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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.
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International Journal of Qualitative Studies on Health
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Controlling emotions—nurses’ lived experiences
caring for patients in forensic psychiatry
Lars Hammarström, Marie Häggström, Siri Andreassen Devik & Ove Hellzen
To cite this article: Lars Hammarström, Marie Häggström, Siri Andreassen Devik & Ove Hellzen
(2019) Controlling emotions—nurses’ lived experiences caring for patients in forensic psychiatry,
International Journal of Qualitative Studies on Health and Well-being, 14:1, 1682911, DOI:
To link to this article:
© 2019 The Author(s). Published by Informa
UK Limited, trading as Taylor & Francis
Published online: 24 Oct 2019.
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Controlling emotionsnurseslived experiences caring for patients in
forensic psychiatry
Lars Hammarström
, Marie Häggström
, Siri Andreassen Devik
and Ove Hellzen
Department of Nursing, Mid-Sweden University, Sundsvall, Sweden;
Department of Health Sciences, Nord University, Namsos, Norway
Purpose: Nurses working in forensic psychiatry often encounter offenders who have a severe
mental illness, which may cause ethical challenges and influence nursesdaily work. This
study was conducted to illuminate the meaning of nurseslived 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
resignationand 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 vulnerabilityand Regulating
oneself). Further, working in forensic psychiatry challenged nursesidentity 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 patientsexperiences and
respond accordingly. Utilizing strategies rooted in compassion such as self-reflection, emo-
tional regulation, and distancing themselves when necessary may enable nurses to more
effectively respond to patientsneeds.
Accepted 16 October 2019
Encounters; forensic nursing;
forensic psychiatry; lived
experience; nurse-patient
relationship; nursing;
hermeneutic approach
Forensic psychiatry provides services for offenders with
severe mental illnesses (Nedopil, Taylor, & Gunn, 2015).
Patients have often committed acts of violence
(Rydenlund, Lindstrom, & Rehnsfeldt, 2019). According
to Vorstenbosch, Bouman, Braun, and Bulten (2014)one
third of the offenders who commit these acts have
a severe mental illness, if a diagnosis is established after
a forensic psychiatric examination, the person will likely
be admitted to forensic psychiatric care, which is char-
acterized by long hospital stays. In an environment that is
characterized by security (Doyle, Quayle, & Newman,
2017) and can be experienced as restricted (Olausson,
Danielson, Berglund Johansson, & Wijk, 2019). The caring
relationship is central to forensic nursing (Encinares,
McMaster, & McNamee, 2005) and a major part of care
consists of nursesencounters with the patient (Tenkanen
et al., 2016), and Rask and Brunt (2006)notesthatnurses
should promote conversations with patients. Patients
may receive as little as half hour and 1.5 hours per day
for treatment and structured activities, respectively
(Sturidsson, Turtell, Tengström, Lekander, & Levander,
2007). Social interactions constitute the remainder of
the work according to Rask and Hallberg (2000).
To interact with people in psychiatric nursing cre-
ates possibilities to affect patientsmental illness, and
it is a key component of the rehabilitation process
(Hellzen & Asplund, 2006). A caring conversation
between the nurse and the patient could indicate an
improvement in the patients health (Rydenlund et al.,
2019); however, there is currently scant research con-
cerning these encounters. There is some evidence
that healthcare professionals can be judicial; do not
listen; and lack the adequate competence to address
hopelessness, apathy, anger, and sorrow (Harris,
Happell, & Manias, 2015). The fact that the patient
has committed a crime may cause stress and frustra-
tion, thus damaging the potential relationship
between nurse and patient and fostering mistrust
(Harris et al., 2015).
Forensic psychiatric care is complex, regardless of
whether the care is viewed as care or control (Kettles
& Woods, 2006; Maroney, 2005). Little is known about
how nurses respond to patientsexperiences
(Myklebust & Bjorkly, 2019). Løgstrup (1997) pre-
sented a phenomenological-hermeneutic ethical
demandhe stressed that encounters with other
people come with a distinct responsibility: people
exist together and are dependent on each other.
CONTACT Lars Hammarström Department of Nursing, Mid Sweden University, Holmgatan 10, Sundsvall, Sweden
2019, VOL. 14, 1682911
© 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
People extradite themselves to a me and yourela-
tionship. Examples of such actions are to show trust,
mercy, openness, and honesty. When they are absent,
it is an indication of a selfish, modern world, and the
ethical requirements transform into a duty.
Since the care is characterized by constraint and
coercion, patientsdignity may be offended through
objectification (Jacobson, 2009). Rask (2002) stressed
that a trusting relationship between the patient and
nurse can improve forensic care; however, this
requires a deeper understanding of nursing in foren-
sic care. It is known that a caring relationship is of
importance, but to what extent and how these
encounters unfold in clinical practice is relatively
unknown (Goulter, Kavanagh, & Gardner, 2015).
There is a plea of nurses to be caring, protecting
and trustful (Tingleff, Hounsgaard, Bradley, Wilson, &
Gildberg, 2019). According to Hörberg, Sjogren, and
Dahlberg (2012), patients in forensic care express that
this trusting relationship is missing. The question is,
how can forensic care that is custodial and corrective
be based on nursing, and how can caretakers equip
themselves with the necessary tools derived from
nursing and ethics according to Hörberg (2015)?
Meeting other people comprises a permanent fusing
between understanding and impression by establishing
trust in inter-human relationships. Meeting another per-
son comes with expectationsan anticipation that the
other will receive us and fulfil our expectations. Løgstrup
(1997) posits that, if the expectation is not received, there
is a risk of meaninglessness. It is necessary to evaluate the
care from the nursesperspective (Selvin, Almqvist, Kjellin,
Lundqvist, & Schroder, 2019). Nurses must be supported
so that they provide care that eases patientssuffering
and prevent future crimes. If feelings like fear, disorienta-
tion, and anger become the foundation of care, the care-
takerswillnotbeabletoeasepatientssuffering (Sjögren,
2004). Nurses endeavour to make patients submiss to the
care, thus becoming manageable and displaying positive
behavioural adaptation. According to Hörberg (2008), the
complexity of forensic care is that nursestasks are contra-
dictorythey are supposed to care, guard, and protect;
connect with the patient; create a trusting relationship;
ease the patientssuffering; and improve their health and
wellbeing. Letting a patients expressions become the
nurses impression, confronting the nurse with the risk
of letting intuition and emotions affect his/her caregiving
(Devik, Enmarker, & Hellzen, 2013). The aim of this study
was to illuminate the meaning of nurseslived experi-
ences of encounters with patients with mental illnesses in
forensic inpatient care.
Materials and methods
Qualitative research involves studying things in their
natural setting, attempting to make sense of, or inter-
pret, phenomena and the meanings people bring to
them (Creswell & Poth, 2018). These meanings consti-
tute individualslived experiences and can be
expressed through reflection on actions in narratives
(Lindseth & Norberg, 2004) of nurses encounters with
patients with mental illnesses in forensic inpatient care.
Procedure and setting
Narrative interviews were conducted with 13 partici-
pants, based on a model of sample size in qualitative
selection and information power (Malterud, Siersma, &
Guassora, 2015). All participants worked at a forensic
hospital in Sweden. The clinic consists of approximately
180 employees and 100 patients. Most patients are men
aged 2545 years who were convicted of some sort of
violent crime. Approximately 60% of patients have schi-
zophrenia or another psychotic disorder. An invitation
to participate was mailed, with written information
about the study and a consent form, to the heads of
the clinic and each ward. Study approval was obtained
by the head of the clinic.
Participants and data collection
A purposive sample was recruited among nurses with
experience of caring for patients with mental illnesses in
forensic inpatient care. The interviews were conducted
at the forensic clinic, at a preferred place chosen by the
participants. Participants were 10 men and 3 women
(median (Md) age = 36 years, age range = 2867 years).
Participants had worked in forensic psychiatric care
between 5 and 46 years (Md = 11 years), and there
were 5 registered nurses, among those 3 specialist
nurses in psychiatric care and 8 assistant nurses, all
with special training in psychiatric care.
In the presentation of the results, all staff are referred to
as nurseto conceal their identities. Data collection was
conducted through recorded, individual, and narrative
interviews with open-ended questions (Mishler, 1986).
Participants were asked to narrate their lived experiences
of encounters with patients with mental illnesses in for-
ensic inpatient care. The interviews lasted from 41 to
60 minutes (M= 48 min). The main questions included,
Can you tell me about an encounter with a patient that
evoked negative feelings?and Can you tell me about an
encounter with a patient that evoked positive feelings?
Further questions included, How did you feel?,”“Can you
tell me more?,and Has that happened before?.The first
author transcribed the interviews verbatim.
Phenomenological-hermeneutic approach
The interview text was interpreted using a phenomeno-
logical-hermeneutic approach (Lindseth & Norberg,
2004). The process of interpreting the text goes through
three phases: naive understanding, structural analysis,
and comprehensive understanding. During the first
phase, the naive understanding the text was read many
times with an open mind; this was to get an overall
awareness of the text, which ends in a formulation of
the initial understanding of what the text is about.
The second phase, the structural analysis, is a more pre-
cise form of analysis to recognize parts and patterns and
to seek clarification of the text through outdistance and
a critical way of being. This was achieved by analysing all
the meaning units, which was sorted into themes and
subthemes. The last phase of analysis was the compre-
hensive understanding, which is a form a dialectic move-
ment between explanation and understanding; it is a way
of seeing the whole considering its parts, and the parts
considering the whole. It is an analytical, in-depth inter-
pretation of all three phases. Altogether, this interpreta-
tion produces a comprehension of what the whole text
represents. The process of interpretation is not linear;
rather it is a spiral, dialectic movement between the parts.
All participants received information about the research
both orally and in writing. All participants provided
written consent, which was stored by the first author.
Participation was voluntary, and all interviewees were
guaranteed confidentiality. All participants could, at any
time, cease participation. All participants were provided
with the first authors and supervisorscontact informa-
tion. Ethical approval was obtained by the regional
ethical review board (no. 2018/157-31) and was con-
ducted per the Declaration of Helsinki (WMA, 2008).
Naive understanding
During their work, nurses face various patient expres-
sions. The encounters are based on nurseswillingness
to do well; however, they are sometimes characterized
by violence, resistance, and threatsthus creating var-
ious obstacles that arouse feelings of frustration, disap-
pointment, fear, and humiliation. Contrastingly,
encounters can also be positive, evoking feelings of
competence, compassion, satisfaction, pride, trust, and
pleasure concerning patientsrecovery.
The text implies that encounters with patients who
commit serious crimes can be arduous to understand
and difficult to navigate for nurses, owing to the long-
term care and ambivalence that occurs because of the
diverse aspects of care including protecting society
and doing what is best for the patients. These oppos-
ing views are also described as a potential source of
conflicta conflict based either on caring and alle-
viating suffering or on guarding and fostering
patients. However, letting patientsexpressions make
an impression and thus sensing their vulnerability can
guide the nurses in regulating their own feelings.
Structured analysis
Multiple structured analysis resulted in four themes
and ten subthemes, see Table 1. The presentation of
the essential meanings of the phenomenonnurses
encounters with mental ill patients in forensic inpati-
ent careis written in present tense and describes
how the phenomenon is; i.e., the meaning and not
what the participants said about it.
Theme 1: being frustrated
Being frustrated means being upset about ones lim-
itations as a nurse concerning what they want and
what they can do for the patient. It includes feelings
of seeing oneself as strong, taking on responsibility,
acting alone, and coming to short for unattainable
demands. The feeling of perplexity around what it
means to care for forensic psychiatric patients is
strong. Nurses sometimes do not know how or what
to do or say to reach the patient, except that they
know what the patient has done is wrong, illegal, and
totally unjustifiable. This theme consists of two sub-
themes: fighting resignation and being disappointed.
Fighting resignation
Not having anything to orient themselves to after the
care creates a sense of perplexity, resignation, and
hopelessnessdespite repeated attempts to reach
Hopelessness isnt an unusual feeling; it can come over
you sometimes. It can come when you dont know how
to respond to someone in order to get your meaning
across. This may feel dull when trying to reach them; it
sometimes feels hopeless when you have tried so much,
and nothing works.
Nurses may feel despair when they do not obtain
positive results. Nurses also become confused when
they assess a patient as ready to leave the clinic but
the patient does not manage to integrate back into
society. They feel indecisive and seek explanations
for why.
to be cared for in our clinic. It often is so anyway because of
Table I. Overview of themes and subthemes.
Being frustrated
Fighting resignation
Being disappointed
Protecting oneself To shy away
Being on your guard
Being disclosed
Being open-minded Being confirmed
Developing trust
Developing compassion
Striving for control Sensing mutual vulnerability
Regulating oneself
all the relapses, which leads to an extension of care times.
Its not so much an annoyance as a sense of hopelessness.
But itsspecialherewith the long times of care.
Long-term care may result in a sense of powerlessness
and lack of control among nurses since they do not
see the results of their work in patientsdevelopment.
Coming up short of unrealistic demands and not
reaching expectations feels wrong and reinforces feel-
ings of hopelessness. Being part of an environment
that gives what is considered bad care could be
demoralizing for the nurse. Not seeing the results of
their work despite their ambitions is expressed by
nurses feeling anonymous and powerlessness.
Being disappointed
Being disappointed means becoming aware of the let-
downs that could arise when caring in forensic psychiatric
care. It is a challenge to meet the feelings of disappoint-
ment with colleagues. The work does not, at times, feel
fair. According to the nurses, thefactthattheyarerespon-
sible for care is something that they must live with.
Its hard to always be the one who says no, and you
get upset when the patients are on you all the time.
Nurses expressed that interacting with individual
patients also means having an overall sense of the
patient, which he or she brings to the next meeting.
Becoming aware that it is not always easy to show
understanding towards the patient and that it can be
difficult to live up to expectations can evoke anger
and a sense of failure.
I may carry with me some frustration from a previous
meeting; then, it might be easier for me to overreact
and get frustrated in a similar situation.
Becoming aware of how to work, think, and act is
important for nurses. Nurses expressed that long-
term care can affect them negatively, with feelings
of frustration due to the patients illness that some-
times does not show any improvement. Wanting to
help and then being rejected by the patient fosters
nursessense of frustration. However, both becoming
aware and recognizing their own shortcomings helps
nurses cope with this frustration.
I can link it directly to work efforthow much com-
mitment I have put into this, how many mind maps,
how many whiteboard pens I have worn out on this
patient, [and] how much feet I have rasped. When
I finally present that, I think you and I have come up
with the solution,the patient responds, that sounds
hard.Then, the frustration grows.
Theme 2: protecting oneself
The theme of protecting oneself includes encounters
that evoke negative feelings among nurses. This
theme consists of three subthemes: to shy away,
being on your guard, and being disclosed.
To shy away
Working in forensic psychiatric care means being
exposed to patients who have committed heinous
crimes, such as violent crimes and sexual abuse
against children. Nurses explain this as a reason that
it is sometimes difficult to approach the patient and
that they are uncertain in the care they must provide.
I feel like Im getting angry. He tried to murder a little
girl in the most brutal way I heard of. There goes my
own limit to be able to feel goodness and love. I could
not care for him in the same way I care for other
murderers. For me it was the exception.
Nurses know what the patients need; however, they
cannot satisfy it. Instead, the situation is handled by
avoiding contact with the patient. The nurses
expressed that, whatever they do, everything feels
Theres one patient where I find it difficult to feel good-
ness and love. Its a patient that I thought was horrible.
He was a pedophile. Many considered him the best
patient. Because he did exactly what you said. [He]
handled himself perfectly; but, I could not see him in
the eyes. I just said hello and what was necessary.
Distancing also resulted from nurses feeling that
patients were a threat and that they could lash out
in violence. This fear led to uncertainty in their care,
which affects nursesactions and the caring relation-
ship. This also led to contradictory emotions, because
sometimes nurses are not prepared to pay the price
that it can cost to handle their feelings.
Its worse when you get scared. When you feel that
youre about to get hit, or when you feel that the whole
situation is threatening, you have to put down all of
your energy to be able to cope with the situation.
Being on your guard
Working as a nurse in forensic psychiatry means being
on your guard. There is a nagging feeling that, at any
time, a situation can occur. To prevent dangerous
situations the nurse needs to be constantly on
guard. Sometimes the patients history and profes-
sional experience help the nurse stay one step ahead.
With some patients, you have to be on your guard. You
dont let them behind your back. Such times, its not
entirely safe to be at work. You know what they have
done. Perhaps they have a history of being rowdy.
For some reason, I got a weird feeling when he walked
by. Something wasnt righta gut feeling. So, I turned
around because I felt he was behind me. He was one of
those who you needed to have your eyes on.
New patients create uncertainty because there is
a lack of knowledge about the patient. Therefor they
need to proceed with caution when encountering
new patients. Sometimes the distrust is linked to the
patientsexperiences. The nurses work experience
indicates that a frightened patient may be dangerous.
[It] reminds you of that one time a patient attacked
you, for example. It also means that you might be
a little more cautious when you are going to meet
this patient. Maybe you keep a little more distance
because you do not feel completely safe with him.
I didnt know him. [I] didnt know what he was capable
of. He was very wound up and frightened.
Being disclosed
Being humiliated by a patient can affect nurses, espe-
cially if it occurs frequently or in front of other people.
Feeling disclosed is hard to defend against and may
make nurses lose their composure.
I think this person has found a sensitive point in me
where I am somehow vulnerable or become offended.
Sometimes I can withstand almost anything while
sometimes I can withstand almost nothing; those
times I will be sincerely offended.
Being unable to change the situation was problematic
for nurses. Nurses want to handle the situation and
stand up for themselves. Instead, theres a feeling of
being disclosed and an inability to act like they do
with other patients.
I took it personally. A thing that normally does not
concern me; but, he managed somehow to get under
my skin.
Theme 3: being open-minded
Being open-minded refers to nursesability to under-
stand patientshistory and disease. It is needed for an
effective patientnurse relationships. This theme con-
sists of three subthemes: being confirmed, developing
trust, and developing compassion.
Being confirmed
Being confirmed means that nursesengagement
increases. The feeling of not being alone in the situa-
tion decreases when nurses receive validation from
their colleagues. They feel that they are easily under-
stood by colleagues who have similar experiences in
forensic psychiatric care and thereby understand the
caring relationship. This evokes a willingness to pro-
vide care.
I think it matters for my commitment. I think we, in the
staff group, are still quite good at when someone
manages to do something good. That you get to hear
it. I can feel, that if I receive praise, [that] its something
I want to maintain.
Patientsexpressions of gratitude contribute to the
caring relationship. The nurses appreciate when the
patients value good nursing care, which increases
nursesself-esteem and fosters continued commit-
ment. Long-term forensic care with severely ill
patients is so arduous, that when there is success
with a patient, it brings nurses joy and validates the
work they do.
The patients dont show much gratitude; but some do
it. Then, you get energy and a great feeling in the body.
Then, I feel that youre doing something meaningful.
Developing trust
Developing trust is vital for the caring relationship
and means having the courage to open up to the
patient and taking the patient seriously. Showing con-
fidence in the patient means that the relationship
becomes predictable.
If I can trust the patient I also dare morelike, sharing
myself. When I learn how to respond to him, I feel more
secure. Then you dare more. I cant feel the mood of the
patient if I go around being scared or dont feel safe.
Trust also means that the balance of power is reduced
by the patients participation. Knowing the patient
may also mean being together, through that the dis-
tance and paternalistic relation between the two par-
ties is decreased.
For me, I think the key has been that I managed to
create trust through my encounters. You should meet
his needs and listen. He should feel involved.
Developing compassion
Letting the patient make an impression means seeing
the personand not just the patient.Becoming
aware of and recognizing the vulnerability of the
patients situation characterizes these interactions.
She then told me about her whole life. To hear about
how her life has beenabout why she committed the
crime she had done. It all felt very tragic.
It is not only the patients life that makes an impres-
sion on the nurse; the patientstemperament is also
of importance. If the patient is perceived as a child,
the nurse may find it easy to provide care since feel-
ing sorry for the patient evokes empathy.
All of a sudden, he begins to cry. It all became very
different very suddenly. You felt how frightened he was
how small he was. I felt very sorry for him.
Reflecting on the patients expressions over time pro-
moted a deeper relationship between nurses and
patients. Which may also create a more caring
Ive been with these patients for several years. Ive
established stronger ties with them. Thus, I become
more personally involved in them. Over time, it has
surely become so that I maybe care more about
Theme 4: striving for control
This theme consists of two subthemes: sensing
mutual vulnerability and regulating oneself.
Sensing mutual vulnerability
Sensing mutual vulnerability refers to the feeling that
occurs when the nurses are affected by the patients
expressions. Nurses feel vulnerable when they per-
ceive patientsvulnerability. It was described as frus-
trating when patientswellbeing and health were at
risk. Feelings of sadness and loneliness affected
patients, which seemed to arouse a sense of compas-
sion among nurses. Nurses used intuition and empa-
thy to guide their responses to some patients.
I feel its tough; [it is] hard to be among these patients
because they feel so amazingly bad. I already felt before
that he was afraid. It was as if he felt crowded. He could
not flee even if he wanted to. He could just as easily
become aggressive to deal with the situation.
Regulating oneself
Regulating oneself refers to nursesresponsibilities,
including legally, concerning patientscare. Care is
described as special, because the patient group has
complex problems and partly because the institution
environment is characterized by a high level of secur-
ity. In nursing care, the nurses must balance between
patientsrights and the safety of society. The care is
complicated as patients may be ill, aggressive, and
If theyre being aggressive, then youve to stop and
think before going into a situation. Some may be so
provocative; but, if you can find your own sense of
security and calmif its from colleagues or whatever
the encounter with the patient will be better. You
have to keep track of your own feelings in order to
take care of someone elses feelings.
If nurses are unable to cope with their feelings, there
is a risk that they will lose control of themselves and
the situation. Regulating oneself in such a situation
means, if possible, taking a step back to finding room
to take a breath.
If I am overcome by emotions and find myself losing
control, I try to pull myself out of the situation until
the level of affect decreases. Then I can ponder the
situation [and] think about what has happenedwhy
did I react so strongly? I would say that the feeling
that is most difficult for me to distance myself from,
or to regulate, is fear. Anger is, in a way, more
Comprehensive understanding
The overall interpretation is based on the authors
preunderstanding and naive understanding, themes,
subthemes, and reflecting upon them in relation to
the research question, context, and literature. The
meaning of encountering patients with mental illness
in forensic inpatient care is characterized by the asym-
metric relationship between the nurse and the
patient. This constitutes a fundamental moral chal-
lenge that nurses must cope with. For the nurses,
the encounters involved being frustrated, protecting
oneself, being open-minded and striving for control.
Patientsexpressions of threat, violence, and provoca-
tive behaviour threaten nursesprofessional identity.
Nonetheless, nurses attempted to empathize with
patientsexperiences and displayed competence in
assessing patientsexpressions. Nurses placed them-
selves in a vulnerable position by acknowledging
patientsuniqueness and individual needs. This strat-
egy fostered self-reflection, situational assessment,
and compassion for patients. This allows nurses to
control themselves, the patient, and the situation.
The aim of this study was to illuminate the meaning
of nurseslived experiences of encounters with
patients with mental illnesses in forensic inpatient
care. We found four themes, further broken down
into ten subthemes, that shed light on interviewees
lived experiences: Being frustrated,”“Protecting one-
self,”“Being open-minded,and Striving for control.
We found that patientsexpressions emotionally
affected nursescaring actions and preferences as
well as their professional self-esteem and moral
Working in a forensic environment challenges
nursesidentity as a healthcare professional because
of their obscurity and vulnerability in stressful work
situations. Moral distress is an inherent risk in forensic
psychiatric care with its complex patient group that
have varied problems. This leads to an institutional
environment characterized by a high level of security
in the interface between law and psychiatry (Carroll,
Lyall, & Forrester, 2004). Nurses may experience dis-
tress when dealing with their own fear owing to
patientspotentially provoking and violent behaviour.
This means that the provision of competent and com-
passionate care can be compromised by nursesfear
and lack of knowledge. The care approach may also
fail owing to a lack of self-confidence or courage in
nursesinteractions with patients. However, this is
a balancing act, and power is an underlying issue.
Nurses are empowered by their expertise and their
mission but disempowered because they must try to
adjust to patientscomplexities.
Working in forensic psychiatry means providing
nursing care for long periods. Patients who are calm
are often perceived as accepting of the care given and
following the rules according to Eivergard, Enmarker,
Livholts, Alex, and Hellzen (2018). Nurses often
expressed being frustrated by not being able to
reach patients or make progress in their treatment.
A major part of forensic nursing is being firm, setting
limits, and defining boundaries, which affect the
nursepatient relationship (Bowen & Mason, 2011).
There is always a risk that the encounters are viewed
as paternalistic (Hörberg et al., 2012; Norvoll &
Pedersen, 2016; Selvin, Almqvist, Kjellin, & Schröder,
2016). Forensic inpatient care is strenuous owing to
long hospital stays (Rao et al., 2009), and nurses with
negative perceptions may be more likely to provide
poor care quality (Kukulu & Ergun, 2007).
According to Jacob, Gagnon, and Holmes (2009),
feelings of frustration, disappointment, and resigna-
tion can be obstacles that nurses must overcome.
These feelings can make nurses doubt their own
actions, which becomes clearer if these feeling occur
for a long time (Dennis & Leach, 2007). This could also
influence patients to experience insecurity and
powerlessness. This is because nurses do not see the
patient as dynamic individuals; rather, they are
viewed as or she is but static, one-dimensional people
(Lilja & Hellzén, 2007). According to Olausson et al.
(2019), a relationship can be a lifelinesaving the
patient from loneliness and contributing to their well-
being. If patients sense that nurses are attempting to
empathize with them, it may foster trust and open the
lines of communication. Strengthened by the ethos of
caring and ethics, nurses must engage with patients,
which too will promote trust (Rydenlund et al., 2019).
The theme protecting oneself refers to nurses
lived experiences concerning facing the unpleasant.
Nurses expressed a distance between themselves and
the patients as a way of dealing with mixed emotions
that arises when caring for patients who committed
despicable crimes. However, nurses must strive to
look beyond patientscrimes and backgrounds,
instead focusing on support and recovery (Bowring-
Lossock, 2006). This is difficult when feeling unsafe or
afraid, which negative affects the caring environment
(Leutwyler & Wallhagen, 2010). Being exposed to
threats, violence, and provocative behaviour was
described by all the nurses, and this can contribute
to a distance in the nursepatient relationship.
Consistently, patientsability to follow the rules and
not showing aggressive behaviour is deemed accep-
table patient behaviour in the eyes of nurses
(Eivergard et al., 2018).
Results from this research indicate that within
a highly regimented context, nurses are socialized to
incorporate representations of the patients as being
potentially dangerous. Thus, they distance themselves
from idealistic conceptions of care. The results also
emphasize the implication of fear in nursepatient
interactions, particularly how fear reinforces nurses
need to create a safe environment. This results in
a consistent negotiation between risk and security,
in which nurses are forced to scrutinize their actions
and preventing nursesfuture engagement. This can
be contradictory since not knowing or uncertainty
about a patient is a source of feeling unsafe.
Continuity and being present leads to the patient
feeling safe in the nursepatient relationship, which
creates opportunities to further establish a good rela-
tionship and, in turn, increases the ability to make the
patientsneeds visible (McCann & Phillips, 2007).
Our findings showed that not knowing the patient
makes it unpredictable and difficult to determine how
to best care for the patient, which was also suggested
by Holmes, Murray, and Knack (2015). Forensic psy-
chiatric care is a restricted environment, and beyond
what is considered a normallife (Olausson et al.,
2019). Patients express a longing for encounters in
which the nurse is the one taking a step forward
and not disappearing when times are tough
(Lindström, 1995). Not feeling safe also fosters hope-
lessness, and it can be an obstacle to understanding
patientsviews on health, wellbeing, and existence.
A state of being non-judgemental, present, and open
towards the patient is desirable for forensic nurses
(Bowen & Mason, 2011).
Nursescan facilitate patientspath to health by
expressing a willingness to understand patients
experiences (Rydenlund et al., 2019). In forensic psy-
chiatry, fear is considered a part of the milieu. Nurses
present a frontnot showing fear as a way of dealing
with these emotions. It is a self-protective strategy
that is necessary to see the patient as a human
being, regardless of whether the patient is evoking
fear. This is considered an obtainable professional
value (Jacob & Holmes, 2011).
Like all nursing care, nursing practice in forensic
psychiatry care is grounded in ethics, and the ethical
responsibilities underlie all nursing interactions
towards individuals, next of kin, and colleagues (ICN,
2014). When caring for a patient who emotionally
touches them, it was revealed that the nurses were
opened themselves to patientsvulnerability.
Expressing sympathy towards patients and being
open-minded are critical aspects of nursing care.
Developing compassion can promote nurses to be
fair, respectful, consistent, and knowledgeable in their
encounters with patients (Maguire, Daffern, & Martin,
2014). The nursepatient relationship in forensic psy-
chiatric settings should be grounded in trust and
confidence, and patients require opportunities for
emotional reconciliation, as suggested by Salzmann-
Erikson, Rydlo, and Wiklund Gustin (2016). Being
a nurse in forensic psychiatry is a complex role, and
there is a tension between maintaining safety and
promoting a therapeutic and patient-centred
approach (Green, Shelly, Gibb, & Walker, 2018).
Nurses strive to maintain professional boundaries
and aspects of therapeutic communication, including
establishing trustand validation,according to
Doyle et al. (2017). Establishing a trusting relationship
with patients in forensic psychiatric settings is viewed
as a less oppressive way to control patients and guide
them in directions that are preferable for the nurses
and for society. This could be achieved through
encounters in which the gap between the patient
and the nurse is reduced (Salzmann-Erikson et al.,
2016). Encounters in forensic psychiatry invite nurses
to carry the burden of guilt and suffering during long
periods (Rydenlund et al., 2019), which our findings
suggest is made possible by having trust and
Our findings also suggest that nurses were often
emotionally affected by patientsexpressions of
threat, violence, and provocative behaviour. This
situation forced a nurse, when the situation become
too severe, to take a step back and distance him/
herself from the patient as a way of regulating one-
self. Sometimes forensic nurses need to distance
themselves from their patients because of policies or
procedures around control (Gillespie & Flowers, 2009).
It is a challenge for nurses to maintain a positive
relationship with patients, especially when they have
been threatened, harassed, insulted, or physically
injured by a patient. Nurses must move past their
own feelings towards the patient and attempt to
help the patient regain trust in them to preserve
their relationship (Holmes et al., 2015).
Nurses described that encounters also means
facing suffering and their own reactions to it. Trying
to maintain a positive relationship through encoun-
ters that vary from normaleveryday circumstances,
nurses must look past the problematic behaviours
and understand that what they are seeing in patients
is the illness and not actual badbehaviour, as
described by Holmes et al. (2015). Our findings show
that, when nurses understand this, they can see
beyond the façade. This enables nurses to detect
patientsconceptions of themselves. This indicates
that the caring encounter is formed by patients
needs. The nurses described that facing patientssuf-
fering sometimes required that the nurse take a step
backnot to abandon, but rather to come closer,
which is also described by Vincze, Fredriksson, and
Wiklund Gustin (2015).
The findings in our study can be understood con-
sidering the Danish philosopher Løgstrup (1983), who
stated that vulnerability is a fundamental condition of
human life. Our findings indicate the importance of
nursesvulnerability when participating in anothers
life. According to Løgstrup (1997), meeting anothers
expressions is also ontologically, an inter-human act
where each one of the actors turns to each other in
a person-to-person encounter in which they are
guided by their perception and vulnerability. For
nurses, the challenge is also how professionalism
plays in to their interpretation of the situation. Our
findings indicate that in some occasions the caring
encounter is formed by the patients needs and the
nurses ability to regulate their own expressions.
Regulation means inviting the patient into the room
of awareness,where the two parties meet each other
and themselves (Devik et al., 2013). Through regula-
tion, nurses can open the doorto the room of
awarenessand let the patients expression make an
impression without hiding behind the protection of
ones own foreknowledge and a stereotyped view of
forensic psychiatry patients.
Logically, the keyto the room of awarenessis
nursesability to interpret patientsexpressions.
According to Løgstrup (1983), interpretation is in the
movement between perception and understanding.
Our findings clearly indicate that nursesperception
were affected, which was also seen in other studies
(Vincze et al., 2015). According to Løgstrup (1978),
understanding can also create a distance and is linked
to our preconceptions, where cultures and knowledge
are embedded. The nurse is moved and affected,
present in the perception of something that does
not leave him or her untouched (Vincze et al., 2015).
In other words, being present with the patient is
challenging when the nurse is confronted, not only
with the patients expressions, but also with their own
reactions. If a nurse encounters a patient with his/her
prior knowledge and with a preparedness to categorize
what has been said, the room of awarenessmay
become locked (Hellzen & Asplund, 2002).
Encountering patientsexpressions may be a painful
and frightening experience; however, nurses must
have the courage to stay with the patient and evaluate
both their own and patientssafety. One way to deal
with situations like this is to narrate their experience of
patientsbehaviour without questioning it. Instead
a true interest, manifested as an effort to understand
the patients experience and encourage openness of
feelings, is awoken in the nurse. As Løgstrup (1983)
states, interpretation of sensation is a way of being in
the world, sensing openness to people who wanting us
something. This means that in the interpretation the
nurse experience what it means to be not only human
in the world but also how she relates to what touches
her in the perception, an appeal of caring for the other
based on compassion.
In conclusion, to care for patients within forensic
psychiatry means facing numerous of situations that
threatens the nurses professional identity. Letting the
patients expression make an impression, taking
a step backward to be able to take a step forward
by regulating own emotions. Such strategies, creating
a temporary distance, enables nurses to come closer
to the patients to be able to alleviate suffering,
despite sometimes facing threats, violence and humi-
liation, making decisions based on compassion and
the patients needs.
Methodological considerations
Trustworthiness depends on truthful narratives of lived
experiences (Lindseth & Norberg, 2004). The first author
was known to most of the participants, which hopefully
meant that the participants could speak truthfully and
freely. On the one hand, this might facilitate trust and that
participants could speak freely and truthfully. On the
other hand, this could cause participants to be cautious
and afraid to reveal weaknesses. On the third hand, it also
challenged the first authors pre-understanding and abil-
ity to discover implicit messages. To overcome this obsta-
cle, the author tried to be attentive and ask questions so
that new and unexpected elements could be revealed.
The first author has strived towards self-awareness of
which has been encouraged through self-reflection and
discussions with the other authors. The first author con-
ducted all interviews, transcribed the text, and conducted
initial analyses. Some of the other authors lacked first-
hand knowledge in forensic care and contributed with
contesting throughout the analysis. However, all authors
contributed significantly to this manuscript. The two
main questions were formalized as either positive or
negative, which could suggest that the narratives from
the participants could be affected in either direction,
which could also mean that some encounters or
a certain group of patients were forgotten. By requesting
both negative and positive experiences from encounters,
the intention was also to trigger the participantsmemory
when narrating. It may be easier to remember experi-
ences that have been emotional touching, and asking for
specific incidents is a recognized technique when work-
ing with narrative inquiry (Drew, 1993).
This article does not present an absolute truth or
distinct evidence; rather, it can shed light on nurses
lived experiences of encounters with patients with men-
tal illnesses in forensic inpatient care. Hopefully, it will
encourage more research concerning how patients
expressions impact nurses and the care they provide. It
should be considered that forensic psychiatry is gov-
erned and controlled by laws that may differ nation-
wide; therefore, the current results should be viewed as
lived experiences in the Swedish context.
The researchers express our gratitude to those who partici-
pated and contributed to this study.
Disclosure statement
No potential conflict of interest was reported by the
Notes on contributors
Lars Hammarström, PhD student at Mid Sweden University,
research focused on encounters in forensic psychiatry.
Dr Marie Häggström,PhD,is assistant professor at the
Department of Nursing science at Mid Sweden University.
Häggströms doctoral research focused on ICU transitional
Dr Siri Andreassen Devik,PhD,is assistant professor at
department of health science at Nord university, and centre
for care research Mid Norway, and her doctoral research
focused on home nursing care In rural areas.
Prof Ove Hellzen,PhD,is Professor at the Department of
Nursing science at Mid Sweden University. Hellzens doc-
toral research focused on mental health care.
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... Some may appear calm in the heat of a court appearance, while others may fear receiving a request for forensic psychiatric assessment. A study identified that when facing forensic psychiatry cases, professionals may feel frustrated, open-minded, and in need of control and protection, as the four key themes mentioned by nurses from forensic inpatient care [2]. A national survey of Indonesian psychiatrists found that more than half of general psychiatrists feel incompetent when assessing forensic psychiatric cases, thus making it the most common reason for referral [3]. ...
... Emotion also has a more profound impact on forensic psychiatry services, as it is known to affect clinical reasoning in at least three aspects: [1] emotional response to contextual pressures, where in forensic psychiatric cases, there is always a gap for fear, conflict, uncertainty, unpredictability and discomfort which trigger individual awareness of their emotion; [2] emotional responses to others, where individual awareness of their emotion trigger need for action (or in forensic psychiatric cases -avoidance of action) and [3] intentional exclusion of emotion from clinical decision making, where individuals unconsciously keep their emotions separate from their clinical decision-making process [6]. ...
... The original MEQ instrument consisted of 4 domains: frequency, intensity, duration, and regulation for each emotion. We specified these emotions to be assessed in 4 different forensic psychiatry settings: [1] criminal cases, [2] civil cases, [3] administrative law cases, and [4] as expert witnesses in court. We also modified the scales in frequency and duration domains for use in forensic psychiatry settings. ...
Full-text available
Objective: Emotion is essential in psychiatrists' clinical decision-making in conducting forensic psychiatric evaluations. However, psychiatrists may not be aware of their own emotions and thus prone to the risk of bias in their evaluations. An English version questionnaire was previously developed to assess emotional response and regulation. This study aims to assess the validity and reliability of the translated and adapted Indonesian version of The Multidimensional Emotion Questionnaire (MEQ) among Indonesian general psychiatrists in forensic psychiatry settings. Method: This is a cross-sectional study that translated and adapted The Multidimensional Emotion Questionnaire (MEQ) designed by Klonsky et al. This study was conducted between August 2020 and February 2021, involving 32 general psychiatrists across the country who represented general psychiatrists from different educational backgrounds, clinical experiences, and workplace settings. The translation process was done by a certified independent translator and tested for validity by Item-Level Content Validity Index (I-CVI), Scale-Level Level Content Validity Index (S-CVI), and corrected item-total correlation. Cronbach's alpha values measured reliability aspects. Results: The MEQ was valid and reliable, with an I-CVI score of 0.97-1, an S-CVI score of 0.99, and Cronbach's alpha values of 0.85-0.98 for each emotion. The majority of items had a corrected item-total correlation of higher than 0.30. Conclusion: A proper and available tool to measure general psychiatrists' emotions in evaluating forensic psychiatric cases is essential in enhancing evaluators' awareness of their own emotions to eventually mitigate bias. The Multidimensional Emotion Questionnaire (MEQ) was valid and reliable for Indonesian forensic psychiatry contexts.
... This means they deal with heightened emotions and risk becoming emotionally blunted, which affects motivation and the well-being of both themselves and the patients when caring in a high-security hospital (Hui et al., 2017). Hence, a strategy to manage emotions or "regulate oneself" and not to act upon conflicting emotions is necessary-a clinical strategy and concept that has emerged from a prior study (Hammarström et al., 2019). ...
... Emotions that stem from being confronted by patients' expressions of suffering force carers to unravel and understand these expressions to give an adequate response based on compassion rather than abandoning the patient in a time of need (Hammarström et al., 2020). To deal and cope with these stressful situations, carers use the strategy of controlling their own emotions, regulating themselves to avoid acting on the initial feeling of frustration, fear or anger, remaining in the situation and getting a grip on themselves to feel emotionally ready to handle the situation and patient (Hammarström et al., 2019). Regulation of emotions and arousal mediates behavioural responses to environmental stressors and helps the individual avoid aggressive or disciplinary actions; instead, they can solve the situation using a calm approach (McDonnell et al., 2015). ...
... The emotional burden of caring in a forensic setting means that carers are becoming increasingly vulnerable to burnout (Edward et al., 2017) and must deal with stressful situations characterized by threats, violence and harassment from patients over long periods. This also means that carers must deal with emotions such as frustration, fear, humiliation and disappointment (Hammarström et al., 2019). For this reason, carers must learn and develop further skills that promote recovery and decrease restrictive practices. ...
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Purpose This study aimed to illuminate the essential meanings of carers’ lived experience of regulating themselves when caring for patients with mental illnesses in forensic inpatient care. Methods Qualitative analysis was used to analyse data from narrative interviews with open-ended questions conducted with nine carers, which were analysed using a phenomenological-hermeneutic approach. Results Findings revealed three themes, “preserving oneself as a carer,” “building an alliance with the patient” and “maintaining stability in the community.” Carers not only regulated emotions related to patients but also the ward to facilitate a caring climate. For carers, encounters with patients meant facing expressions of suffering that evoked unwanted emotions. Regulating one’s emotions also meant being emotionally touched and facing one’s vulnerability. Conclusion Regulating oneself was a strategy used by carers to get closer to the patient and establishing a trusting relationship. Regulating oneself meant becoming aware of one’s shortcomings, not projecting them onto others, which may impair establishing relationships with patients and fulfilling the aim and caring task of forensic psychiatry. This study stresses the importance of carers being guided to manage their conflicting emotions and vulnerabilities and finding courage and an approach that allows a permissive climate of self-reflection.
... While the notion of the transition of newly qualified nurses has been explored, there is less known about those with previous nursing experience or those entering specific environments, including mental health nursing (Kinghorn et al., 2017). Although nurses represent a significant portion of the mental health workforce, concerns surrounding workload, stress, workplace aggression and violence impact the choice to work in either mental health nursing or forensic mental health services (Giralt Palou et al., 2019;Hammarström et al., 2019;Oates et al., 2020). Unlike other mental health settings, forensic mental health requires nurses to find a balance between care and control to ensure that the interests of patients and the community are met (Smith & Sekula, 2018). ...
... While participants in this study acknowledged prior expectations regarding security and patients' past offences, the reality of this exposure was still initially confronting for some. Though an ability to separate patients from their history is essential in establishing therapeutic relationships (Hammarström et al., 2019), in practice, processing and working with potentially distressing knowledge is challenging (Ireland et al., 2022;Oates et al., 2020). ...
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Aim The aim of the study was to investigate why registered nurses seek forensic mental health employment and explore their initial impressions of this setting. Design Explanatory sequential mixed methods. Methods Registered nurses employed in a forensic mental health hospital completed an online survey about their reasons for seeking work in forensic mental health and their transition into the setting. To fully explore findings, semi‐structured interviews were conducted with a sub‐group of survey respondents. Descriptive statistics were used to analyse survey data, and thematic analysis was used to analyse the interviews. Results Sixty‐nine respondents completed the survey, and 11 interviews were conducted. Prior interest in forensic mental health and encouragement from hospital staff were considered important influences in seeking forensic mental health employment. New knowledge, changes in clinical responsibility, exposure to patients' background offences and security processes overwhelmed some participants initially. However, participants reported that the initial challenges of their transition revealed opportunities to develop genuine connections with patients. Conclusion This study provides a new understanding of the reasons why nurses seek employment in forensic mental health and the challenges and opportunities experienced when first working in this setting. Such professional and personal elements need to be considered by organizations to strengthen recruitment strategies and support future nurses' transition into forensic mental health settings. Impact This study provides new knowledge about recruiting and supporting nurses' transition into forensic mental health employment. As such, it informs policymakers, clinical services and managers about strategies needed to attract and retain this workforce. Patient or Public contribution No public or patient involvement.
... Most patients admitted to AFMHIS are remanded or detained under relevant legislation (such as a Mental Health Act), due to the risk posed to themselves or to others, including public safety Young, 2011). Patients present with significant mental illness and challenging behaviours such as hostility and violence, as well as complex physical health needs (Hammarström, Häggström, Devik, & Hellzen, 2019;. Aggression, and the threat of aggression is a daily occurrence in these settings (Laiho, Hottinen, Lindberg, & Sailas, 2016). ...
... The very nature of the AFMHIS epitomises restrictiveness by ward design, ward routine and physical, procedural and relational security procedures, which can contribute to an increased risk of aggression and violence (Hammarström et al., 2019;Maguire, Ryan, Fullam, & McKenna, 2022;Urheim et al., 2020). ...
Reducing or eliminating restrictive practices (specifically seclusion, restraint, and Pro Re Nata [PRN] psychotropic medications), is a global health priority due to the risk of patient harm, workforce stress, injury, and human rights issues. In 2013, the United Nations ‘Report of the Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment,’ declared that the use of restrictive practices was inhumane and tantamount to torture. This declaration added pressure globally on governments and mental health services to reduce or eliminate the use of these practices. While governments and organisations implemented strategies to achieve this goal, data on the use of seclusion and restraint suggested that after a downturn in rates, frequency and duration, the use of these practices increased, particularly in the adult forensic mental health inpatient setting (AFMHIS). Furthermore, international rates of PRN psychotropic medication use in AFMHIS have not been reported by government agencies and therefore, have not received the same level of scrutiny as seclusion and restraint and require investigation. Understanding what factors can contribute to the use of restrictive practices is critical to being able to influence policy, procedure, and practice changes. Indeed, the very nature of AFMHIS provides unique challenges in reducing and eliminating the use of restrictive practices, however, research is lacking in this setting. The aim of this research was to explore the use of restrictive practices in the AFMHS. A multiphase mixed method research design (QUAN-qual) was used, with three quantitative and one qualitative research studies conducted in an AFMHIS in Australia. Integration and analysis of the study results occurred during the reporting stage of the thesis. Firstly, a survey compared the attitudes of nurses from acute and AFMHSs towards the use of PRN psychotropic medications. Secondly, an exploration of the experiences of nurses working in the AFMHIS was completed. Thirdly, retrospective data collection was completed at an AFMHIS to evaluate whether seclusion use was influenced by nurse, clinical or contextual factors. Finally, the influence of patient factors on the use of seclusion was explored by undertaking a retrospective case file audit on all patients admitted to an AFMHIS over a six- month period. The results of the literature review and each study are presented through a sequence of five peer reviewed journal articles and four standard thesis chapters. The findings of the studies provide insight into the experiences of nurses working in this unique setting and the care they provide. Practice differences in the use of PRN psychotropic medications were identified between forensic and mental health nurses working in acute inpatient settings. The study exploring nurses’ experience of working in an AFMHIS identified four critical factors that influenced their practice experiences: (i) working in an interesting but challenging environment, (ii) specialty expertise, (iii) exposure to aggression, and (iv) the importance of effective teamwork and leadership. The analysis of staffing variables and the use of seclusion identified three staffing variables that had an influence on the use of seclusion: the number of registered nurses on duty, the presence of the shift coordinator and having a lead nurse on shift. The study analysing patient factors and the use of seclusion identified two patient characteristics, gender, and diagnosis, that increased the likelihood of a seclusion event occurring. This research addressed gaps in knowledge by reporting rates of restrictive practices within an AFMHIS. In addition, the results elicited new information in understanding the influence of patient and nurse characteristics on the use of restrictive practices. Recommendations are made regarding practice improvement resulting from the findings of this research as well as areas for future research. Available from
... In this study, many participants indicated that they felt alone, isolated and lacked support from administrators / managers and colleagues during the transition period. Previous literature recognises that relational support in FMH influences the emotional safety of staff ( Barr, Wynaden, & Heslop, 2019 ) and the quality of nursing care ( Hammarström, Häggström, Devik, & Hellzen, 2019 ), which is considered essential for working with complex patient needs. The consequences of a lack of support and mistrust between colleagues can be significant with emotional exhaustion and burnout ( Doyle, Quayle, & Newman, 2017 ;Robertson et al., 2020 ). ...
Background With the growing need for nurses in forensic mental health settings, understanding the experiences of transition and perceptions of the setting is important to support staff retention. Aim To explore registered nurses’ experiences of working in a forensic mental health setting. In particular, to understand their transition experience, perceptions of the practice environment and intention to stay within the setting. Methods Registered nurses employed in a high-secure forensic mental health hospital in New South Wales, Australia, completed an online survey including the Revised Professional Practice Environment Scale and Nurse Retention Index. Findings Sixty-nine participants responded to the survey. During the first year of their employment, participants reported feeling isolated, lacking support and being anxious when providing patient care. In terms of the environment, participants perceived ‘internal work motivation’ as positive in the environment when compared to ‘handling disagreement and conflict’. While many intended to continue their nursing careers for the foreseeable future, 45.3% of participants were undecided about whether they would leave the forensic setting. Discussion Due to the complexity of forensic mental health practice, the reporting of poor experiences of transition and issues regarding support and conflict is concerning. Considering the importance of workplace culture and teamwork in forensic mental health, strategies to enhance positive interpersonal relationships is essential. Conclusion Given the predicted future workforce shortages, this study highlights a need for appropriate supports for nurses’ transitioning into forensic mental health employment to enhance workplace satisfaction and retention.
Forensic mental health nurses (FMHN) provide care to address the needs of people who have mental illnesses across a range of diverse settings. The Clinical Reasoning Cycle (CRC) has been identified as a potential framework to assist FMHNs; however, adaptations were required to reflect the unique nature of the clinical setting. This study aimed to explore adaptations made to determine suitability prior to implementation in practice. Nominal Group Technique was used to explore suggested adaptations determined from a previous study and reach a consensus on the changes. Fourteen senior nurses from a state‐wide Forensic mental Health (FMH) service participated. A consensus was reached for two proposed changes. Data were analysed using thematic analysis. Three main themes were interpreted from the data; FMH adaptations are warranted, the focus of the CRC, and who owns the cycle? Nurses in this study considered the need to include offence and risk issues due to the impact these factors have on the therapeutic relationship and cognitive bias; however, they also identified the need to focus on recovery‐oriented care while engaging in clinical reasoning. Nurses in this study also expressed some reluctance for nursing to ‘own' the model, due to concern that ownership may cause division among the team or result in inconsistency in care. However, some participant's suggested the CRC with adaptations assisted FMH nurses to articulate their specialist skills and knowledge to others and highlight the nursing contribution to care. Further work is needed to finalize adaptations with a focus on engaging the consumer carer workforce and interdisciplinary team.
While forensic mental health has seen considerable growth over the last two decades, little is known about the experience of registered nurses working in these environments. This study used a qualitative descriptive approach and interviewed 11 registered nurses to explore the interpersonal experiences of transition into a forensic mental health hospital. The data revealed three themes. ‘Observing what's safe’ examined nurses' ability to maintain safety in the context of inconsistent practices among colleagues. ‘Navigating cliques and divisions’ focused on nurses' sense of belonging and adapting to professional and personal groups. Finally, ‘gaining management support’ reflected nurses' experiences of engagement with management. This study provides new insight into nurses' experience of adapting to employment in forensic mental health settings and highlights the importance of positive support strategies for workplace transition.
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CITATION de Vries MG, Verkes R-J and Bulten BH (2022) See think act scale: Validation of the Dutch version of a measure of relational security in high secure forensic psychiatric care. Relational security is considered an essential form of security in forensic psychiatric care. Research on relational security is important, but is hampered by the lack of instruments to assess and monitor this concept in clinical practice. Within this current study the psychometric properties of the Dutch version of the See Think Act (STA) scale, an instrument designed to measure relational security as perceived by forensic staff members within secure settings, was studied. Results show that the internal consistency of the STA total scale was good. However, the internal consistency of the subscales was relatively low compared to other studies using the original English or the Chinese version of the STA scale. The factor structure found in the original English version of the scale was not confirmed within this sample. With regard to the validity of the instrument results were promising, finding relationships with aspects of ward climate and team reflexivity. Further research and development is needed regarding the STA scale, making it more suitable for monitoring and studying this clinically relevant concept in forensic care.
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Purpose: To translate the Korean version of Nurses' Attitudes Towards the Forensic Psychiatric Patients Scale (NAFPPS-K) into Korean and to test validity and reliability as well.Methods: Participants were 275 psychiatric nurses in South Korea who completed the self-reported online survey of the NAFPPS-K. Twenty-five items were used for item analyses, exploratory factor analyses, and confirmatory factor analyses, as well as for examining internal consistency.Results: The four factors of “Concerns about Recidivism (seven items)”, “Social Distance (four items)”, “Burden of Providing Care (four items)” and “Willingness to Provide Care (four items)” were identified based on the results of item reduction and exploratory factor analyses. Theses factors accounted for 58.1% of the total variance of the NAFPPS-K. Fitness of the modified mode was acceptable ( x <sup>2</sup>=331.56, CFI=.92, TLI=.91, GFI=.89, RMSEA=.07). Cronbach’s ⍺ of the 19 items was .83.Conclusion: This study identifies the validity and reliability of the NAFPPS-K. Four factors of the NAFPPS-K may be useful in evaluating the nurses' attitude for forensic psychiatric patients.
Nurses regularly encounter feelings of disgust in practice, from bodily fluids and wounds to the criminal histories of patients. Though these experiences are widespread in nursing practice, there exists a culture in which they are regularly and intentionally ignored by nurses, and have received little attention in the literature. French-Bulgarian philosopher Julie Kristeva described these feelings of disgust within her psychoanalytic concepts of abjection and the clean and proper self. When nurses experience abjection, they work to protect and maintain the boundaries of the clean and proper self. This paper will employ a conceptual analysis to explore the implications of abjection and the maintenance of the clean and proper in nursing practice, with a specific focus on forensic nursing. A literature review of scientific articles and monographs addressing issues of disgust and abjection was conducted. The work of Kristeva provides the theoretical framework for this analysis. The analysis illustrates that nurses erect boundaries between themselves and patients, with significant consequences for patient care. An enactment of rituals to avoid the uncomfortable feelings of abjection and an effort to maintain the clean and proper self is widespread in nursing practice. Acknowledging the presence of abjection in nursing practice, recommendations are given on how to both embrace and overcome this experience.
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Background: Therapeutic staff-patient interaction is fundamental in psychiatric care. It is recognized as a key to healing in and of itself, or a premise to enhance psychiatric treatment adherence. Still, little is known about how these interactions are recorded in nursing documentation. The purpose of the study was to assess the quality and quantity of staff-patient interactions as recorded in progress notes in nursing documentation. Methods: The study has an observational registry study design. A random sample of 3858 excerpts was selected from progress notes in 90 patient journals on an acute psychiatric unit and an open inpatient district psychiatric centre (DPC) in Norway. The Scale for the Evaluation of Staff-Patient Interactions in progress notes (SESPI) was used to assess the progress note excerpts. It is developed to assess the quality and quantity in excerpt descriptions of staff-patient interactions in terms of empathic attunement. Descriptive statistics were calculated for the total sample and for each ward separately. Ordinal and multinomial logistic regression were used to estimate control for shift type, staff education level, and type of hospital ward. Results: Only 7.6% of the total number of excerpts (N = 3858) described staff-patient interactions sufficiently to analyze them in terms of attunement. Compared to the DPC, the acute ward reported more staff-patient interactions. The evening excerpts reported more successful types of attunement than those from the night shifts. Education level did not contribute significantly to our models. Conclusion: These findings present a unique insight into the quality and quantity of mental health nursing documentation regarding staff-patient interactions. Therapeutic interactions where staff tried to attune to the patients were rarely described. However, this is the first study measuring nursing documentation with the SESPI, and more studies are required to validate the scale and our findings. One potential clinical implication of this research is the development of a scale that personnel in psychiatric wards can have for evaluation of the quality of their reporting practice with emphasis on staff-patient interactions. By regular use this may help keeping up emphasis on emphatic attunement in milieu treatment contexts.
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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.
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Currently, women comprise about ten percent of those sentenced to psychiatric forensic clinics in Sweden. Those who are sentenced to forensic care because of offending and violent behaviour have already taken a step away from the usually expected female behaviour. On the other hand, there are many women in forensic care who have not committed crimes, but who instead self-harm. Studies have identified a gender bias in diagnosing and care in psychiatric settings, but there are few studies conducted on women in forensic care. The present study therefore examined how the situation of women patients and female norms are expressed in the staff’s talk about these women during verbal handovers and ward rounds at a forensic clinic in Sweden. The aim was to explore how psychiatric staff, in a context of verbal handovers and ward rounds, talk about women who have been committed to forensic psychiatric care, and what consequences this might have for the care of the patients. The content of speech was examined using audio recordings and a method of analysis that was inspired by thematic analysis. The analysis identified that the staff talked about the women in a way that indicates that they expected the women to follow the rules and take responsibility for their bodies in order to be regarded as acceptable patients.
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Forensic mental health nursing is a complex role and there is a tension between maintaining safety and promoting a therapeutic and patient centred approach. The use of restrictive practises such as seclusion is an issue. Two focus groups with registered nurses exploring attitudes and factors used in decision-making about seclusion use were analysed using interpretive description. Participants described the need to reduce the use of seclusion and the problematic nature of its utility as an ongoing intervention in contemporary mental healthcare. It was clear that there were complexities and competing variables involved in the decision-making process.
Introduction: Increased knowledge about forensic psychiatric patients' relatives' perceptions in regard to the use of mechanical restraint (MR) is necessary, if clinical practice is to be improved and to achieve a reduction in the use and frequency of MR. However, a specific knowledge deficit about relatives' perspectives on the use of MR limits the evidence base considerably. Aim: The aim of this study was to investigate the perceptions of MR held by relatives of forensic psychiatric patients' including factors impacting its use and duration. Method: Qualitative interviews were conducted with 15 parents of patients within a forensic psychiatry setting and thematically analyzed. Findings: Two main themes were identified, namely, “care and protection” and “inclusion and involvement,” and one subtheme, “information.” These themes revealed the framework used by parents to construct a sense of “trust or distrust” about the ability of staff to provide adequate and safe care for their adult children in the forensic psychiatric setting. Conclusion: Some parents in this study considered that forensic psychiatric staff used MR as a necessary protection. However, most parents held strong negative perceptions regarding the use of MR and the quality and safety of care provision. It is apparent that parents in this study believed they should be included and involved in the care in situations associated with the use of MR, because they considered that this could reduce its use. Further research is required to target interventions to reduce the use and duration of MR episodes and to improve clinical practice in forensic psychiatry.
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.
Social climate is a commonly evaluated aspect of inpatient forensic mental health settings. However, there is little clarity in the literature on the components of social climate. To identify these components, qualitative studies of staff and patient experiences of social climate were systematically reviewed using best fit framework synthesis. An a priori framework was developed based on nine existing models of social climate. A systematic search identified twenty studies of sufficient quality to be included in the review. These studies included staff and patient perspectives across all levels of inpatient forensic settings. In all twenty-two themes were identified in the review papers. From these themes, a model of social climate was developed. Seven factors were identified as part of the social climate, including the therapeutic relationship, care and treatment orientation, the secure base and four aspects of the ward environment. The findings indicate that common measures of social climate may not fully represent the construct. Themes related to the patient group, the staff group, the physical environment and system level factors were identified as influencing social climate. The model described allows for consideration of interventions to positively influence social climate.
Background: In forensic psychiatric care, a hermeneutic caring conversation between caregivers and patients can improve health outcomes. The hermeneutic approach entails starting from the whole and involves openness for what is shown as well as paying attention to the different parts. One way to deepen these conversations is to take advantage of both the caregivers' and the patients' life experiences. Research questions: The purpose of the study is to discuss and reflect on what hermeneutic caring conversations can mean for a deepened understanding of the movement in the health processes of patients in forensic care, patients who are in deep suffering. Research design: This study uses a hermeneutic methodology. Conversations with patients receiving care in forensic psychiatry are deepened using texts from philosophy, caring science, and poetry. The outcome emerges through a phase of creating patterns. Participants: Three patients in forensic care. Ethical considerations: This study builds on a doctoral thesis approved by The Ethical Review Board at the Faculty of Medical and Health Sciences, Linköping, Sweden. Findings: Hermeneutic caring conversations provide a possibility for rich caring conversations with patients who are often not given a voice. These conversations are seen as ethical expressions of hermeneutic caring communion that affect patients' health processes in a positive way. Discussion: It takes courage and responsibility to initiate and conduct these conversations as the patients volunteer to share their suffering. In hermeneutic caring conversations, the caregiver's attitude is crucial for the transference of knowledge. Conclusion: This study provides a preliminary outline for hermeneutic caring conversations. A caring culture that provides time and space to prepare hermeneutic caring conversations is a prerequisite for the implementation of hermeneutic caring conversations.