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

The Maintenance Model of Restrictive Practices: A Trauma-Informed, Integrated Model to Explain Repeated Use of Restrictive Practices in Mental Health Care Settings

Nurses are at the forefront of care in mental health services but their role is conflicted; they carry the most responsibility for care and also for restrictive practices. The harmful effects of restrictive practices for mental health patients are well documented, have attracted negative media attention, public concern, and criticism directed specifically at nursing staff. The need to reduce restrictive practices has been highlighted by patients, carer groups, legislators, policy makers, academics, and mental health service providers. Policies and best practice guidelines have resulted, but restrictive practices remain a global problem. This theory paper proposes that inertia is partly due to the absence of a coherent model that explains the initiation and maintenance of restrictive practice in inpatient mental health settings. The conceptual development and synthesis of the model and its practical implications are discussed.

Alexithymia and Forgiveness Levels of Forensic Psychiatric Patients

The current cross-sectional study was performed to examine levels of alexithymia and forgiveness in forensic psychiatric patients. Data were collected between March 2022 and August 2022 at a high-security forensic psychiatric hospital affiliated with a city hospital in Turkey. A personal information form prepared by the researchers, the Toronto Alexithymia Scale, and the Heartland Forgiveness Scale were used to obtain data. Participants comprised 132 forensic psychiatric patients who agreed to participate in the study. A significant negative correlation was found between alexithymia and forgiveness levels of participants (p < 0.01, r = -0.259). In other words, as alexithymia levels increased, participants were found to be less forgiving. In addition, results suggest that forensic psychiatric patients are susceptible to alexithymia and higher levels of forgiveness. Determining forgiveness and alexithymia levels of forensic psychiatric patients will contribute to the structuring of care to be offered to these patients. [Journal of Psychosocial Nursing and Mental Health Services, 62(6), 27-35.].

Reducing use of seclusion on a male medium secure forensic ward

The reduction of restrictive practices is a priority for mental health inpatient services. Often such practices are considered to increase patients' feelings of anger, loneliness, hopelessness and vulnerability. Moreover, such approaches are counterintuitive to both recovery-orientated and trauma-informed practice.Our project, based in a male 15-bed secure forensic ward, aimed to reduce the duration (outcome measure) and frequency (balancing measure) of the use of seclusion by 10% over 6 months. Following the analysis of our local data systems and feedback from both patients and staff, we identified the high levels of use of seclusion, and reluctance to terminate it. These included a lack of awareness of the effective and appropriate use of such a facility, a hesitancy to use de-escalation techniques and an over-reliance on multidisciplinary team and consultant decision making.We subsequently designed and implemented three tests of change which reviewed seclusion processes, enhanced de-escalation skills and improved decision making. Our tests of change were applied over a 6-month period. During this period, we surpassed our original target of a reduction of frequency and duration by 10% and achieved a 33% reduction overall. Patients reported feeling safer on the ward, and the team reported improvements in relationships with patients.Our project highlights the importance of relational security within the secure setting and provides a template for other wards wishing to reduce the frequency and duration of seclusions.

The Judiciarization of People Living with Mental Illness: A Grounded Theory on the Perceptions of Persons Involuntary Admitted in Psychiatric Institution

The involvement of people living with mental illness in the judicial process, whether in civil or criminal justice system, is a growing phenomenon that can be defined as judiciarization. Such over-representation of people with mental illness in the justice system is related to several issues, including stigma, experienced coercion, loss of autonomy and social isolation. To explore this understudied phenomenon in nursing research, we conducted a study to better understand how judiciarization affects people living with mental illness. The specific objectives were: 1) to understand how insertion into a judicial process affects people living with mental illness; 2) to explore the perception of these people and their lived experience within the judicial trajectory. For the methodology, grounded theory was used as a research model. The theoretical framework of the total institution, proposed by Erwin Goffman, was used conceptually. Participants were recruited from a university-affiliated hospital. Hospitalized persons who had been involved in the justice system were interviewed (n = 10). Three conceptualizing categories were identified through the analyzed data: 1) Diversity of Judicial Trajectories; 2) Involuntary Psychiatric Admission Process; 3) Judiciarization Lived as a Complex Experience. The results of this research can be used to better inform nurses, clinicians, and policy makers about the impacts of the judiciarization of mental illness, and how clinical practices can be better adapted to populations with very complex health needs.

Family orientation in forensic psychiatric care: An uncertain foundation of distrust

The patients in forensic psychiatric care (FPC) are affected by their illness and the care they receive, but their families are also affected. The family-systems nursing theory has the mutual influence of the family as constituting a core starting point for the health of both the individual and the family and focuses on helping families cope with their situation. The aim of the study was to describe healthcare professionals' experiences of their family-oriented work within FPC. The findings are presented in three themes: A longed-for reciprocity within and with the family, Maintaining a problem-oriented and individual-based tradition, and Caring built on a foundation of distrust. Family-oriented work among healthcare professionals in FPC can only be realized through a pervasive shift in perspective from a predominantly problem-oriented patient focus towards a focus on interactional interplay and patterns. This is based on the belief that there are potential resources for patients and families to change in a healthy way. An educational intervention is suggested as a core starting point for developing a family-oriented practice for healthcare professionals in forensic psychiatric settings.

Being Able to Be Yourself: The Lived Experience of Female Patients in Forensic Psychiatric Care

People in Sweden who commit at least one crime and suffer from a severe mental disorder can be sentenced to forensic psychiatric care. The aim of this study was to describe and gain a greater understanding of the female patients' experiences of their life situation while being cared for in forensic psychiatric care. Interviews with 15 women were conducted and analyzed with a phenomenological hermeneutical method. The results showed the care and the care environment to be dualistic. The women had to be aware that a close neighbor could also be an enemy. They received care in an environment that was unknown, frightening but at the same time a place where they felt secure, and which was predictable.

Patients' Experiences of Participation in High-Security, Forensic Psychiatric Care

The role of patient participation in forensic psychiatric care is unclear, but has been emphasised as important in recent research. This study aims to describe patients' lived experiences of participation in high-security, forensic psychiatric settings. Sixteen patient interviews were performed in this phenomenological study and analysed with a Reflective Lifeworld Research approach (RLR). Results show that participation must be understood in relation to its opposite construct, non-participation. Participation can thus be explained as situations where non-participation is less visible. Actions to develop the training of patient-staff interactions for forensic psychiatric staff to promote patient participation are called for.

"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.

Factors Affecting Treatment Regress and Progress in Forensic Psychiatry: A Thematic Analysis

International variability and shifting trends in forensic psychiatry lead to gaps in national service provision and needs for service development. This study explores these needs through the subjective narratives of those involved in Finnish forensic services, either as forensic psychiatric patients, their parents, or service providers. Data was gathered by means of thematic interview and subjected to thematic analysis. Three main themes emerged: (1) pre-treatment challenges, (2) institutional/treatment-related concerns about therapeutic security and (3) adapting and recovery. The research highlights the need to develop forensic psychiatric services at three levels. First, it calls for increased risk awareness and risk assessment skills at the general psychiatric level. Second, it emphasizes the need for increased therapeutic engagement throughout the rehabilitative process. Third, it calls for structured and meaningful post-discharge aftercare. At all three levels, gradated security-aware standardization and patient triage in forensic services would help to develop and maintain an intact care pathway. This would decrease offending, marginalization, and suffering. Only then can we begin to meet the requirements of the WHO European Mental Health Action Plan. These findings can contribute to the development of international, standardized treatment models for clinical forensic psychiatric practices.

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.

The effect of acceptance and commitment therapy orientated anger management training on anger ruminations and impulsivity levels in forensic psychiatric patients: A randomized controlled trial

PURPOSE

This study aimed at determining the effect of acceptance and commitment therapy (ACT) orientated anger management training on levels of anger rumination and impulsivity in people receiving forensic mental healthcare.

DESIGN AND METHODS

This was a randomized controlled study. The research data were collected between July 2018 and February 2019. The personal information form, Anger Rumination Scale, and Barratt Impulsiveness Scale were used for data collection.

FINDINGS

Total scores on the Barratt Impulsiveness and Anger Rumination Scales were significantly lower in the experimental group than in the control group (p < 0.001).

PRACTICE IMPLICATIONS

This study adds to existing evidence on the provision of anger management training, offering an evidence-based solution along with necessary knowledge and skills for use by forensic psychiatric nurses.

Patients' Expressed Nursing Care Needs in a Forensic Psychiatric Setting

The aim of this study was to describe the patients' nursing care needs in a forensic psychiatric setting in line with the NANDA-I classification. Ten patients sentenced to forensic psychiatric care were interviewed. Data were analyzed by means of directed content analysis with a deductive approach, where we used "served time" as a factor in the analysis, thus creating three categories: newly arrived patients with a length of stay of only a couple of years, patients with a length of stay of around 5 years, and patients with a length of stay of more than 5 years. Thirteen NANDA-I diagnoses were identified during the analyses, distributed on seven different domains. When distributing the given NANDA-I diagnoses according to the created categories, an explanatory pattern emerged, and three themes became apparent: denial, insight, and listlessness. Considering the differences in views, the patients' own recognition of what is a problem, a potential, or a risk could improve a "working relation" and, eventually, a recovery. NANDA-I nursing diagnoses may improve individualized and person-centered care as NANDA-I makes care continuously consistent over time.

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.

Strength- and recovery-based approaches in forensic mental health in late modernity: Increasingly incorporating a human rights angle?

Forensic mental health care is situated across both criminal justice and healthcare systems and is subject to political, cultural, legal and economic shifts in these contexts. The implementation of strength- and recovery-based models of care should be understood in light of these social and structural processes. Drawing on novel empirical fieldwork and the extant literature, we argue that full realisation of strength- and recovery-based principles is at odds with aspects of late modern social control. Not wholly compatible, we highlight how concepts of empowerment, autonomy, identity and connectedness can unhelpfully rub-up against the concepts of punitiveness, otherness and risk management. Conceptually this is problematic, but in frontline forensic psychiatry settings, this has real lived-experience detrimental effects for patients – as our data demonstrate. To address this, a human rights approach might be fruitful. Grounding arguments for strength- and recovery-based principles in the heuristic framework of human rights can offer a set of common values to stimulate reform in forensic mental healthcare. The right to respect for private and family life, home and correspondence under Article 8 of the European Convention on Human Rights and Fundamental Freedoms offers a particularly promising, robust and well-defined framework for these future changes – as we outline.

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

OBJECTIVES

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

DESIGN

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

DATA SOURCES

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

REVIEW METHODS

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

FINDINGS

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

CONCLUSION

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

The Totalising Nature of Secure and Forensic Mental Health Services in England and Wales

This evidence-based opinion piece explores the totalising risk averse nature of secure and forensic mental health services and associated iatrogenic harms in England and Wales. Drawing on the research literature I consider the various influences, both external and internal which impact on the provision of such services and how both the therapeutic alliance and recovery potential for patients may be improved. Especial attention is paid to the deployment of restrictive practise, practitioner attitudes, the potential for non-thinking, and how these may impact on decision-making and the care and treatment of mentally disordered offenders.

The path of compassion in forensic psychiatry

We aimed to deepen our understanding of the concept of compassion in caring for patients with mental illness in forensic psychiatric inpatient care settings. Qualitative analysis was used to illuminate themes from interviews conducted with 13 nurses in a prior study. The audiotaped interviews, which had been transcribed verbatim, were analyzed following a hermeneutic approach. Results revealed the main theme of "being compassionate in forensic psychiatry is an emotional journey" and three themes. Overall, compassion was seen as a changeable asset, but also an obstacle when absent; sensitivity to one's own vulnerability is necessary to overcome that obstacle.

The meaning of significant encounters in forensic care

BACKGROUND

Research in forensic psychiatric care focusing on person-oriented care is ambiguous about matters of quality. The encounters between a healthcare professional (HCP) and patient could influence how connections and relations emerge between the caregiver and the patient.

OBJECTIVES

To better understand caring aspects, this study explores significant encounters in forensic psychiatric care from the perspective of HCPs.

METHOD

This study is based on 34 written narratives from HCPs from two forensic psychiatric hospitals in Sweden. The narratives concern significant encounters with a patient. These narratives were analysed according to methodologies developed by phenomenological and reflective lifeworld research.

FINDINGS

The essence of a significant encounter is a temporal extended phenomenon that both precedes as well as is a consequence of the actual encounter as it occurs. The encounter is unforeseeable and being open to an encounter also means to be vulnerable as it is not predetermined how someone will respond. The significant encounter is an act of sharing, and HCPs may come to understand more about their patients as well as about themselves. Moreover, these encounters seem to create repercussions and hope for the future care.

CONCLUSIONS

The everyday activities of forensic psychiatric care are not trivial activities. Rather, they are important aspects of health care as these everyday encounters can deepen the relationship between the HCPs and their patients and help both the HCPs and their patients develop a sense of hope for the future.

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.

'I know what I need to recover': Patients' experiences and perceptions of forensic psychiatric inpatient care

Patients find forensic psychiatric care inadequate in that they are not treated as individuals and not involved in their own care. The purpose of this study was to describe patients' experiences and perceptions of forensic psychiatric inpatient care. Semi-structured interviews were conducted with 11 inpatients. A qualitative content analysis resulted in a recurring theme, 'I know what I need to recover', and three main categories: 'A need for meaning in a meagre existence', 'A need to be a person in an impersonal context', and 'A need for empowerment in a restricted life'. Participants experienced and perceived forensic care as predominantly monotonous, predetermined, and not adapted to them as individuals, forcing them to fight and adapt to get through it and not lose themselves. Perceived needs were largely ignored or opposed by staff due to the content and structure of care. Findings suggest a need for reflective practices and patient involvement in order to develop and maintain a person-centred and recovery-oriented nursing practice. The study adds to previous research showing the importance of patients in forensic psychiatric inpatient care being listened to and involved in their care. The study is reported in accordance with the COREQ guidelines.

An Interview Study of Professional Carers' Experiences of Supporting Patient Participation in a Maximum Security Forensic Psychiatric Setting

Patient participation in forensic psychiatric settings seems to be complex by nature, and previous studies show that patients rate their participation as lower in this context compared to general psychiatric contexts. Studies on caregivers' perspective could provide a clearer picture of the components and possibilities of patient participation in forensic psychiatry. The aim of the study is to describe carers' experiences in supporting patient participation in a maximum security forensic psychiatric care setting. Twelve psychiatric caregivers were interviewed about how they support patients' participation. The result shows that a complexity of patient participation emerges as a difficult act of balancing the paradoxical role of caring for the patient's interests and development, while simultaneously representing and adhering to the rules and regulations of the system in which one is employed. In conclusion, it is suggested that participation is comprehended as an umbrella term and that focus is directed to conceptualising what caregivers can do in order to create positive patient-carer relationships, as well as what constitutes such a relationship.

Clinicians' perspectives of forensic rehabilitation

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

Transitory masculinities in the context of being sick with prostate cancer

Objective:

to interpret the meanings attributed by men with prostate cancer to the experience regarding their bodies and masculinities during illness.

Method:

ethnographic research with 17 men, guided by the narrative method and theoretical framework of medical anthropology and masculinities. The information was collected through recorded interviews, direct observation and field diary records, which were analyzed by inductive thematic analysis.

Results:

men undergo body and identity transformations when they get sick with prostate cancer, transiting through multiple masculinities, resigning their actions, and occupying subordinate positions in relation to other healthy bodies, which are marginalized in their social relationships and allied with regard to establishing their affective relationships.

Conclusion:

this evidence enhances and deepens the knowledge disclosed in the literature and contributes to the strengthening of nursing care actions when dealing with the sick.

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.

'We try' - how nurses work with patient participation in forensic psychiatric care

RATIONALE

Patients in secure forensic psychiatric care have reduced autonomy because of the constraints imposed on them by compulsion laws. Thus, it is vital that nurses enable patient participation whenever possible. Patient participation, and it's clinical use in forensic psychiatric care, is an understudied field.

AIM

To describe nurses' experiences of their work with patient participation in forensic psychiatric care.

METHODS

Managers at different secure forensic psychiatric institutions in the south of Sweden approved the study, and oral consent was retrieved from informants. Interviews guided by a semi-structured interview guide were conducted with nine nurses from five different forensic psychiatric institutions and analysed with content analysis.

FINDINGS

Nurses describe diverse understandings and abilities in an inflexible setting. This indicates that what participation is, and how to achieve it, is not the same for nurses as for patients. Moreover, patients have different abilities to participate, and the secure setting in itself is perceived as hindering participatory work. Still, participation is described as a crucial part of work that requires a caring relationship. Furthermore, nurses pronounce potentially excluding attitudes and strategies that may obstruct patient participation for all, and at the same time, they have a belief that improvement is possible.

CONCLUSION

Compulsory forensic psychiatric care is a complex care context that requires constant efforts from nurses to balance patients' rights and needs with mandatory care. The very nature of this caring context appears to be a major obstacle when promoting patient participation. Nevertheless, nurses express that they do aim for patient participation, 'they try'. From a patient's perspective, trying is not sufficient and a need for improvement is evident. The results can be of clinical interest in similar secure forensic psychiatric nursing settings, and a point of departure in future development of care striving for increased patient participation for all.

Patients' experiences of assessment and detention under mental health legislation: systematic review and qualitative meta-synthesis

BACKGROUND

Understanding patient experiences of detention under mental health legislation is crucial to efforts to reform policy and practice.

AIMS

To synthesise qualitative evidence on patients' experiences of assessment and detention under mental health legislation.

METHOD

Five bibliographic databases were searched, supplemented by reference list screening and citation tracking. Studies were included if they reported on patient experiences of assessment or detention under mental health legislation; reported on patients aged 18 years or older; collected data using qualitative methods; and were reported in peer-reviewed journals. Findings were analysed and synthesised using thematic synthesis.

RESULTS

The review included 56 papers. Themes were generally consistent across studies and related to information and involvement in care, the environment and relationships with staff, as well as the impact of detention on feelings of self-worth and emotional state. The emotional impact of detention and views of its appropriateness varied, but a frequent theme was fear and distress during detention, including in relation to the use of force and restraint. Where staff were perceived as striving to form caring and collaborative relationships with patients despite the coercive nature of treatment, and when clear information was delivered, the negative impact of involuntary care seemed to be reduced.

CONCLUSIONS

Findings suggest that involuntary in-patient care is often frightening and distressing, but certain factors were identified that can help reduce negative experiences. Coproduction models may be fruitful in developing new ways of working on in-patient wards that provide more voice to patients and staff, and physical and social environments that are more conducive to recovery.

DECLARATION OF INTEREST

None.

The meanings of place and space in forensic psychiatric care - A qualitative study reflecting patients' point of view

The outcome of care for patients sentenced to forensic psychiatric care is of importance not only for the patient but also for society, in preventing new crimes. In recent years, a person-centered perspective is influencing the care, recognizing the design of the physical environment as a therapeutic resource. To capture the complexity of patients' experience of the physical environment, a qualitative approach is needed. The aim of this study was to investigate the meanings of the patient room as a place and space in forensic psychiatric in-patient care from the patients' perspective. An explorative qualitative design was chosen, data were collected by photovoice; a combination of photographs, taken by the patients, followed by interviews. Eleven (N = 11) patients were interviewed. The interviews were analysed by a thematic analysis method. Four themes emerged from the data revealing the meanings of the patient room as a place and space: (i) striving towards normality; (ii) being anchored and protected; (iii) being at-home and homeness; and (iv) being in communion and meaningfulness. The findings show that the physical environment has a say in patients' basic needs and a role in maintaining normality. Substandard reveals a lack of respect and dignity towards this patient group. Involving patients in the design process of new facilities can be a way to make progress.

Forensic psychiatric patients' perceptions of situations associated with mechanical restraint: A qualitative interview study

To reduce the use and duration of mechanical restraint in forensic settings and ensure evidence-based patient care, we need more knowledge about patients' subjective experiences and perceptions. The aim was to investigate forensic psychiatric patients' perceptions of situations associated with the use of mechanical restraint and what they perceive as factors impacting the use and duration of mechanical restraint. Twenty participants were interviewed. Four themes were identified through a thematic analysis: 'overt protest reactions', 'silent protest reactions', 'illness-related behaviour', and 'genuinely calm', which together characterize patients' perceptions of their ways of acting and reacting during mechanical restraint episodes. These themes are linked together in two patterns in the process of mechanical restraint: 'pattern of protest' and 'pattern of illness'. Further research is needed to illuminate the associations between patients' perceptions of being subjected to mechanical restraint and ways of acting and reacting through the process of mechanical restraint.

Patient and staff experiences of quality in Swedish forensic psychiatric care: a repeated cross-sectional survey with yearly sampling at two clinics

Background

Systematic efforts to improve the quality, safety and value of health care have increased over the last decades. Even so, it is hard to choose priorities and to know when the desired results are reached, especially in forensic psychiatric care where there can be a discrepancy between patient and staff expectations of what good quality of care is and how it should be reached. The aim of the present study was to describe and compare patient and staff experiences of quality of care in two forensic psychiatric clinics over a period of 4 years.

Methods

A quantitative design was used and yearly between 2011 and 2014, a total of 105 questionnaires were answered by patients and 598 by staff.

Results

The sample consisted of four different groups; patient and staff in Clinic A and Clinic B respectively. The repeated measurements showed that quality of care, as described by the patients, varied over time, with significant changes over the 4 years. The staff evaluations of the quality of care were more stable over time in both clinics compared with the patients. Generally, the staff rated the quality as being better than the patients but these differences tended to decrease when efforts were made to improve the care.

Conclusions

It is important to highlight both what staff and patients perceive as both high and low quality care. With regular measurements and sufficient resources, training, support and leadership, the chances of successful improvement work increase. This knowledge is important in forensic nursing practice, for teaching and for management and decision makers in the constant work of improving forensic psychiatric care.

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

BACKGROUND

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

AIMS

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

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

Experiences of restrictiveness in forensic psychiatric care: Systematic review and concept analysis

Mentally disordered offenders may be sent to secure psychiatric hospitals. These settings can resemble carceral spaces, employing high levels of security restricting resident autonomy, expression and social interaction. However, research exploring the restrictiveness of forensic settings is sparse. A systematic review was therefore undertaken to conceptualize this restrictiveness. Eight databases were searched for papers that address restrictive elements of secure forensic care in a non-cursory way. Fifty sources (empirical articles and policy documents) were included and subject to thematic analysis to identify 1) antecedent conditions to, 2) characteristic attributes, 3) consequences and 4) 'deviant' cases of the developing concept. The restrictiveness of forensic care was experienced across three levels: individual, institutional and systemic. Restrictiveness was subjective and included such disparate elements as limited leave and grounds access, ownership of personal belongings and staff attitudes. The manner and extent to which these are experienced as restrictive was influenced by two antecedent conditions; whether the purpose of forensic care was to be more caring or custodial and the extent to which residents were perceived to be risky. We argue that there must be a reflexivity from stakeholders between the level of restrictiveness needed to safely provide care in a therapeutic milieu and enable the maximum amount of resident autonomy.

Forensic Psychiatric Patients' Perspectives on Their Care: A Narrative View

PURPOSE

The purpose of this study is to describe forensic psychiatric patients' experiences of and perspectives on forensic psychiatric treatment.

DESIGN AND METHODS

Eight forensic psychiatric patients were interviewed, and the resultant research material was analyzed by narrative analysis.

FINDINGS

Patients' narratives contain different themes telling different things and the personnel need to pay attention to these.

PRACTICE IMPLICATIONS

The findings of the present study should direct the forensic psychiatric personnel's attention to the notion that forensic psychiatric patients' experiences of their treatment can improve the quality of patient-centered care and reduce bureaucracy.

"It Had Only Been a Matter of Time Before I Had Relapsed Into Crime": Aspects of Care and Personal Recovery in Forensic Mental Health

INTRODUCTION

Forensic psychiatry has the dual task of focusing on the prevention of reoffending as well as maintaining psychiatric rehabilitation. No previous studies addressing the patients' own views on reducing their risk of serious reoffending were found.

AIM

This study describes forensic psychiatric inpatients' own views on what aspects of care and personal recovery are important in reducing their risk of serious reoffending.

METHODS

A structured qualitative approach was used. Data were collected from semistructured interviews and analyzed with a systematic qualitative content analysis.

RESULTS

The results highlight aspects of care and personal recovery. Four themes emerged: "time: opportunity for change," "trust: creating a context with meaningful relations," "hope: to reach a future goal," and "toolbox: tools needed for recovery."

DISCUSSION

The themes present with a continuum. At one end, there are patients who appreciated possibilities to participate actively in care and treatment. At the other end, patients felt they had no use for their care. Interestingly, although patients in our study were asked for their opinion on how they could reduce their dangerousness, all themes fit into established personal recovery processes found in general psychiatric populations. The theme "time: opportunity for change" seems to have an overarching importance.

IMPLICATIONS FOR PRACTICE

By understanding the specific content along these themes, relevant to the individual patient, carers may be able to better support their personal recovery journey. Because time spent as inpatients in forensic psychiatry is an overarching issue, carers need to be persistent over time.

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.

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

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

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

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

Caring Science and the Development of Forensic Psychiatric Caring

PURPOSE

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

CONCLUSIONS

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

PRACTICE IMPLICATIONS

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

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

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

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.

A self-destructive care: self-reports of people who experienced coercive measures and their suggestions for alternatives

Coercive measures are commonly used as a method of intervention, despite insufficient evidence for their effectiveness and benefits. The aim of this study was to describe how people who self-harm perceive alternatives to coercive measures in relation to actual experiences of psychiatric care. A total of 19 self-reports have been analysed with qualitative content analysis, resulting in three categories: a wish for understanding instead of neglect; a wish for mutual relation instead of distrust; a wish for professionalism instead of a counterproductive care. In conclusion, if the caregivers can understand and collaborate with the patient, there is seldom any need for coercive measures.

Solving the staff's problem or meeting the patients' needs: staff members' reasoning about choice of action in challenging situations in psychiatric inpatient care

Coercion in challenging situations is often seen as a necessary component of psychiatric care. This study aims to describe staff members' reasoning about their choice of action in challenging situations in inpatient psychiatric care. Focus group interviews with 26 staff members were analyzed using qualitative content analysis. The results provide an overview of the integrated structure of participants' reasoning and suggest that staff members' reasoning about choice of action can be described as a matter of either solving the staff's problems or meeting the patients' needs. These results can be of use in further research, educational interventions, and staff development activities.

The duality of suffering and trust: abused women's experiences of general psychiatric care--an interview study

AIMS AND OBJECTIVES

To elucidate how women subjected to physical, emotional and/or sexual abuse experience the care provided at a general psychiatric clinic after the disclosure of abuse.

BACKGROUND

Violence against women is a major global public health issue, which has an impact on women's lives and mental health as well as generating frequent hospital admission.

DESIGN

Qualitative design with an inductive approach.

METHODS

Interviews with nine women who were recipients of general psychiatric care and had disclosed experiences of abuse to a member of staff were conducted. Qualitative inductive content analysis was used.

RESULTS

The overall theme emerging from the narratives, 'dependency as a reality containing a duality of suffering and trust,' links the categories together. Each subcategory is presented in relation to the categories 'being belittled,' 'being misinterpreted' and 'being cared for.' Experiences of care as caring and noncaring were found in the narratives. Caring could include situations experienced as the women being acknowledged and listened to, situations where staff approached and supported the women in a sensitive way. Experiences of noncaring were when the abuse was disregarded, and when the women were not believed in, were left with burdens of guilt and were offended. A noncaring environment focused primarily on the diagnosis, and the experienced abuse was seen as secondary.

CONCLUSIONS

Abused women are subjected to psychiatric environments where staff are divided into groups of those who believed in and supported the abused women and those who regarded experiences of abuse as a secondary issue and focused on the mental disorder.

RELEVANCE TO CLINICAL PRACTICE

This study provides knowledge of how abused women experience the care provided at a general psychiatric clinic after the disclosure of abuse.