Controlling emotions—nurses’ lived experiences caring for patients in forensic psychiatry

Abstract

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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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:
10.1080/17482631.2019.1682911
To link to this article: https://doi.org/10.1080/17482631.2019.1682911
© 2019 The Author(s). Published by Informa
UK Limited, trading as Taylor & Francis
Group.
Published online: 24 Oct 2019.
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Controlling emotions—nurses’lived experiences caring for patients in
forensic psychiatry
Lars Hammarström
a
, Marie Häggström
a
, Siri Andreassen Devik
b
and Ove Hellzen
a
a
Department of Nursing, Mid-Sweden University, Sundsvall, Sweden;
b
Department of Health Sciences, Nord University, Namsos, Norway
ABSTRACT
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, emo-
tional regulation, and distancing themselves when necessary may enable nurses to more
effectively respond to patients’needs.
ARTICLE HISTORY
Accepted 16 October 2019
KEYWORDS
Encounters; forensic nursing;
forensic psychiatry; lived
experience; nurse-patient
relationship; nursing;
phenomenological-
hermeneutic approach
Introduction
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 nurses’encounters 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 patients’mental 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 patient’s 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 patients’experiences
(Myklebust & Bjorkly, 2019). Løgstrup (1997) pre-
sented a phenomenological-hermeneutic ethical
demand—he stressed that encounters with other
people come with a distinct responsibility: people
exist together and are dependent on each other.
CONTACT Lars Hammarström lars.hammarstrom@miun.se Department of Nursing, Mid Sweden University, Holmgatan 10, Sundsvall, Sweden
INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING
2019, VOL. 14, 1682911
https://doi.org/10.1080/17482631.2019.1682911
© 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 (http://creativecommons.org/licenses/by/4.0/), which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

People extradite themselves to a “me and you”rela-
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, patients’dignity 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 expectations—an 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 nurses’perspective (Selvin, Almqvist, Kjellin,
Lundqvist, & Schroder, 2019). Nurses must be supported
so that they provide care that eases patients’suffering
and prevent future crimes. If feelings like fear, disorienta-
tion, and anger become the foundation of care, the care-
takerswillnotbeabletoeasepatients’suffering (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 nurses’tasks are contra-
dictory—they are supposed to care, guard, and protect;
connect with the patient; create a trusting relationship;
ease the patients’suffering; and improve their health and
wellbeing. Letting a patient’s expressions become the
nurse’s 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 nurses’lived 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 individuals’lived 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 25–45 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 = 28–67 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 “nurse”to 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
2L. HAMMARSTRÖM ET AL.

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.
Ethics
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 author’s and supervisors’contact 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).
Results
Naive understanding
During their work, nurses face various patient expres-
sions. The encounters are based on nurses’willingness
to do well; however, they are sometimes characterized
by violence, resistance, and threats—thus 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 patients’recovery.
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
conflict—a conflict based either on caring and alle-
viating suffering or on guarding and fostering
patients. However, letting patients’expressions 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 phenomenon—nurses’
encounters with mental ill patients in forensic inpati-
ent care—is 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 one’s 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
hopelessness—despite repeated attempts to reach
patients.
“Hopelessness isn’t an unusual feeling; it can come over
you sometimes. It can come when you don’t 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.
“Itcanbeahasslewithapatientgroupthatwouldnotneed
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
INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 3

all the relapses, which leads to an extension of care times.
It’s not so much an annoyance as a sense of hopelessness.
But it’sspecialhere—with 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 patients’development.
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.”
“It’s 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 patient’s illness that some-
times does not show any improvement. Wanting to
help and then being rejected by the patient fosters
nurses’sense of frustration. However, both becoming
aware and recognizing their own shortcomings helps
nurses cope with this frustration.
“I can link it directly to work effort—how 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 I’m 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
wrong.
“There’s one patient where I find it difficult to feel good-
ness and love. It’s 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 nurses’actions 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.
“It’s worse when you get scared. When you feel that
you’re 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 patient’s history and profes-
sional experience help the nurse stay one step ahead.
“With some patients, you have to be on your guard. You
don’t let them behind your back. Such times, it’s 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 wasn’t right—a 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
4L. HAMMARSTRÖM ET AL.

need to proceed with caution when encountering
new patients. Sometimes the distrust is linked to the
patients’experiences. 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 didn’t know him. [I] didn’t 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, there’s 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 nurses’ability to under-
stand patients’history and disease. It is needed for an
effective patient–nurse relationships. This theme con-
sists of three subthemes: being confirmed, developing
trust, and developing compassion.
Being confirmed
Being confirmed means that nurses’engagement
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] it’s something
I want to maintain.”
Patients’expressions of gratitude contribute to the
caring relationship. The nurses appreciate when the
patients value good nursing care, which increases
nurses’self-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 don’t show much gratitude; but some do
it. Then, you get energy and a great feeling in the body.
Then, I feel that you’re 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 more—like, sharing
myself. When I learn how to respond to him, I feel more
secure. Then you dare more. I can’t feel the mood of the
patient if I go around being scared or don’t feel safe.”
Trust also means that the balance of power is reduced
by the patient’s 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 person”and not just “the patient.”Becoming
aware of and recognizing the vulnerability of the
patient’s situation characterizes these interactions.
“She then told me about her whole life. To hear about
how her life has been—about why she committed the
crime she had done. It all felt very tragic.”
It is not only the patient’s life that makes an impres-
sion on the nurse; the patients’temperament 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 patient’s expressions over time pro-
moted a deeper relationship between nurses and
patients. Which may also create a more caring
relationship.
“I’ve been with these patients for several years. I’ve
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
them.”
INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 5

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 patients’vulnerability. It was described as frus-
trating when patients’wellbeing 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 it’s 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 nurses’responsibilities,
including legally, concerning patients’care. 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
patients’rights and the safety of society. The care is
complicated as patients may be ill, aggressive, and
provocative.
“If they’re being aggressive, then you’ve 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 calm—if it’s 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 else’s 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 happened—why
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
manageable.”
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.
Patients’expressions of threat, violence, and provoca-
tive behaviour threaten nurses’professional identity.
Nonetheless, nurses attempted to empathize with
patients’experiences and displayed competence in
assessing patients’expressions. Nurses placed them-
selves in a vulnerable position by acknowledging
patients’uniqueness 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.
Discussion
The aim of this study was to illuminate the meaning
of nurses’lived 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 patients’expressions emotionally
affected nurses’caring actions and preferences as
well as their professional self-esteem and moral
identity.
Working in a forensic environment challenges
nurses’identity 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
patients’potentially provoking and violent behaviour.
This means that the provision of competent and com-
passionate care can be compromised by nurses’fear
and lack of knowledge. The care approach may also
fail owing to a lack of self-confidence or courage in
nurses’interactions 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 patients’complexities.
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
6L. HAMMARSTRÖM ET AL.

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
nurse–patient 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 lifeline—saving 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 patients’crimes 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 nurse–patient relationship.
Consistently, patients’ability 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 nurse–patient
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 nurses’future 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 nurse–patient relationship, which
creates opportunities to further establish a good rela-
tionship and, in turn, increases the ability to make the
patients’needs 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 “normal”life (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
patients’views 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).
Nurses’can facilitate patients’path 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 front—not 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 patients’vulnerability.
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 nurse–patient 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 “trust”and “validation,”according to
INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 7

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
compassion.
Our findings also suggest that nurses were often
emotionally affected by patients’expressions 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 “normal”everyday circumstances,
nurses must look past the problematic behaviours
and understand that what they are seeing in patients
is the illness and not actual “bad”behaviour, 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
patients’conceptions of themselves. This indicates
that the caring encounter is formed by patients’
needs. The nurses described that facing patients’suf-
fering sometimes required that the nurse take a step
back—not 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
nurses’vulnerability when participating in another’s
life. According to Løgstrup (1997), meeting another’s
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 “door”to the “room of
awareness”and let the patient’s expression make an
impression without hiding behind the protection of
one’s own foreknowledge and a stereotyped view of
forensic psychiatry patients.
Logically, the “key”to the “room of awareness”is
nurses’ability to interpret patients’expressions.
According to Løgstrup (1983), interpretation is in the
movement between perception and understanding.
Our findings clearly indicate that nurses’perception
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 patient’s 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 awareness”may
become locked (Hellzen & Asplund, 2002).
Encountering patients’expressions may be a painful
and frightening experience; however, nurses must
have the courage to stay with the patient and evaluate
both their own and patients’safety. One way to deal
with situations like this is to narrate their experience of
patients’behaviour without questioning it. Instead
a true interest, manifested as an effort to understand
the patient’s 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 nurse’s professional identity. Letting the
patient’s 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 patient’s needs.
8L. HAMMARSTRÖM ET AL.

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 author’s 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 participants’memory
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.
Acknowledgments
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
authors.
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.
Häggström’s doctoral research focused on ICU transitional
care.
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. Hellzen’s doc-
toral research focused on mental health care.
References
Bowen, M., & Mason, T. (2011). Forensic and non-forensic
psychiatric nursing skills and competences for psycho-
pathic and personality disordered patients. Journal of
Clinincal Nursing,21, 3556–3564.
Bowring-Lossock, E. (2006). The forensic mental health
nurse, a litterature review. Journal of Psychiatric and
Mental Health Nursing,13, 778–780.
Carroll, A., Lyall, M., & Forrester, A. (2004). Clinical hopes and
public fears in forensic mental health. Journal of Forensic
Psychiatry & Psychology,15(3), 407–425.
Creswell,J.,&Poth,C.(2018). Qualitative inquiry & research
design, choosing among five aspproaches. Los Angeles: SAGE.
Dennis, A. M., & Leach, C. (2007). Expressed emotion and burn-
out: The experience of staff caring for men with learning
disability and psychosis in a medium secure setting. Journal
of Psychiatric and Mental Health Nursing,14(3), 267–276.
Devik, S. A., Enmarker, I., & Hellzen, O. (2013). When expres-
sions make impressions-nurses’narratives about meeting
severely ill patients in home nursing care:
A phenomenological-hermeneutic approach to under-
standing. International Journal of Qualitative Studies on
Health and Well-being,8, 21880.
Doyle, P., Quayle, E., & Newman, E. (2017). Social climate in
foren- sic mental health settings: A systematic review of
qualitative studies. Aggression and Violent Behavior,26,
118–136.
Drew, N. (1993). Reenactment interviewing: A methodology
for phenomenological research. Image - The Journal of
Nursing Scholarship,25(4), 345–351.
Eivergard, K., Enmarker, I., Livholts, M., Alex, L., & Hellzen, O.
(2018). The importance of being acceptable - psychiatric
staffs’talk about women patients in forensic care. Issues
in Mental Health Nursing,1–9. doi:10.1080/
01612840.2018.1514551
Encinares,M.,McMaster,J.J.,&McNamee,J.(
2005). Risk assess-
ment of forensic patients: Nurses’role. Journal of Psychosocial
Nursing and Mental Health Services,43(3), 30–36.
Gillespie, M., & Flowers, P. (2009). From the old to the new:
Is forensic mental health nursing in transition? Journal of
Forensic Nursing,5(4), 212–219.
Goulter, N., Kavanagh, D. J., & Gardner, G. (2015). What
keeps nurses busy in the mental health setting? Journal
of Psychiatric and Mental Health Nursing,22(6), 449–456.
Green, R., Shelly, C., Gibb, J., & Walker, T. (2018).
Implementing seclusion in forensic mental health care:
A qualitative study of staff decision making. Archives of
Psychiatric Nursing,32(5), 764–768.
Harris, D. M., Happell, B., & Manias, E. (2015). Working with
people who have killed: The experience and attitudes of
forensic mental health clinicians working with forensic
INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 9

patients. International Journal of Mental Health Nursing,24
(2), 130–138.
Hellzen, O., & Asplund, K. (2002). Being in a fragmented and
isolated world: Interviews with carers working with
a person with a severe autistic disorder. Journal of
Advanced Nursing,37(4), 346–354.
Hellzen, O., & Asplund, K. (2006). Nurses’narratives about
their residents when caring for people with long-term
mental illness in municipal group dwellings.
International Journal of Mental Health Nursing,15(1),
60–69.
Holmes, D., Murray, S. J., & Knack, N. (2015). Experiencing
seclusion in a forensic psychiatric setting:
A phenomenological study. Journal of Forensic Nursing,
11(4), 200–213.
Hörberg, U. (2008). Att vårdas eller fostras. Det
rättspsykiatriska vårdandet och traditionens grepp (Acta
Wexionensia No 133/2008. ISSN: 1404-4307, ISBN: 978-
91-7636-590-8). Växjö: Växjö University.
Hörberg, U. (2015). Caring science and the development of
forensic psychiatric caring. Perspectives in Psychiatric Care,
51(4), 277–284.
Hörberg, U., Sjogren, R., & Dahlberg, K. (2012). To be strate-
gically struggling against resignation: The lived experi-
ence of being cared for in forensic psychiatric care.
Issues in Mental Health Nursing,33(11), 743–751.
International Council of Nurses etiska kod för sjuksköterskor
(rev.). Översättning av Svensk sjuksköterskeförening.
(2014).
Jacob, J. D., Gagnon, M., & Holmes, D. (2009). Nursing
so-called monsters: On the importance of abjection and
fear in forensic psychiatric nursing. Journal of Forensic
Nursing,5(3), 153–161.
Jacob, J. D., & Holmes, D. (2011). Working under threat: Fear
and nurse-patient interactions in a forensic psychiatric
setting. Journal of Forensic Nursing,7(2), 68–77.
Jacobson, N. (2009). Dignity violation in health care.
Qualitative Health Research,19(11), 1536–1547.
Kettles, A., & Woods, P. (2006). A concept analysis of ‘foren-
sic’nursing (Vol. 8). Brighton: The British Journal of
Forensic Psychiatry.
Kukulu, K., & Ergun, G. (2007). Stigmatization by nurses
against schizophrenia in Turkey: A questionnaire survey.
Journal of Psychiatric and Mental Health Nursing,14(3),
302–309.
Leutwyler, H., & Wallhagen, M. (2010). Understanding physi-
cal health of older adults with schizophrenia. Building
and eroding trust. Journal of Gerontological Nursing,36
(5), 38–45.
Lilja, L., & Hellzén, O. (2007). Disconfirmed in one’s otherness:
A comparison between the nurse’s view of the patient’s
past, present and future and the patient’s own view of the
past, present and future. International Journal of Qualitative
Studies on Health and Well-being,2(3), 131–143.
Lindseth,A.,&Norberg,A.(2004). A phenomenological
hermeneutical method for researching lived
experience. Scandinavian Journal of Caring Sciences,
18(2), 145–153.
Lindström, U. (1995). Ensamhetskänslan sviker inte, En kva-
litativ studie rörande patienters upplevelser av vårdkultur
och vårdrelation på psykiatriskt sjukhus. Åbo: Instutionen
För Vårdvetenskap, Rapport,6/1995, 38–41.
Løgstrup, K. (1978). Skabelse og tilintetgørelse.
Religionsfilosofiske betragtninger [Creation and destruc-
tion. Religious philosophical considerations].
Copenhagen: Gyldendal. In Danish, 1978.
Løgstrup, K. (1983). Kunst og erkendelse. Kunstfilosofiske
betragtninger [Art and realization. Art philosophical con-
siderations]. Copenhagen: Gyldendal. In Danish, 1983.
Løgstrup, K. E. (1997). The ethical demand. Notre Dame, IL:
University of Notre Dame Press.
Maguire, T., Daffern, M., & Martin, T. (2014). Exploring nurses’
and patients’perspectives of limit setting in a forensic
mental health setting. International Journal of Mental
Health Nursing,23(2), 153–160.
Malterud, K., Siersma, V. D., & Guassora, A. D. (2015). Sample
size in qualitative interview studies: Guided by informa-
tion power. Qualitative Health Research. doi:10.1177/
1049732315617444
Maroney, M. K. (2005). Caring and custody: Two faces of the
same reality. Journal of Correctional Health Care,11(2),
157–169.
McCann, E., & Phillips, L. (2007). The subjective experience of
people who regularly receive depot neuroleptic medica-
tion in the community. Journal of Psychiatric & Mental
Health Nursing,14, 578–586.
Mishler, E. G. (1986). Research interviewing: context and nar-
rative.cambridge. MA: Harvard University Press.
Myklebust, K. K., & Bjorkly, S. (2019). The quality and quan-
tity of staff-patient interactions as recorded by staff.
A registry study of nursing documentation in two inpa-
tient mental health wards. BMC Psychiatry,19(1), 251.
Nedopil, N., Taylor, P., & Gunn, J. (2015). Forensic psychiatry
in Europe: The perspective of the Ghent Group.
International Journal of Psychiatry in Clinical Practice,19
(2), 80–83.
Norvoll, R., & Pedersen, R. (2016). Exploring the views of
people with mental health problems on the concept of
coercion: Towards a broader socio-ethical perspective.
Social Science Medicine,156, 204–211.
Olausson, S., Danielson, E., Berglund Johansson, I., & Wijk, H.
(2019). The meanings of place and space in forensic
psychiatric care - A qualitative study reflecting patients’
point of view. International Journal of Mental Health
Nursing,28(2), 516–526.
Rao, H., Mahadevappa, H., Pillay, P., Sessay, M., Abraham, A.,
& Luty, J. (2009). A study of stigmatized attitudes towards
people with mental health problems among health
professionals. Journal of Psychiatric and Mental Health
Nursing,16(3), 279–284.
Rask, M. (2002). Swedish forensic psychiatric nursing care: Nurse
´s views of values, theories and practice.(Doctoral thesis).
Malmö: Lund University: Department of Psychiatry.
Rask, M., & Brunt, D. (2006). Verbal and social interactions in
Swedish forensic psychiatric nursing care as perceived by
the patients and nurses. International Journal of Mental
Health Nursing,15(2), 100–110.
Rask, M., & Hallberg, I. (2000). Forensic psychiatric nursing
care –Nurses apprehension of their responsibility and
work content: A Swedish survey. Journal of Psychiatric
and Mental Health Nursing,7, 163–177.
Rydenlund, K., Lindstrom, U. A., & Rehnsfeldt, A. (2019).
Hermeneutic caring conversations in forensic psychiatric
caring. Nursing Ethics,26(2), 515–525.
Salzmann-Erikson, M., Rydlo, C., & Wiklund Gustin, L. (2016).
Getting to know the person behind the illness - the
significance of interacting with patients hospitalised in
forensic psychiatric settings. Journal of Clinical Nursing,25
(9–10), 1426–1434.
Selvin, M., Almqvist, K., Kjellin, L., Lundqvist, L. O., &
Schroder, A. (2019). Patient and staff experiences of quality
in Swedish forensic psychiatric care: A repeated
10 L. HAMMARSTRÖM ET AL.

cross-sectional survey with yearly sampling at two clinics.
International Journal of Mental Health Systems,13,8.
Selvin, M., Almqvist, K., Kjellin, L., & Schröder, A. (2016). The
concept of patient participation if forensic psychiatric
care: The patient perspective. Journal of Forensic
Nursing,12(2), 57–63.
Sjögren, R. (2004). Att vårda på uppdrag kräver visdom: En
studie om lidandet hos och vårdandet av patienter som
sexuellt förgripit sig på barn (Acta Wexionesia, no 37).
Växjö: Växjö University.
Sturidsson, K., Turtell, I., Tengström, A., Lekander, M., &
Levander, M. (2007). Time use in forensic psychiatry: An
exploratory study of patients’time use at a Swedish for-
ensic psychiatric clinic. International Journal of Forensic
Mental Health,6(1), 79–86.
Tenkanen, H., Taskinen, H., Kontio, R., Repo-Tiihonen, E.,
Tiihonen, J., & Kinnunen, J. (2016). Nurses’time use in
forensic psychiatry: Core interventions outlined in the
finnish clinical practice guideline on schizophrenia.
Journal of Forensic Nursing,12(2), 64–73.
Tingleff, E. B., Hounsgaard, L., Bradley, S. K., Wilson, R. L., &
Gildberg, F. A. (2019). A matter of trust and distrust:
A qualitative investigation of parents’perceptions about
the use of mechanical restraint on their adult children in
a forensic psychiatric setting. Journal of Forensic Nursing,
15(2), 120–130.
Vincze, M., Fredriksson, L., & Wiklund Gustin, L. (2015). To do
good might hurt bad: Exploring nurses’understanding
and approach to suffering in forensic psychiatric settings.
International Journal of Mental Health Nursing,24(2),
149–157.
Vorstenbosch, E. C. W., Bouman, Y. H. A., Braun, P. C., &
Bulten, E. B. H. (2014). Psychometric properties of the
forensic inpatient quality of life questionnaire: Quality of
life assessment for long-term forensic psychiatric care.
Health Psychology and Behavioral Medicine,2(1), 335–348.
WMA. (2008). World Medical Association declaration of
Helsinki Ethical principles for medical research involving
human subjects. Retrieved from http://www.wma.net/en/
30publications/10policies/b3/
INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 11