harm) and containment (e.g. seclusion and physical restraint) and understand barriers and facilitators to intervention effects.

Design

Intervention development informed by Experience-based Co-design and uncontrolled pre and post feasibility evaluation. Systematic reviews and qualitative interviews investigated contextual variation in use and effects of de-escalation. Synthesis of this evidence informed co-design of an intervention to enhance de-escalation. An uncontrolled feasibility trial of the intervention followed. Clinical outcome data were collected over 24 weeks including an 8-week pre-intervention phase, an 8-week embedding and an 8-week post-intervention phase.

Setting

Ten inpatient wards (including acute, psychiatric intensive care, low, medium and high secure forensic) in two United Kingdom mental health trusts.

Participants

In-patients, clinical staff, managers, carers/relatives and training staff in the target settings.

Interventions

Enhancing de-escalation techniques in adult acute and forensic units: Development and evaluation of an evidence-based training intervention (EDITION) interventions included de-escalation training, two novel models of reflective practice, post-incident debriefing and feedback on clinical practice, collaborative prescribing and ward rounds, practice changes around admission, shift handovers and the social and physical environment, and sensory modulation and support planning to reduce patient distress.

Main outcome measures

Outcomes measured related to feasibility (recruitment and retention, completion of outcome measures), training outcomes and clinical and safety outcomes. Conflict and containment rates were measured via the Patient-Staff Conflict Checklist. Clinical outcomes were measured using the Attitudes to Containment Measures Questionnaire, Attitudes to Personality Disorder Questionnaire, Violence Prevention Climate Scale, Capabilities, Opportunities, and Motivation Scale, Coercion Experience Scale and Perceived Expressed Emotion in Staff Scale.

Results

Completion rates of the proposed primary outcome were very good at 68% overall (excluding remote data collection), which increased to 76% (excluding remote data collection) in the post-intervention period. Secondary outcomes had high completion rates for both staff and patient respondents. Regression analyses indicated that reductions in conflict and containment were both predicted by study phase (pre, embedding, post intervention). There were no adverse events or serious adverse events related to the intervention.

Conclusions

Intervention and data-collection procedures were feasible, and there was a signal of an effect on the proposed primary outcome.

Limitations

Uncontrolled design and self-selecting sample.

Future work

Definitive trial determining intervention effects.

Trial registration

This trial is registered as ISRCTN12826685 (closed to recruitment).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/101/02) and is published in full in Health Technology Assessment; Vol. 28, No. 3. See the NIHR Funding and Awards website for further award information.

Context

Conflict (a term used to describe a range of potentially unsafe events including violence, self-harm, rule-breaking, medication refusal, illicit drug and alcohol use and absconding) in mental health settings causes serious physical and psychological harm. Containment interventions which are intended to minimise harm from violence (and other conflict behaviours) such as restraint, seclusion and rapid tranquilisation can result in serious injuries to patients and, occasionally, death. Involvement in physical restraint is the most common cause of serious physical injury to National Health Service mental health staff in the United Kingdom. Violence to staff results in substantial costs to the health service in sickness and litigation payments. Containment interventions are also expensive (e.g. physical restraint costs mental health services £6.1 million and enhanced observations £88 million per annum). Despite these harms, recent findings indicate containment interventions such as seclusion and physical restraint continue to be used frequently in mental health settings. Clinical trials have demonstrated that interventions can reduce containment without increasing violence and other conflict behaviours (e.g. verbal aggression, self-harm). Substantial cost-savings result from reducing containment use. De-escalation, as an intervention to manage aggression and potential violence without restrictive practices, is a core intervention. 'De-escalation' is a collective term for a range of psychosocial techniques designed to reduce distress and anger without the need to use 'containment' interventions (measures to prevent harm through restricting a person's ability to act independently, such as physical restraint and seclusion). Evidence indicates that de-escalation involves ensuring conditions for safe intervention and effective communication are established, clarifying and attempting to resolve the patient's concern, conveyance of respect and empathy and regulating unhelpful emotions such as anxiety and anger. Despite featuring prominently in clinical guidelines and training policy domestically and internationally and being a component of mandatory National Health Service training, there is no evidence-based model on which to base training. A systematic review of de-escalation training effectiveness and acceptability conducted in 2015 concluded: (1) no model of training has demonstrated effectiveness in a sufficiently rigorous evaluation, (2) the theoretical underpinning of evaluated models was often unclear and (3) there has been inadequate investigation of the characteristics of training likely to enhance acceptability and uptake. Despite all National Health Service staff being trained in de-escalation there have been no high-quality trials evaluating the effectiveness and cost-effectiveness of training. Feasibility studies are needed to establish whether it is possible to conduct a definitive trial that can determine the clinical, safety and cost-effectiveness of this intervention.

Moral distress in nurses in developing economies: an integrative literature review

Background

Moral distress has been extensively studied in developed economies; however, not much in terms of studies has been carried out in developing economies.

Objective

To review the literature reporting the experience of moral distress in nurses in health care settings in developing economies.

Design

An integrative literataure review was used.

Method

Cumulative Index of Nursing and Allied Health Literature, Medical Literature Analysis and Retrieval System Online Cochrane and Psych INFO were searched to retrieve titles and abstracts of papers on the experience of moral distress in nurses in developing economies.

Results

Sixteen articles reporting the experience of moral distress in nurses in developing economies published between 1984 and March 2019 were used for the review. Analysis of the findings revealed seven themes, nurses' experience of moral distress, inadequate material and human resources, end-of-life challenges, cultural and religious beliefs as a source of moral distress, perceived inactions of medical and nursing staff, impact of moral distress on nurses in developing economies and coping strategies.

Conclusion

There is paucity of empirical studies on moral distress in nurses in developing economies. More qualitative studies are needed in various cultural settings to enhance its understanding in nurses working in developing economies.

Developing entrustable professional activities to enhance application of an aggression prevention protocol

AIM

The research aim of this study was to seek feedback from prevention of aggression training experts about the suitability of Entrustable Professional Activities (EPAs) as an assessment tool for an Aggression Prevention Protocol. The protocol was designed to structure intervention to prevent aggression and reduce the use of restrictive practices following risk assessment using a validated instrument (the Dynamic Appraisal of Situational Aggression).

BACKGROUND

Preventing aggression and limiting the use of restrictive practices are key priorities for inpatient mental health services. Assessing clinical activities using a competence framework has limitations, particularly when determining complex interventions. EPAs could provide a suitable method for assessing complex clinical activities like de-escalation and limit setting, which comprise some of the interventions in the Aggression Prevention Protocol. EPAs are new to forensic mental health nursing; therefore, feedback was sought regarding the utility of EPAs to assess aggression prevention interventions.

METHODS

Data were collected via focus groups including 11 aggression prevention experts from Australia and New Zealand. A thematic analysis, comparative analysis and a Strength, Weakness, Opportunity and Threats analysis was conducted.

RESULTS

Three themes were interpreted from the data: 1) Frameworks such as the APP are needed to work towards elimination of restrictive practices; 2) APP-EPAs afford an opportunity to set the standard for practice; and 3) 'who watches the watchers', were identified by the experts as well as areas to enhance EPAs prior to introduction into practice.

CONCLUSIONS

EPAs address a practice-gap and offer a framework to assist movement towards elimination of restrictive practices, while prompting best-practice, self-reflection and practice improvement guidance.

Mental Healthcare workers' experiences in managing psychiatric patients' aggression in Maseru

Background

Aggression and violence in psychiatric clinical facilities are a common case, and mental healthcare workers utilise various management strategies to combat it. It is therefore crucial for mental healthcare workers to acquire skills for the management strategies of aggressive behaviour of psychiatric patients.

Aim

The aim of the study was to describe mental healthcare workers' experiences in the management strategies of aggressive and violent behaviour by psychiatric patients in Maseru district.

Setting

A psychiatric hospital situated to the south in Maseru in the rural countryside and general hospital located in the western lowlands of Lesotho in the village of Morija were used.

Methods

This study adopted a qualitative, exploratory, descriptive and contextual research design. There were two focus group interviews conducted per clinical facility, which consisted of six members in each group. There were four participants for individual interviews from psychiatric clinical facility and three individual interviews from general clinical facility.

Results

Thematic analysis of the data resulted in themes and sub-themes. These were psychological intervention strategy, physical strategy, chemical strategy, empowerment strategy and policy strategy. Participants viewed various management strategies of aggressive and violent behaviour of psychiatric patients they utilise in clinical facilities as effective.

Conclusion

The mental healthcare workers' experiences in managing aggression and violent behaviour of psychiatric patients were expression of psychological, physical, chemical, empowerment and policy strategies.

Contribution

The study will enhance the knowledge, skills and attitudes regarding management strategies that mental healthcare workers can utilise in managing aggressive and violent behaviour of psychiatric patients.

Forensic mental health nurses' experiences of rebuilding the therapeutic relationship after an episode of physical restraint in forensic services in Ireland: A qualitative study

Few studies have explored how forensic mental health nurses can rebuild the therapeutic relationship following an episode of physical restraint in the acute forensic setting. In this study, we aimed to redress this gap in the literature by exploring with forensic mental health nurses the factors that enable or hinder the rebuilding of the therapeutic relationship following an episode of physical restraint. A qualitative study design was used to capture participants' experiences, views and perceptions of the therapeutic relationship following an episode of physical restraint in the acute forensic setting. Data were collected through individual interviews with forensic mental health nurses (n = 10) working in an acute forensic setting. Interviews were audio recorded, and transcribed verbatim and accounts were analysed using thematic analysis. Four themes were identified: 'Building a Recovery Focused Therapeutic Relationship'; 'Authoritarian Role'; 'Inevitable Imbalance'; 'Rebuilding the Therapeutic Relationship'; plus two sub-themes 'Facilitators to rebuilding' and 'Barriers to rebuilding'. Findings suggest that an inevitable imbalance exists in building a recovery-focused therapeutic relationship and at times, is hindered by the authoritarian role of the forensic mental health nurse. Recommendations for changes in clinical practice and in upcoming policies should incorporate a dedicated debrief room and protected time for staff to debrief effectively following restraint. Routine post-restraint-focused clinical supervision would also be beneficial to mental health nursing staff.

Is mental health staff training in de-escalation techniques effective in reducing violent incidents in forensic psychiatric settings? - A systematic review of the literature

BACKGROUND

Inpatient violence is a relevant issue in forensic psychiatric settings. Relevant guidelines recommend that restrictive measures are to be used exclusively if de-escalation and other preventive strategies have failed and there is a risk of harm to patients or staff if no action is taken. However, restrictive measures are untherapeutic and can be harmful. In order to enable staff to intervene before inpatient violence or other serious incidents occur and thus to avoid restrictive measures, mental health staff training programs including de-escalation components are being adopted in general as well as forensic mental health settings. There is growing evidence for the efficacy of mental health staff training in de-escalation techniques in the field of general psychiatry. However, there are no reviews evaluating the effectiveness of these interventions in reducing violent incidents in forensic psychiatric settings. Here we present the first literature review on the effectiveness staff training in de-escalation techniques in the field of forensic psychiatry.

METHOD

We searched relevant databases for original research on the effectiveness of reducing violence in forensic psychiatric settings. Studies were included if they investigated staff training programs with de-escalation techniques in forensic mental health settings.

RESULTS

A total of 5 relevant studies were identified. None of the studies was a randomized controlled trial. Four studies were before and after comparisons without control group. A one group post-test-only design was used in one study. Methodological quality was low. The maximum sample size was 112 participants. Results indicated no relevant impact of mental health staff training in de-escalation techniques on the rate of violent incidents in forensic psychiatric wards. However, staff seemed to feel safer following the training. Results have to be interpreted cautiously due to several methodological and content-related limitations.

DISCUSSION

Evidence for the effectiveness of staff training in de-escalation techniques on reducing verbal and physical aggression in forensic settings remains very limited. The existing definitions of terms like de-escalation, de-escalation training and de-escalation techniques in the healthcare context appear rather vague. Although some positive changes are reported across a variety of outcome measures it remains unclear to what extent staff training in de-esclation techniques contributes to a reduction in aggressive incidents and restrictive measures in forensic psychiatry. The clinical implications of this review are therefore limited. Yet, an important implication for future research is that a more comprehensive approach might prove worthwhile. Conducting a further review integrating a wide range of complex interventions aimed at the reduction of inpatient violence rather than focusing on de-escalation only, might be a worthwhile approach.

Exploring Bias in Restraint Use: Four Strategies to Mitigate Bias in Care of the Agitated Patient in the Emergency Department

Agitation is a routine and increasingly common presentation to the emergency department (ED). In the wake of a national examination into racism and police use of force, this article aims to extend that reflection into emergency medicine in the management of patients presenting with acute agitation. Through an overview of ethicolegal considerations in restraint use and current literature on implicit bias in medicine, this article provides a discussion on how bias may impact care of the agitated patient. Concrete strategies are offered at an individual, institutional, and health system level to help mitigate bias and improve care. Reprinted from Acad Emerg Med 2021; 28:1061-1066, with permission from John Wiley & Sons. Copyright © 2021.

Changes in dietary patterns among Bangladeshi adult population during the COVID-19 pandemic: A web-based cross-sectional study

Background

The home confinement induced by the COVID-19 pandemic affects individuals’ mental wellbeing and increases unhealthy behaviors, such as minimum to no physical activity, overeating, and substance use.

Objective

This study aimed to assess the changes in dietary patterns among the Bangladeshi adult population during the COVID-19 pandemic and identify their determinants.

Methods

This web-based cross-sectional survey was carried out from 10–17 December 2020 using an e-questionnaire based on Google Forms. A semi-structured e-questionnaire was forwarded to the participants – Bangladesh citizens aged above 18 years – through social media platforms and email in order to collect information about socio-demographic issues and multidimensional dietary patterns. From the initial 817 responses gathered through snowball sampling, 748 responses were retained. Bivariate and multivariate analyses were executed.

Results

The findings suggest that 50% of the participants reported a reduction in weight and physical activities, while approximately 52% experienced increased sleep time. One in three participants (31.4%) experienced a decrease in food buying capacity. The findings further indicate that women were 1.65 times more likely to reduce food consumption than men. Meanwhile, employed people were about 34% less likely to increase food consumption than their unemployed counterparts. People who were getting more than 6 h of sleep per day were nearly 61% less likely to increase food consumption than people who slept for less than 6 h per day. People struggling to buy food items were 2.31 times more likely to reduce food intake than people with no such limitations.

Conclusions

The study shows that COVID-19 has substantially affected Bangladeshi people’s common food consumption patterns. Being confined within the household, primarily due to countrywide lockdowns and ‘general holidays’, has affected both the dietary patterns and the financial wellbeing of people. Therefore, the concerned authorities should promote effective nutrition education and healthy dietary behaviors; meanwhile, financial support or incentives for people in need are also strongly advocated.

Perceptions of patient aggression in psychiatric hospitals: a qualitative study using focus groups with nurses, patients, and informal caregivers

BACKGROUND

Aggression in psychiatric hospitals has been of interest to researchers. Information on how different stakeholders perceive patient aggression remains equivocal. Even less is known about possible similarities or differences in stakeholders' perceptions of how aggressive behaviour is understood, managed and prevented in psychiatric hospitals. We aimed to explore multiple viewpoints on patient aggression, its possible causes and outcomes, and development ideas for prevention and management.

METHODS

A qualitative design was adopted. The data were collected using focus group interviews. A thematic approach was used for interpretation. The data were collected on 15 adult wards in two inpatient psychiatric settings in Hong Kong. Participants were nurses working on the psychiatric inpatient wards, patients admitted to the wards, and informal caregivers visiting inpatient wards (N = 94).

RESULTS

Commonalities between all groups were found on how patient aggression is perceived, and why it occurs. Patients and especially nurses described how patient aggression occurred with no clear reason or forewarning and how patients were physically controlled or restricted after aggressive events. Only nurses and patients expressed experiencing physical burden, while all groups considered psychological burden to be a consequence of aggression. All groups proposed that helpful attitudes among nurses, better communication, structural changes, and better self-management skills would prevent patient aggression. Risk assessment was proposed only by nurses and patients, while safety measures were proposed by nurses and informal caregivers only. The use of restrictive interventions to manage aggressive events was proposed by all groups.

CONCLUSIONS

Despite the complex diversity of perspectives in different stakeholder groups regarding patient aggression, the findings highlighted that it is possible to achieve some mutual understanding of aggression in psychiatric hospitals and identify areas to be developed. Staffs' attitudes and skills for engagement and communication with patients and informal caregivers should be improved. There is also still room to develop the therapeutic environment and culture toward meaningful activities during the treatment period.

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.

Exploring bias in restraint use: Four strategies to mitigate bias in care of the agitated patient in the emergency department

Agitation is a routine and increasingly common presentation to the emergency department (ED). In the wake of a national examination into racism and police use of force, this article aims to extend that reflection into emergency medicine in the management of patients presenting with acute agitation. Through an overview of ethicolegal considerations in restraint use and current literature on implicit bias in medicine, this article provides a discussion on how bias may impact care of the agitated patient. Concrete strategies are offered at an individual, institutional, and health system level to help mitigate bias and improve care.

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.

An immune-centric investigation of Coronavirus in the women with cancers; A review article

Cancer is one of the growing chronic diseases in the world that kills large numbers of people every year. The disease affects the human immune system. The function of the body's organs under the influence of this disease loses its main function. Studies have shown that people with cancer are at higher risk of dying from Coronavirus. Because of the outbreak, wide clinical spectrum, pathogenesis of infection in Coronavirus, recognition and evaluation of this virus in populations with a risk factor for cancer is important. Many women develop chronic diseases such as cancer throughout their lives. Examining and recognizing Coronavirus in the women with cancer can increase our awareness of the disease. In this article, considering Coronavirus, we discuss the function of the immune system in cancer and corona, the concepts related to the topic, and the known solutions with an emphasis on cancer.