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Online video games and patient–staff power relations. A qualitative study of care and custody in forensic psychiatry

Authors:
  • Aarhus University Hospital Psychiatry
  • Institute of Clinical Medicine Aarhus University & Aarhus University Hospital Psychiatry

Abstract

Introduction In recovery-oriented care, forensic psychiatric nurses must engage in care relationships with patients (FPs) while focusing on ward security. Online video games (OVG) may provide a platform for negotiating power and social relations. Studies showing how OVG interventions may influence power balances in forensic psychiatric care are needed to guide clinical practice. Aim To study how power relations were articulated between FPs and staff in an OVG intervention in a Danish forensic psychiatric ward. Method Data consists of three months of observational data and interviews with three staff members and six patients. We used sociologist Pierre Bourdieu’s framework of field, power, and capital to analyze data. Results The OVG intervention consists of two power fields, “in-game” and “over-game.” In-game concerned the practice of gaming. Over-game described the organization of the gaming intervention. Specific logics, skills, and symbolic capitals drove power in each field. Discussion Power in-game was open to FPs and staff, leading to symmetric power relations. Power over-game was open to staff only, resulting in asymmetrical power relations. Implications for practice OVG interventions may facilitate power balancing in forensic psychiatry. These insights may guide the development of new OVG interventions for patients and nurses in mental health care.
J Psychiatr Ment Health Nurs. 2021;00:1–11.
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1wileyonlinelibrary.com/journal/jpm
Received: 13 July 2021 
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Revised: 12 Novemb er 2021 
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Accepted: 9 December 2021
DOI: 10.1111/jpm.12813
ORIGINAL ARTICLE
Online video games and patientstaff power relations. A
qualitative study of care and custody in forensic psychiatry
Morten Deleuran Terkildsen1,2 | Harry G Kennedy2,3,4 | Christian Jentz2,5 |
Lisbeth Uhrskov Sørensen2,5
This is an op en access arti cle under the ter ms of the Creative Commons Attribution L icense, which pe rmits use, dis tribu tion and reprod uction in any med ium,
provide d the original wor k is properly cited.
© 2021 The Authors . Journa l of Psychiatric and Mental Health Nursing published by J ohn Wiley & Sons Ltd .
1DEFACTUM - Public Health & Hea lth
Services Research, A arhus, Centr al
Denmark Region, Denmark
2Depar tment of Forensic Psychiatry,
Aarhus University Ho spital Psychiatry,
Denmark
3Trinity Col lege Dub lin, Universit y of
Dublin, Ireland
4Centra l Menta l Hospit al, Dundrum ,
Ireland
5Depar tment of Clinic al Medicine, Faculty
of Health, Aarh us University, Denmark
Correspondence
Morte n Deleuran Terkildsen, DEFACTUM
- Public He alth & He alth Se rvices
Research, Aar hus, Central Denmark
Region, Denmark.
Email: Morten.Terkildsen@stab.rm.dk
Funding information
DFP, AUHP funded t he pape r. DFP was
not involve d at any stage of study desig n,
data collection or anal ysis, interpretation
of data, report writing or the de cision to
submit this manuscript for publication
Accessible summary
What is known on the subject?
Frontline forensic mental health staff often face challenges when providing
recovery- orientated care, as they must balance between caring for the foren-
sic psychiatric patient and at the same time ensuring safety and security for all
other patients and staff at the ward.
Research shows that balancing between care and custody in everyday clinical
practice is possible, but more practical nursing studies showing ways of balanc-
ing power relations are needed to guide clinical practice.
Online video games are increasingly recognized as promising new tools to pro-
mote social relations, establish competencies and re- articulate power relations
in therapeutic environments.
What the paper adds to existing knowledge?
This paper provides insights into how using online video gaming interventions
may influence the establishment of social power relations of staff and forensic
psychiatric patients. It adds to existing research by providing a conceptual way
to study and understand how mental health nurses may balance between care
and custody, delivering care to accommodate patients' needs without compro-
mising safety and security at the ward.
This study answers a call in current research by providing qualified knowledge
regarding the use of online video gaming to build and sustain therapeutic rela-
tions in mental health care.
What are the implications for practice?
Our paper suggests that balancing between care and custody is possible by
using online video gaming interventions in forensic psychiatry. It moreover pro-
vides practice- close knowledge that may inspire and guide clinical mental health
nurses to further develop online video gaming interventions in mental health
care for the benefit of their patients.
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    TE RKILDS EN ET aL.
1 | INTRODUCTION
Re s e ar ch is in c r ea s i ng l y pa yi n g at te n ti o n to th e di le mm a s of pr ov id -
ing high- quality and secure recovery care within forensic psychi-
atry (Mann et al., 2014; Marshall & Adams, 2018; Martin & Street,
2003). Recovery- orientated care emphasizes equality in relations
and relies on therapeutic relationships where power is more sym-
metrically distributed between nurses and forensic psychiatric pa-
tie nt s (FPs) (Mann et al., 2014). Care and t reatmen t ba se d on mor e
symmetric power relations are challenging in forensic psychiatry.
FPs are double stigmatized by being both vulnerable and in need
of care and treatment but also dangerous and in need of risk man-
agement (Brooker & Ullmann, 2008). Consequently, nurses need
to engage with FPs as therapeutic and custodial agents (Adshead,
2000; Livingston et al., 2012). A s custodial agents, nurses man-
age potential risks FPs pose to themselves, other FPs, staff and
society in general (Gildberg et al., 2010; Maden, 2007; Martin
& Street, 2003). This custodial role may promote asymmetri-
cal power in patient– nurse relationships, placing power with the
nurses. Also, the custodial role is considered counterproductive to
the therapeutic nursing role and recovery- oriented care (Cashin
et al., 2010; Mann et al., 2014; Marshall & Adams, 2018; Martin &
Stre et , 20 03; S la de, 20 09) However, rese arch ar gue s t ha t c ar e a nd
custody may successfully coexist in forensic psychiatry (Peternelj-
Taylor & Johnson, 1996).
1.1  |  Rationale
Research increasingly recognizes online video games (OVGs) as a val-
uable therapeutic intervention in mental health care (Boldi & Rapp,
2021; Rosegrant, 2012; Steadman et al., 2014). When played in a
structured form, OVGs may teach participants important individual
and social competencies to establish and maintain new social identi-
ties and relations. OVGs may also promote feelings of empowerment
an d re spe ct am ong par tici pants via gr ou p rec og nit io n in pr ac tice rea l-
ized via gaming skills (Boldi & Rapp, 2021; Freeman & Wohn, 2017;
Granic et al., 2014; Wright et al., 2002). OVGs are also a scene for ne-
gotiating power relations (Consalvo, 2007; Toft- Nielsen & Krogager,
2015). Despite showing promise as a therapeutic instrument in men-
tal health care, few have studied the use of OVG interventions in fo-
rensic psychiatric settings. Research states that we need to examine
new practices that provide FPs with competencies to strengthen
their social relations and provide alternate identities, something often
found severely challenged among FPs in forensic psychiatric wards
(Barnao & Ward, 2015; Clarke et al., 2016). Furthermore, research
Abstract
Introduction: In recovery- oriented care, forensic psychiatric nurses must engage in
care relationships with forensic psychiatric patients (FPs) whilst focussing on ward
security. Online video games (OVGs) may provide a platform for negotiating power
and social relations. Studies showing how OVG interventions may influence power
balances in forensic psychiatric care are needed to guide clinical practice.
Aim: Our aim was to study how power relations were articulated between FPs and
staff in an OVG intervention in a Danish forensic psychiatric ward.
Method: Data consist of three months of observational data and interviews with three
staff members and six patients. We used sociologist Pierre Bourdieu's framework of
field, power and capital to analyze data.
Results: The OVG intervention consisted of two power fields, “in- game” and “over-
game.” In- game concerned the practice of gaming. Over- game described the organi-
zation of the gaming intervention. Specific logics, skills and symbolic capitals drove
power in each field.
Discussion: Power in- game was open to FPs and staff, leading to symmetric power
relations. Power over- game was open to staff only, resulting in asymmetrical power
relations.
Implications for practice: Online video game interventions may facilitate power bal-
ancing in forensic psychiatry. These insights may guide the development of new OVG
interventions for patients and nurses in mental health care.
KEYWORDS
forensic, nursing role, psychosocial intervention, recovery
   
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TERKILD SEN ET aL .
must focus on practices where power relations defined by the care-
and- custody dichotomy in forensic psychiatry are balanced (Dorkins
& Adshead, 2011; Hillbrand et al., 2010; Mann et al., 2014; Marshall
& Adams, 2018; Mar tin & Street, 2003; Simpson & Penney, 2011).
1.2  |  Objective
The objective of this qualitative study is to understand how power
relations are negotiated between FPs and staff in an OVG interven-
tion in a medium secure forensic psychiatric ward.
1.3  |  Aim
Our paper aims to use the knowledge acquired to inform existing
discussions concerning care and custody and provision of secure re-
covery to guide future mental health nursing practices in forensic
psychiatry.
2 | METHOD
We used a qualitative ethnographic approach with an interpretive
analysis to study the relations bet ween FPs and staff in the OVG
intervention (Braun & Clarke, 20 06; Hammersley & Atkinson, 1995).
This social constructivist approach underlines the contextual nature
of knowledge and knowledge production and the importance of re-
flexiv it y. We the refo re viewe d OVG as a social pr ac tice wh er e pa r ti c-
ipants negotiate meanings within local contexts (Boellstorff, 2006).
2.1  |  Research team and reflexivity
The research team included one anthropologist (AN), two psychia-
trists and one mental health nurse. AN collected data from inter-
views, informal conversations and observations. All researchers
participated in the development of the study and analysis. Three
researchers had clinical experience with forensic psychiatry. Their
expertise was continuously subjected to reflection to prevent po-
tential preconceptions guiding the study.
We informed FPs that the research team had no authority at the
ward and could not influence treatment plans. St aff and FPs were
told that we would maintain confidentialit y. Care was taken to spend
equal amounts of time with FPs and staf f.
2.2  |  Context
The study was conducted at a Danish medium secure forensic psy-
chiatric war d. The ward has 16 male FPs age d 18– 55 yea rs . The war d
has the equivalent of 43 full- time employees and discharges 3– 5 FPs
pe r y ear.
In the intervention, FPs and staff play an OVG (Counter- Strike
GO) together one day weekly from 3.30– 9 pm to counter FP iso-
lation and promote social skills. FPs and staff chose the game in
unison. In Counter- Strike GO, two teams of five players compete
Goal to improve Examples
Communication Patient s who do not speak ver y much because of their negative mental
health symptoms will be tr ained on how to communicate when
gaming.
Patient s acting as in- game leaders are trained to guide the group by
precise instructions, give kindly worded instructions and avoid
abusive verbal out bursts.
Social skills Patient s who are assigned a tedious t ask in the game are trained to
adhere to the mission for the sake of the group.
Patient s who quit in the middle of a game due to, e.g., frustration are
asked to stay because it will comprise the chance of winning for the
entire team if they quit before the end of the game.
Good players are instructed to teach less t alented players.
Handling aggression Patient s are trained to use positive expressions to praise and recognize
their fellow player s instead of yelling and being abusive.
TAB LE 1  Individually negotiated
goals for patients prior to and during the
online video game recovery- oriented
intervention in a Danish medium security
forensic psychiatric ward
TAB LE 2  Typical schedule for a session of online video gaming in
a Danish medium security forensic psychiatric ward
03.30– 04.00 pm Review the program for the session
04.00– 04.15 pm Break
04.15– 04.30 pm Continue review
04.30– 05.30 pm Gaming session with the game of the
day
05.30– 06.0 0 pm Evaluation of the game
06.00– 06.45 pm Dinner and smoking break. The
instructors eat together to
evaluate the session
06.45– 09.00 pm New game based on the number of
participants
09.00– 09.30 pm Instruc tors document the session
for each patient in the electronic
patient file
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    TE RKILDS EN ET aL.
to either eliminate the opposing team or solve predefined mission
goals. The first team to win 16 rounds wins the match (Weblink 1).
FPs may ask staff for referral, or other staf f may refer the FP. Upon
referral, the staff screen FPs by inter view and by gaming together.
Once accepted into the group, the staff and the FP agree on indi-
vidual goals (Table 1). Staff evaluate the goals after each session
(Table 2). Before admission to OVG, FPs receive a written set of rules
for the session (Table 3).
The staff instructors are cer tified OVG coaches. Each OVG
session begins with a teaching and training module (Table 2).
Afterwards, the group plans the remaining session and chooses the
in- game leader, either a FP or staff.
2.3  |  Participant recruitment and selection
This study is based on dialogues and interviews with six FPs and
three staff members in the gaming group at the time of the study.
The group consisted of seven FPs (19– 54 years) and three staff
members.
The staff responsible for organizing the intervention consisted
of one educator and two nurse assistants (3135 years), all with a
minimum of 3 years of work experience in forensic psychiatry.
All participants provided informed consent to participate in the
study. Their consent included allowing observation, participating in
interviews and recording informal conversations. One FP declined
the interview.
2.4  |  Ethics
We followed the American Anthropological Association's guidelines
for qualitative research (www.ethics.ameri canan thro.org). We ob-
tained informed signed consent before the study— start based on
oral and written information. It was repeated orally before every
interview that participants could always withdraw their consent.
The ward consultant considered all participating FPs able to give
informed consent. AN remove d names and id entifiable details to an-
onymize the results. All FPs were offered to read the final draft to
ensure they felt unidentifiable. In Denmark, studies that do not in-
clude human biological material and are based on questionnaires and
interviews do not require permission from the Ethical Committee
according to the Promulgation of the Law on Ethical management of
Health Science Research Projects (Weblink 2).We made an inquiry
to the hospital ethical committee. They confirmed that according to
Danish law, the study did not need approval from an ethical board.
2.5  |  Data collection and processing
During 3 months in 2019, AN collected data by participant obser-
vation at the ward and during OVG (Boellstorff, 2012; Spradley,
1980). Data also included informal dialogues and interviews to
provide thick ethnographic descriptions (Hastrup, 2003; Wolcott,
2005). During fieldwork, AN par ticipated in 13 hours of observa-
tion and engagement in informal dialogues at the ward from 8 am
to 3 pm to understand life at the ward. From 3.309 pm, AN ob-
served the OVG intervention for a total of 60 h, where he noted
dialogue between participants and their physical actions in the
gaming room. AN also participated in OVG to understand gaming
practices (Boellstorff, 2012). Informal dialogues and observations
were written down. Initially, we focussed upon observing and dis-
cussing with FPs and staff how they experienced life at the ward,
their relations and the OVG inter vention. We observed who did
what, when and for what reasons, and who was perceived as in
charge during gaming. After observations, we discussed with FPs
and staff what being in charge meant for them and their relations.
Based on these data, AN developed interview guides, in which the
TAB LE 3  Written information for patients participating in online
video gaming inter vention in a Danish medium security forensic
psychiatric ward
The online video gaming group is a social activity seeking to provide
a fun and rewarding communit y mixed with healthy competition
and good team spirit.
The group is a structured treatment that aims to strengthen your
social competencies and tolerance towards other people. The
group is an arena for relationship- building and training social
skills. T he social focus precedes t he competitive aspect at all
times. The instructors will regularly offer training sessions
connected with t he regular weekly meetings where participants
are expected to at tend.
How to join the group: A sk the online video gaming staff or your
contact person.
When: Wednesdays 3.30– 09.00 pm.
Attendance: You are expected to attend training sessions from
3.30 pm.
Cancellation: Everyone can have a bad day or an important
appointment, but for the team's sake, repor t your cancellation as
soon as possible to an instructor or your contact person.
Team spirit: Good team spirit precedes good team performance. We
expect you to try to avoid discussions about guilt and mis takes.
We expect you to play construc tively with curiosity to improve
your skills. We expec t you to be loyal to the team and the in-
game leader's decisions. Give a high five rather than complain.
Breaks: Between games, we encour age you to leave the room and
take a 5- min break in the g arden to relax and get ready for the
next round.
Hygiene: Indoor climate is vital for concentration and performance
when gaming for longer periods. The gaming room has several
hot PCs, and player s may sweat with great concentration .
Therefore, it is essential to attend the gaming session in clean
clothes and that you shower during the day. Please avoid coming
to the gaming room straight from physical exercise.
Cleaning up: After the session, please clean your space and wip e all
surfaces with a disinfec tant swap, including your headset. Tidy
up your headset, your chair and clean up any rubbish.
Food and drink: Eating is not allowed in the gaming room. This
includes snacks, e.g. chips, peanuts and popcorn.
We look forward to playing with you. The s taff
   
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TERKILD SEN ET aL .
topics of ward life and gaming, gaming competencies and roles,
and roles, relations and power were further explored. The inter-
view guide was developed based on discussions with the research
team during fieldwork. Interviews took place at the ward, lasted
15– 60 min, and were transcribed verbatim. We coded data with
Nvivo 12.
2.6  |  Data analysis
We followed Braun and Clarke's (2006) method to analyze data. It
involves multiple readings of data whilst gradually developing and
validating the analysis. The analysis process covers the data collec-
tion phase. Our analysis followed Braun & Clarke's six steps.
1. Our analysis began during fieldwork. AN would meet with the
research group at regular intervals to discuss observations and
ideas to explore. Af ter fieldwork, AN first conducted a thor-
ough reading of field notes and interviews focussing on how
the participants articulated social relations, understandings of
the OVG intervention and how they distributed power. This
reading supported the research aim as well as a preliminar y
understanding achieved during fieldwork. The content was
discussed with the research group to identify analytical ideas
further.
2. AN reflexively reread field notes and interviews to develop
initial codes. Codes were discussed with the research group.
Subsequently, AN coded the material.
3. Codes were structured into potential themes. Though not ini-
tially theor y- driven, we found a solid theoretical resonance be-
tween these codes, potential themes and the framework of Pierre
Bo ur die u. It be c ame the sub jec t of fur ther expl ora tio n (S ec tion 2.7 ).
4. An additional code set, based on Bourdieu's framework, was de-
veloped and discussed with the group. The material was recoded
by AN, structured into potential themes and subthemes and then
reviewed in the group.
5. Themes were defined and named. Two central themes and several
subthemes emerged.
6. The remainder of the analysis was performed by AN and regularly
discussed with the research group.
We used method triangulation during data collection and re-
searcher triangulation during the analysis to develop the results. AN
discussed initial findings and concepts with FPs and staff during the
fieldwork to further qualify the results. During the final analysis, AN
visited the ward to discuss the results with FPs and staff.
2.7  |  Theory
We followed the theoretical framework of sociologist Pierre
Bourdieu to analyze the relationship between power, con-
text and gaming practice. We approached the intervention as a
practice unfolding within local fields (Consalvo, 2007; Toft- Nielsen
& Krogager, 2015). According to Bourdieu, fields are understood
as social spaces (Bourdieu, 1990, 1998). These are specialized
domains of practice, centred around a field logic referring to self-
evident and therefore nonreflected values, rules and interests of
that particular field (Andersen et al., 2015). An individual's posi-
tion within a f ield is defined by his/her access to different forms of
capital acting in accordance with the logic of that field (Bourdieu,
1998; Bourdieu & Wacquant, 1992). Capit al may be understood
as encompassing economic, social and cultural as well as critical
symbolic forms. Symbolic capital refers to recognition and pres-
tige (Bourdieu, 1998). To obtain recognition, one has to possess
the kind of capital perceived as important in a field. Possession
of symbolic capital and power is highly connected, and power is
abstracted from relations bet ween people, according to their ac-
cumulated symbolic capital within a field (Andersen et al., 2015;
Bourdieu, 1990, 1998).
3 | RESULTS
The observations and interviews with staff and FPs regarding the
OVG intervention revealed how power between FPs and staf f could
be understood as highly contextual and delineated between two
power fields: “in- game” and “over- game.”
3.1  |  Power “in- game
We suggest that power in- game is tied to the practice of gaming to-
gether. This form of power emerged from a logic viewing good gam-
ing as the result of a coll ec tive enter pr ise. Power in- game, among FPs
and staff, was perceived as distributed according to the possibility of
obtaining and the possession of specific individual and social gaming
skills. Following the game's logic, these skills were considered essen-
tial and provided group recognition to those possessing them.
3.2  |  Winning as a collective enterprise
Both staff and FPs explicitly stated that OVG's central logic was to
win a match against another team. One FP explained:
Winning! I like to win I mean, that's what it's all about
after all.
(Dialogue field note 11)
Moreover, they expressed that winning should be achieved by a
successful team ef fort. The idea that winning should be accomplished
by a team was formulated in the intervention's official ruleset. FPs and
staff who had been gaming before entering the intervention men-
tioned that this was an inherent logic of team gaming in the broader
gaming community. A staf f member uttered:
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    TE RKILDS EN ET aL.
It's when all sort of pitch in. I mean when there is some
sort of togetherness in the game. We have been god-
dam together on this (…) something we have done as
a team.
(Interview ST)
Correspondingly, one FP elaborated how winning via team effort
was more important than individual glor y:
If I die thir t y ti me s wi thout shoot in g anyone, but we st ill
win (as a team), then it's really a nice match for me.
(Interview FP)
Staff and FPs also expressed that specific skills were needed and
valued in this logic of winning as a collective enterprise. These were
social gaming skills and individual gaming skills.
3.3  |  Social gaming skills in- game
Staff and FPs framed social gaming skills as specific practical skills
that were necessary to learn in order to be able to perform as a team
player.
One FP expressed, “It's about working together.”
Another FP elaborated how this involved accepting and stick-
ing to the role the team gave you, e.g. playing defensively for the
sake of the team even when an offensive push could offer per-
sonal wins. Team communication would equally be framed as an
essential social gaming skill. One staff member said “team com-
muni cat io n is everythin g.” A FP el abo rated how the abilit y to com-
municate to team member s was the hallmark of a good player and
a good game:
That you are good at communicating (to your team-
mates) and observing stuf f (for the team) (…) good
tone and good communication.
(Interview FP)
Both FPs and staff acknowledged that obtaining these skills was
essential for successful participation in- game. Neglecting to obtain
them could ruin the entire team, as it would undermine the game's
log ic . One staff mem be r recalled a part icular playe r lacki ng these sk ills:
That 's why it wa s so met im es fr us t ratin g to play with (FP
name) because he disobeyed the rules (i.e., He didn't
play for the team).
(Interview ST)
3.4  |  Individual gaming skills in- game
Apart from exhibiting good social skills, it was equally important to
possess individual gaming skills to be successful.
Being skilled at hitting the enemy (aim) in- game was perceived
as an impor tant individual skill by both staf f and FPs. One FP said:
It's important that you're good at aiming. Him (FP
name), him (FP name) and him (staff name) are proba-
bly best. They're important and can really make a dif-
ference for the team. I'm coming along, but their aim is
good. He (FP name) can pull off some cr azy headshots.
(Dialogue field note 6)
Correspondingly, a FP talked about one of the staff member's su-
perior ability to hit the enemy:
I especially like to play with him (staff name) on the
team because I like to win.
(Interview FP)
Another valued and important individual skill was “gaming sense”
or “understanding the game.” This included knowing when to push
areas of the map, utilize the equipment in the game, and position one-
self when engaging the enemy. One FP said:
Knowing these things is what makes you a good player
and what sets you apart from others.
(Dialogue field note 10)
This shared logic of winning as a collective enterprise and realizing
it through individual and social gaming skills created new positions for
FPs and staf f.
3.5  |  Skills and power positions in- game
Both parties used “gamers,” “players,” or “gaming nerds” to describe
themselves and teammates in- game. These descriptors were seen as
diminishing differences between staff and FPs. One staff member
stated:
When I'm in here (the gaming room), we are all just
gaming nerds.
(Interview ST)
A FP used similar wording in an interview, calling all participants
players:
You don't con sider that th ey 're staf f (an d we are FP s). In
there, we just all play together.
(Interview FP)
When the FPs talked about life at the ward in general, they called
the staff members “staff.” Power positions in- game were expressed as
highly dependent on the par ticipants' social and individual skills. One
staff member described it this way:
   
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TERKILD SEN ET aL .
When we are in there, it's the skills in the game that
decide who you are, and what you can do.
(Dialogue field note 12)
For staff and FPs alike, the possibilities for acquiring skills and be-
comi ng a vital reso urce for the tea m were seen as tied to the indi vid ual
player's diligence in playing the game, following the rules, and learning
the rope s. Bot h gr oups percei ve d th ey had equ al pos si bilitie s in obt ai n-
ing these skills.
Those acknowledged by all participants as having already ob-
tained these skills were perceived as particularly vital to the success
of the team, exemplified by a FP:
He (FP name) is really one of the good ones. He can
hit, and he knows tactics and when to say things.
Therefore, he is very important to the team if we want
to win.
(Dialogue field note 9)
Revealingly, differences in social and individual gaming skills
carved out a hierarchy in- game. Both staff and FPs saw high de-
grees of social and individual gaming skills defining who could be
“leaders of the team” in- game. Leaders had the right to dictate
orders to fellow players, regardless of being FP or staff. One FP
uttered:
In there, patients also get to decide. He (FP name) is
go od, an d he (s t aff na m e) an d (st aff nam e) al so li s te n
when he gives orders.
(Dialogue field note 7)
One staff member complemented the statement:
We know that (FP name) and (FP name) are team cap-
tains because they have played it so much.
(Interview ST)
Overall, the mutual social acceptance of a gaming hierarchy based
on gaming skills as a form of capital led to re- articulations of power
in- game. All saw this as contrasting the established FP– staf f relations
outside the OVG intervention.
3.6  |  Power “over- game”
In the analysis, we interpreted power over- game to refer to the
intervention's professional clinical and organizational part. Power
over- game emerged from the staff's perception that the gaming
intervention could be a potent forensic psychiatric treatment if
it followed specific organizational and gaming rules. Power over-
game was distributed according to the possession of a particu-
lar professional form of knowledge, based on a clinically relevant
education.
3.7  |  OVG as a professional treatment:
Clinicians and power over- game
All staff members described the OVG intervention as a treatment
option that could potentially teach FPs important social skills to
control aggression, increase their concentration and break their fre-
quent periods of isolation. They also described it as a way to monitor
FPs' behaviour and psychiatric symptoms and observe their abilit y to
handle stress. One staf f member mentioned:
It's a treatment group, not a cozy leisure group. We
have many assignments (for the FP). There is teaching
and they have goals set up, each of them.
(Interview ST)
The staff emphasized that the intervention was regulated by
explicit rules stapled to the gaming room door (Table 3). FPs could
only enter the group by referral. Admittance was cleared with
staff. The staff evaluated each FP after the gaming session and
documented a summary in the patient record. FPs who disobeyed
the rules were excluded. Once a FP had been allowed to par take,
participation was mandatory. Absence was only allowed with a
valid excuse. What constituted a valid reason was decided by the
st af f. Bef or e gaming se ssio ns, t he st af f would often se ek out FP to
ensure participation.
The knowledge, skills and safety responsibilities required to or-
ganize the OVG intervention as treatment (over- game) were seen as
open to staff only. The staff viewed the abilit y to produce and en-
force the OVG inter vention's organizational rules as a professional
clinical task for which they possessed specific professional knowl-
edge, abilities and responsibility for therapeutic safety. One staff
member said:
It's one thing to be good at gaming, but we have a pro-
fessional angle here. We can see what can work and
what can't, differently than the patient can […]. We
need to look at the safety issue for the other patients
an d ours e lve s […]. It can' t all be op en to deba te be cau s e
we need to fit this intervention not only with the rest
of the depar tment but also with the patients' disease.
(Dialogue field note 13)
The staff were explicit and articulate concerning the distinction
between in- game and over- game competencies.
I can give him (FP name) responsibility for the tactics
and what we do in the gam e, but all the stu f f ar ou nd the
game (…) how we speak to each other an d such, it is st ill
necessary that I am there.
(Interview ST)
Thus, whilst power in- game coul d be symmetrically distr ibu ted be-
tween FPs and staff, power over- game was recognized as positioned
8 
|
    TE RKILDS EN ET aL.
with the staff. A staff member explained that more symmetric distri-
bution of power in- game did not translate to power over the gaming
room:
We are not equal (in the sense of power in the room:
Danish) but equal (in the gaming sense: Danish).
(Interview ST)
Forensic psychiatric patient s were ver y aware of the rules and the
organization of the inter vention and recognized the unique clinical po-
sition that gave to the staff the right to produce and enforce these
rules. FPs were invited to put forward suggestions for developing the
inte rvention. Yet, despite making suggestio ns to improve th e interven-
tion (e.g. suggest alternative schedules), FPs verbally acknowledged
that the power to make a final decision rested with the staff due to
their position as clinical professionals. One FP said:
We still know that they're staf f, and you have to do as
they say in there. They(staf f) have rules (for the room)
like no saying fuck and cursing, no hitting the keyboard.
There are rules you have to follow.
(Interview FP)
Another FP emphasized this distinction as self- evident:
In this place, the staff set the agenda (for the interven-
tion). Of course, that's how it is. They say something,
and you do as you are told.
(Interview FP)
Despi te acknow ledging the staff 's power ove r- game, this was not a
significant issue and was rarely mentioned in FP interviews.
4 | DISCUSSION
We found that the OVG intervention consisted of two power fields:
“in- game” and “over- game.” In- game concerned the practice of gam-
ing and over- game the organization of the intervention. Power in-
game was equally open to FPs and staff, leading to symmetric power
rela tions . By co nt r as t , power ove r- gam e wa s ope n to st aff only, lead -
ing to asymmetrical power relations (Table 4).
Forensic psychiatric patients need treatment to relieve suffering
and reduce the risk of future violence. Forensic psychiatric services'
challenge is finding ways to facilitate a process of increasing st a-
bility, providing insight, building working alliance and reducing risk
(Kennedy, 2002). Even though this is a complex task, finding ways
of balancing between care and custody in practice is vital in foren-
sic nursing care (Dorkins & Adshead, 2011; Hillbrand et al., 2010;
Mann et al., 2014; Marshall & Adams, 2018; Martin & Street, 2003;
Simpson & Penney, 2011).
Our study of a new OVG intervention demonstrated that power
between FPs and staff was a nuanced and field- bound notion.
Working for a common cause and realizing it via cooperation is
essential to many OVGs (Frostling- Henningsson, 2009). By follow-
ing Bourdieu's concept s of field and power (Andersen et al., 2015;
Bourdieu, 1990, 1998; Bourdieu & Wacquant, 1992), our study
demonstrated that when staf f and FPs played OVG together, they
developed a common logic in which winning as a collective enter-
prise should be accomplished as team efforts using social and indi-
vidual gaming skills. As found in our study, following such explicit
gaming rules and appropriating specific individual and social skills
for the team's benefit have been underlined by several video game
studies as inherent components of successful OVG play (Freeman &
Wohn, 2017; Kim et al., 2017; Seo & Jung, 2016).
In mental health care interventions, these game mechanisms
may help stimulate prosocial behaviour among patient groups
where social functioning is challenged (Boldi & Rapp, 2021; Granic
et al., 2014). Significantly, they may also help promote stron-
ger therapeutic relations by redefining staffpatient social roles
and offering a sense of sharing meaningfulness on equal terms
(Rosegrant, 2012). Following Rosegrant (2012), we found that
gaming together re- articulated existing staff– FP categories re-
placing them with "players". This promoted mutual respect and
recognition of roles and abilities outside the roles of FP and staf f.
Establishing such relationships through OVG may forefront FPs'
competencies, sense of own worth, personal resources and a sense
of responsibility (Coffey, 2006; Mezey et al., 2010; Rask & Brunt,
2007; Resnick et al., 2005). They can also help overcome alien-
ation and isolation by allowing a sense of belonging to a group,
referenced as “self- transcendence” (Wharewera- Mika et al., 2020).
Moreover, by favouring a common identity of being players, the
of te n highl y sti gm atized FP identi ty (B rooker & Ullma nn , 2008 ) be-
came downplayed during gaming.
TAB LE 4  Definition and element s of “Power In- game” vs. “Power Over- game” in online video game sessions in a medium secure forensic
psychiatric ward, Denmark, 2019
In- game Over- game
Definition The practice of gaming together The organization of a professional treatment
intervention
Logic Winning as a social enterprise Providing therapeutic safety and security
effec tive clinical treatment
Symbolic c apital Individual and social gaming skills Clinically relevant education
Patientstaff power distribution Symmetric Asymmetric
   
|
 9
TERKILD SEN ET aL .
It may seem counterproductive to play a violent first- person
shooter video game with FPs in forensic psychiatric wards. Yet, re-
search indicates no current links between playing OVG and com-
mitting real- world violent acts (Granic et al., 2014). This resonates
with our experience, as staff and consultants did not observe any
increase in aggression after the FPs and staff star ted playing OVG.
Gaming skills, roles and hierarchical power are highly intertwined
(Consalvo, 2007; Freeman & Wohn, 2017; Toft- Nielsen & Krogager,
2015). This makes OVG interventions relevant when aiming to prog-
ress from power asymmetry towards power symmetr y. Recognizing
social and individual skills as the defining symbolic capital when
in- game, FPs and staff viewed their possibilities for acquiring this
symbolic capital as equally open to both. This situation promoted
a sense of power equality in- game between them. It also provided
new possibilities for repositioning power from st aff to FPs in- game.
By contrast, the organizational issue of the OVG intervention
(over- game) was defined by a clinical logic. This logic resulted in
power relations closely resembling the asymmetric power relations
between FPs and staff described as inherent to forensic psychia-
try (C aplan, 1993; Mann et al., 2014; Martin & Street, 2003; Rask &
Brunt, 2007). Defining the OVG intervention as a psychiatric treat-
ment, the staff articulated a familiar position, where knowledge and
skill are necessary to make rules for participation in a treatment
intervention came from formalized professional education (see
(Andersen et al., 2015; Helman, 1990)).
Equal relationships are essential for recovery (Slade, 20 09).
Psychiatric nurses' interests and approaches may be steered by
care ideas based on relational equality and power symmetry with
FPs (Martin & Street, 2003). Yet, custodial orientations may easily
prevail skewing power relations towards asymmetr y between them
(Maden, 20 07). Our paper illustrates that when organized as an
intervention, the unique features of OVG may provide a platform
where the balancing of power is possible on different levels.
Interestingly, this distribution of power to FPs need not be an
all- or- nothing task for positive FP– nurse relationships to emerge.
In our study, the staff engaged in redistributing power to patients
in- game whilst retaining control over the intervention (over- game).
Distinguishing between “power in- game” and “power over- game”
may of fer ways to understand the therapeutic value of OVG in se-
cure forensic hospitals. At the same time, it is essential to recognize
the protective value of professional boundaries when maint aining
relational security (Royal College of Psychiatrists, 2015), particu-
larly in therapeutically safe environments where patients prone to
violence can be challenged concerning sensitive but dysfunctional
beliefs and emotions (Tighe & Gudjonsson, 2012).
Online video game is a growing phenomenon and for many
children an inherent part of social life (Granic et al., 2014). In
2020, counterstrike GO had more than 1.3 million online players
(Weblink 3). Therefore, using OVG in future mental health care
could provide staff with a common platform to establish mean-
ingful relations with mental health care patients for which OVG
is a part of life. In forensic psychiatry, OVG interventions could
help promote alternative identities, recognize FP competencies,
destigmatize and ultimately help balance power in FP– nurse rela-
tions. Yet, we need to understand balancing by taking a microper-
spective on OVG, acknowledging that power as a notion is related
to concrete field practices.
5 |  LIMITATI ON S
In Bourdieu's framework, fields are sites of stability and change with
ongoing power struggles between established participants and new-
comers to the field (Bourdieu & Pierre, 1977; Bourdieu, 1998). The
FPs and staff had already gamed together for an extended period
before our data collection. No new FPs entered during our study.
Furthermore, the FPs had already progressed from an admission
ward to a rehabilitative medium secure forensic psychiatric ward due
to prior progress in reducing the risk of violence (Müller- Isberner
et al., 2007) and building working alliance and trust (Donnelly et al.,
2011). Consequently, the introduction of new par ticipants in the
group during the study period could have instigated power strug-
gle s infl ue nc in g th e lo gi c, symbolic cap it al s an d po we r po sitions pre-
sented in our analysis.
This qualitative study explores the social relations and issues of
power following an organized therapeutic OVG inter vention. Yet,
casual OVG has been shown to promote similar therapeutic effects.
Whether the therapeutic effects related to the in- game field could
be obtained by staff and FPs simply gaming as a leisure social activ-
ity should be investigated further. Further quantitative studies are
needed to explore the possible effec t on outcomes such as gaming
disorder, social interaction and ward atmosphere.
6 | CONCLUSION
Our results suggest that nurses can balance care and custody by
using OVG interventions in forensic psychiatry.
7 | RELEVANCE STATEMENT
Research is lacking concerning how forensic psychiatric nurses may
balance between engaging in care relationships with patients and
focussing on ward securit y. This paper addresses this research gap.
Qualitatively, it explores how participation in a video- gaming inter-
ventio n for forensic psyc hiatr ic staff and patients influence s the bal-
ance between the different power relations of the care- and- custody
dichotomy. It conceptualizes how balancing between care and cus-
tody for nurses may be understood and achieved using online video
gaming. The insights may help develop future recovery- orientated
interventions using video games for nursing staff.
ACKNOWLEDGEMENTS
We are grateful to the Department of Forensic Psychiatry (DFP),
Aarhus University Hospital Psychiatry (AUHP), head nurse Birgitte
10 
|
    TE RKILDS EN ET aL.
Jensen and consultant Antonio Di Lieto for collaboration and support
for this study. The intervention was designed by pedagogue Morten
Trier Josefsen and nurses- assistant Rasmus Poulsen DFP, AUHP.
CONFLICT OF INTEREST
The authors declare no conflicts of interests related to the
manuscript.
AUTHOR CONTRIBUTIONS
Anthropologist Morten Deleuran Terkildsen (MD) designed the
study. Medical Doctor Lisbeth Uhrskov Sørensen (LU), Nurse
Christian Jentz (CJ) and Medical Doctor Harry Kennedy (HK) revised
the study protocol. MD collected and performed data analyses and
drafted the manuscript. LU, C J and HK provided crucial intellectual
input on study design and contributed substantially to interpreting
findings and manuscript revision.
ETHICS STATEMENT
The study, involving interviews with forensic psychiatric patients
at a medium secure ward in Denmark, was entered and registered
at the Legal Office at Central Region, Denmark (file number:1- 16-
02- 289- 19). According to the Consolidation Act on Research Ethics
Review of Health Research Projects, Consolidation Act number
1338 of 1 September 2020, section 14(2) notification of observa-
tion and interview projects to the research ethics committee system
is only required if the project involves human biological material.
Therefore, this study may be conducted without an approval from
the ethics committees.
DATA AVAILAB ILITY STATE MEN T
Research data are not shared due to privacy or ethical restrictions.
ORCID
Morten Deleuran Terkildsen https://orcid.
org/0000-0002-0974-3164
Harry G Kennedy https://orcid.org/0000-0003-3174-3272
Christian Jentz https://orcid.org/0000-0002-4203-1994
Lisbeth Uhrskov Sørensen https://orcid.
org/0000-0003-1896-8362
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SUPPORTING INFORMATION
Additional suppor ting information may be found in the online
version of the article at the publisher ’s website.
How to cite this article: Terkildsen, M. D., Kennedy, H.,
Jentz, C ., & Sørensen, L. U. (2021). Online video games and
patient– st aff power relations. A qualit ative study of care
and custody in forensic psychiatry. Journal of Psychiatric
and Mental Health Nursing, 00, 1– 11. https://doi .org /10.1111/
jpm.12813
... This echoes with our study in which reciprocity, stressed by equality and the creation of stronger relationships, were seen as the explicit foundation of the mealtime social interactions between patients and staff. Communal meals were seen as an opportunity for social interactions and conversations that were reciprocal and not defined by the power relations otherwise present in forensic psychiatric wards (Martin & Street, 2003;Terkildsen et al., 2021). In our study, patients underlined how the COVID-19 measures implemented, which meant that meals were now eaten in new and smaller groups, created greater inclusion between staff and patients alike. ...
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... Having arranged our data in meaningful groups, we started identifying themes. At this stage, we found a strong resonance between our codes, our initial themes, and a theoretical framework (Terkildsen et al., 2021). ...
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... It is widely agreed that RPs should be minimised as patients report primarily adverse effects of being subjected to such measures [2]. RPs have been found to cause physical and psychological harm [3], lead to violence, and damage the therapeutic alliance, widely acknowledged as essential to achieving patient recovery [4,5]. Conversely, violence prevention in psychiatric wards is essential to maintain a therapeutically safe environment and protect other patients and staff [1]. ...
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