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

Exploring Social Interactions in the Context of Justice System Involvement: Perspectives of Patients and Psychiatric Nurses

Psychiatric nurses who work with people who are involved with the justice system experience ethical and moral tension arising from their dual role (care and control). This is known to significantly affect the development of a therapeutic relationship between nurses and patients. (a) better understand how justice system involvement affects people living with mental disorders and the nurses who work with them; (b) explore the influence of judiciarization on social interactions between these actors. Grounded theory (GT) was used as the qualitative methodology for this research. Semi-structured interviews were conducted with participants. The study was carried out in three different units of a psychiatric institution: Psychiatric Intensive Care Unit, Emergency Department, and Brief Intervention Unit. A sample of 10 patients and 9 psychiatric nurses was recruited (n = 19). Theoretical sampling was used to recruit participants. We followed the iterative steps of qualitative GT analysis (open coding, axial coding, constant comparison, and modelization). Three main themes emerged from the qualitative analysis: (a) Experience of Justice System Involvement, (b) Crisis, (c) Relational Aspects and Importance of the Approach. These results will inform nurses and healthcare providers about the impacts of justice system involvement on people living with mental illness and how clinical practices can be better adapted to this population with complex health needs.

Staff responses to interventions aiming to reduce mechanical restraint in adult mental health inpatient settings: a questionnaire-based survey

PURPOSE

To explore mental health staff's responses towards interventions designed to reduce the use of mechanical restraint (MR) in adult mental health inpatient settings.

METHODS

We conducted a cross-sectional, questionnaire-based survey. The questionnaire, made available online via REDCap, presented 20 interventions designed to reduce MR use. Participants were asked to rate and rank the interventions based on their viewpoints regarding the relevance and importance of each intervention.

RESULTS

A total of 128 mental health staff members from general and forensic mental health inpatient units across the Mental Health Services in the Region of Southern Denmark completed the questionnaire (response rate = 21.3%). A total of 90.8% of the ratings scored either 'agree' (45.2%) or 'strongly agree' (45.6%) concerning the relevance of the interventions in reducing MR use. Overall and in the divided analysis, interventions labelled as 'building relationship' and 'patient-related knowledge' claimed high scores in the staff's rankings of the interventions' importance concerning implementation. Conversely, interventions like 'carers' and 'standardised assessments' received low scores.

CONCLUSIONS

The staff generally considered that the interventions were relevant. Importance rankings were consistent across the divisions chosen, with a range of variance and dispersion being recorded among certain groups.

Nurses' and patient' descriptions about forms of power in pro re nata medication participation in forensic psychiatric care: A qualitative secondary analysis

Despite there being an emphasis on patient participation in their own care, it has been a challenge in pro re nata (PRN, as the circumstance arises) medication in forensic psychiatric care. The power imbalance in treatment relationships can be a barrier to patient participation and should therefore be further explored. This qualitative descriptive study aimed to explore the aspect of power in the descriptions of patients and nurses interviewed in a Finnish forensic psychiatric hospital about patient participation in PRN. A qualitative secondary analysis was conducted through the semi-structured interviews of the patients (n = 34) and nurses (n = 19). The data were analysed with deductive content analysis. The Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines were used to ensure comprehensive reporting. The findings revealed that patients and health professionals may have conflicting goals in PRN and that they both use power to try to achieve them. Power in PRN was described in different forms, including authority, force, manipulation and persuasion. Based on our results, the power that health professionals have in PRN medication is particularly based on their legitimate authority and the hierarchical structures of the hospital environment. Patients also hold power in the dynamics of PRN medication care, but their position as a power holder can vary individually and situationally. Recognizing different forms of power and supporting patients with a decreased capacity for decision-making is essential for promoting high-quality and patient-centred forensic psychiatric nursing.

Using a trauma-informed care framework to explore social climate and borderline personality disorder in forensic inpatient settings

Tensions between therapeutic and security needs on forensic wards can create a social climate which is challenging for both mental health nurses and patients. Social climate refers to the physical, social and emotional conditions of a forensic ward which influence how these environments are experienced. For patients with borderline personality disorder (BPD), previous trauma means that the social climate of forensic settings may be experienced as retraumatising, negatively impacting the outcomes and wellbeing of both patients and mental health nurses. Trauma-informed care (TIC) has been offered as a contemporary framework for mental health nursing in inpatient units which aims to create a therapeutic social climate. In this critical review, we drew widely on literatures examining the social climate in forensic settings, the relationships between patients with BPD and staff (including mental health nurses), and the experiences of patients with BPD in forensic and inpatient settings to draw out the implications of scrutinising these literatures through the lens of TIC. Attending to the physical, social and emotional conditions of social climate in secure settings highlights how forensic wards can mirror trauma experiences for patients with BPD. Implementing TIC in these contexts has the potential to evoke positive shifts in the social climate, thus reducing the risk of retraumatisation and leading to improved outcomes for patients and staff.

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.

A phenomenological reflection on women's lived experience of giving in circumstances of material scarcity

There is a robust body of research that examines problems women with criminal-legal system involvement face, the support they need, how they get it, from whom, and how they use it. Rarely do we pause to consider what resources such women already have, the support they give, or what those experiences teach us about how to support them. In this study, my purpose was to reflect on the phenomenon of giving as experienced by women who have few material resources and whose lives have been disrupted by repeat incarcerations. I analyzed four lived experience descriptions of giving from interviews conducted in 2016-2017 with 10 women who had significant histories of criminal-legal system involvement, unstable housing, and little or no income. Using concepts from hermeneutic phenomenology and the practice of phenomenological study described by Max Van Manen, I analyzed giving wholistically, selectively, and in detail. I discerned that the women's experience of giving was relationally structured as exchange, with both past and future aspects. In selective and detailed analysis, themes of "taking in" and "being there" and a gem or essential feature of automaticity/personhood presented themselves. Women found meaning, value, and a sense of belonging in giving to others even when they struggled to meet their own needs. The findings suggest potential directions for nursing practice, research, and advocacy, including work to recognize, build on, and remunerate women's affiliative care-giving and support-while also putting pressure on community health and social services delivery systems to better serve those in need.

Patient participation in forensic psychiatric care: Mental health professionals' perspective

Patient participation is a central concept in modern health care and an important factor in theories/models such as person-centred care, shared decision-making, human rights approaches, and recovery-oriented practice. Forensic psychiatric care involves the treatment of patients with serious mental illnesses who also have committed a crime, and there are known challenges for mental health staff to create a health-promoting climate. The aim of the present study was to describe mental health professionals' perceptions of the concept of patient participation in forensic psychiatric care. Interviews were conducted with 19 professionals and were analysed with a phenomenographic approach. The findings are presented as three descriptive categories comprising five conceptions in an hierarchic order: 1. create prerequisites - to have good communication and to involve the patient, 2. adapt to forensic psychiatric care conditions - to take professional responsibility and to assess the patient's current ability, and 3. progress - to encourage the patient to become more independent. The findings highlight the need for professionals to create prerequisites for patient participation through good communication and involving the patient, whilst adapting to forensic psychiatric care conditions by taking professional responsibility, assessing the patient's ability, and encouraging the patient to become more independent without adding any risks to the care process. By creating such prerequisites adapted to the forensic psychiatric care, it is more likely that the patients will participate in their care and take more own responsibility for it, which also may be helpful in the patient recovery process.

Subordinated masculinities: A critical inquiry into reproduction of gender norms in handovers and rounds in a forensic psychiatric care

AIMS AND OBJECTIVES

To examine how gendered discursive norms and notions of masculinity are (re)produced in professional conversations about men cared for as patients in forensic psychiatric care, with a particular focus on the centrality of language and gender.

BACKGROUND

During verbal handovers and ward rounds, care staff converse to share information about patients and make decisions about their mental status. Spoken language is thus a pivotal tool in verbal handovers and ward rounds, one able to reproduce discourses and gender norms.

DESIGN

Qualitative. Data collected from audio recordings of verbal handovers and ward rounds in a forensic psychiatric clinic were subjected to discourse analysis. The COREQ checklist was used.

RESULTS

While discussing patients, staff subordinated them by reproducing a discourse typical of heteronormative, family-oriented care. The overarching discourse, which we labelled subordinated masculinities, was supported by three other discourses: being unable to take responsibility, being drug-addicted and performing masculinity. Such discourse was identified as a disciplining practice that subordinate's patients as a means to maintain order, rules and gender norms.

CONCLUSION

The study reveals a caring practice that position male patients as children or disabled individuals and, in that way, as subordinated other men within a context were staff reproduces a heteronormative family structured care. The process also reveals a practice were downplaying aggressive and deviant behaviour could disempower and reduce patients´ responsibility for personal actions and their possibilities to participate in their care. That finding especially seems to contradict previous findings that patients want to be able to act responsibly and, to that end, want care staff to help them.

RELEVANCE TO CLINICAL PRACTICE

Nurses need to deepen their understanding of how language (re)produces discursive norms of gender and masculinity in forensic care and that process's consequences for such care.

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.

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

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

'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.

System Entrapment: Dehumanization While Help-Seeking for Suicidality in Women Who Have Experienced Intimate Partner Violence

Attention to power imbalances when seeking help for suicidality after having been controlled within intimate partner violence (IPV) is crucial in improving health care delivery. Well documented in the literature is the correlation between suicidality and IPV and that help-seeking for each is difficult; however, a gap exists when both intersect. The process of women's help-seeking is explored in this feminist grounded theory and photovoice multiple qualitative method study. Analysis of interviews with 32 women from New Brunswick, Canada, and photovoice meetings with seven women revealed a basic psycho-social problem. System Entrapment or being dehumanized while seeking help for suicidality occurred as a result of perceived invalidation from health care providers' lack of empathy. Further harm while providing services to women feeling suicidal can be prevented with a shift from an individualist model toward a trauma and violence informed approach. Understanding the contextual factors influencing women's suicidality may reduce victim blaming.

The question of meaning-a momentous issue for qualitative research

In this article, we identify some worrying problems in the contemporary practice of qualitative research, such as the confusion regarding content and meaning in content analysis, the frequent use of standardized methods that avoids philosophy, as well as the description/interpretation dichotomy in empirical research. Since they all arise from a failure to understand the concept of meaning, we return to the question of meaning as the axis that qualitative research pivots around. We examine the meaning of meaning, and how meaning differs from content, and we then ask what consequences this has for research. Even though our analysis is rooted in phenomenological philosophy, we argue that that the ideas that we present are valid for any qualitative research approach. The question of understanding and relating to meaning, we argue, is a momentous issue for qualitative research, where we either continue safeguarding the very essence of qualitative research as dealing with human phenomena, or give it up in favor of more pragmatic and clear-cut methods that seemingly does away with the question of meaning.

'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.

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.

'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.

The Role of the Registered Nurse Working in Substance Use Disorder Treatment: A Hermeneutic Study

Substance Use Disorders (SUDs) are a national public health crisis. However, there is minimal existing research literature on the role of the nurse working in SUD treatment. The purpose of this study was to describe the meaning of the professional role of the registered nurse working in the SUD setting. The study utilized a Heideggerian Phenomenological approach with a modified Colaizzi method for analysis and interpretation. The nine study participants, two males and seven females, aged 27-60 had worked in SUD treatment for 1-37 years. Three major themes, with sub-themes, emerged: Defining the Role for Self; Learning the Role; and Navigating with Ease in an Unchangeable Culture. Findings demonstrated that nurses in SUD treatment value their role and the care of patients with SUDs. Patient recovery or relapse influenced job satisfaction. Significantly, the findings highlighted an outdated role with rigid boundaries and no real contemporary identity. Findings can be used to address the need for a contemporary SUD nursing identity and to support ongoing involvement of nurses in health policy related to SUDs.

Methodological support for the further abstraction of and philosophical examination of empirical findings in the context of caring science

Phenomena in caring science are often complex and laden with meanings. Empirical research with the aim of capturing lived experiences is one way of revealing the complexity. Sometimes, however, results from empirical research need to be further discussed. One way is to further abstract the result and/or philosophically examine it. This has previously been performed and presented in scientific journals and doctoral theses, contributing to a greater understanding of phenomena in caring science. Although the intentions in many of these publications are laudable, the lack of methodological descriptions as well as a theoretical and systematic foundation can contribute to an ambiguity concerning how the results have emerged during the analysis. The aim of this paper is to describe the methodological support for the further abstraction of and/or philosophical examination of empirical findings. When trying to systematize the support procedures, we have used a reflective lifeworld research (RLR) approach. Based on the assumptions in RLR, this article will present methodological support for a theoretical examination that can include two stages. In the first stage, data from several (two or more) empirical results on an essential level are synthesized into a general structure. Sometimes the analysis ends with the general structure, but sometimes there is a need to proceed further. The second stage can then be a philosophical examination, in which the general structure is discussed in relation to a philosophical text, theory, or concept. It is important that the theories are brought in as the final stage after the completion of the analysis. Core dimensions of the described methodological support are, in accordance with RLR, openness, bridling, and reflection. The methodological support cannot be understood as fixed stages, but rather as a guiding light in the search for further meanings.