The word forensic has been derived from the Latin word 'forum' which is translated to mean 'of the law. Therefore, forensic appertains to the law. Kettles et al (2007) opine that in the UK, FMHNs (forensic mental health nurses) work with a small group of persons whose mental health problems are linked to offending behaviour. The forensic mental health nursing practice thus takes place in diverse settings, though it has been shown to extend to other areas, including prisons, hospitals, young offender institutions, units providing high, medium, and low security, police stations, court diversion schemes (for example, magistrates' courts (Kettles et al. 2007), emergency and accident units, and community settings (Wix & Humphreys 2005). Rutherford and Duggan (2007) have defined forensic mental health care as care provided to offenders who are mentally disordered; individuals placed under secure hospitals by the criminal justice system. The FMHN often encounters problems, in addressing the therapeutic needs of mentally disordered offenders and at the same time, dealing with the security, legal, as well as public safety issues (MacInnes et al. 2014). Pryjmachuk (2011) indentifies forensic mental health as one of the areas of mental health practice that has elicited a lot of apprehension among the public and the mental health professionals alike. This apprehension is partly as a result of misunderstanding of the word 'forensic' which has legal connotations about it. The focus of this paper is to explore the conflicting roles of the FMHNs as they endeavour to provide care and treatment to the and at the same time, ensure public safety. An attempt shall also be made to explore how FMHNs can effectively fulfil their forensic and nursing roles.
Debate on the conflicting roles of the forensic mental health nurse
The nursing discipline has been the focus of considerable debate regarding the predominant components of the Forensic Mental Health (FMH) nursing role (Adlam et al. 2012). Confusion regarding the role of a FMHN exists owing to the terms and language used in reference to the work of FMHNs which appears inconsistent both in terms of scope and practice. Kettles et al. (2007) intimates that there is a dire need to fully understand the role of the FMHN with all groups of patients and in all settings. This is due to the growing complexity in patients' need and problems, and by extensions, nurses' roles (Dale et al. 2001). According to Kettles et al. (2007), 'the majority of general mental health nurses work with individuals with histories of offending in (non-forensic) settings, including acute admission wards; services for children and young people and older people; therapeutic communities; and facilities for treatment and recovery, as well as individuals with problematic substance use’ (p. 1). As can be seen, the role of a FMHN is not restricted to definite settings or client groups.
The typical forensic patients tend to be a rather highly complex group characterised by a strong probability of presenting with such multiple problems as cognitive impairment, personality disorder (Kingsley 2012), substance misuses, and psychosis (Bartlett & McGauley 2010), as well as a host of offending behaviours. Forensic patients are largely under criminal justice or mental health legislation, and majority of them are either subjected to mandatory measures in the community or have been detained in hospital. In case of mentally disorders patients who might have pose a serious risk to harm or have already committed serious offences, these are often placed in Restriction Orders. As stipulated by the courts. Such restricted patients are thus governed by the MOP (Memorandum of Procedures) which spells out how restricted patients ought to be treated and managed.
The context of forensic nursing entails security and ensuring a safe environment for staff and patients. While mental health care setting provide care to individuals characterised by high levels of social exclusion, disadvantage, and homelessness, on the other hand, we need to acknowledge that forensic environment largely attends to individuals with more complex needs (Kettles, Woods & Collins 2001) such as individual in high security hospitals.
Nurses view themselves as mainly fulfilling a caring role and as such, endeavour to tend to place the patient at the centre of their care that they provide. Upholding the general duty to care protects nurses form possible claims of negligence. However, the caring role to that the FMHNs are expected to fulfil is not as simple as that of other nurses given that they are dealing with individuals who have committed serious criminal offences (Khalifa & Gibbon 2009). For this reason, FMHNs find themselves operating under a system in which their role as therapeutic change agents come into conflict with their custodial role (Kirby et al. 2004). The environment notwithstanding, FHMNs should view it as their professional responsibility to uphold patient safety and adapt to the demands of the physical care environment as a means of improving the patients' physical and mental health. Constantino, Crane and Young (2012) note that the dilemma between care and custody that FMHNs encounter is “a significant quandary that is often simply stated, rather than described and discussed” (p. 239). Short et al. (2009) are of the opinion that the issues of care versus custody seems to have stalled, even as Constatino et al (2012) report of a possible coexistence between the principle of care and containment. According to Forster (2001), psychiatry is a key aspect of the regulatory structure of society, adding that the psychiatric nurses has a wealth of experiences in integrating treatment goals with control and detection objectives. According o Constantino et al. (2012), the issue of custody versus care is vital to forensic mental health nursing practice, and to correctional health nursing.
Therapy versus security
FMHNs are often faced with a key dilemma of security versus therapy. In this case, security describes the physical security of patient management such as control of violence incidents on the wards, bars, doors, and perimeter walls. Other procedures may also be integrated into the security settings through policy formulation as a means of enhancing security. They include counting patients, searches, use of lighters, escorting, visiting, and searching staff. Even as many of these procedures are viewed as being vital, they have frequently expressed an ethos of security. Therefore, FMHNs face the dilemma in terms of the tension in trying to offer therapeutic services on the one hand, and operationalizing security procedures, on the other hand (National Forensic Nurses' Research and Development Group 2008). Sadly, simply organising various roles for nursing staff and security is not a suitable solution because problems of another nature could emerge in a system whereby the nurse practitioner operates alongside security staff. FMHNs might face a conflict between the circumstances surrounding a heinous crime from which the patient has committed and experience of outrage on the part of the nurse over such heinous crime. Overcoming such a dilemma hinges on the holistic model of treatment adopted and crucially, the nurse-patient relationships which enable the FMHN to examine the trauma felt by the offender, in spite of being held in a secure environment. Rask and Brunt (2006) carried out a study to assess Swedish forensic psychiatric nurses' views of their content of work, areas of responsibility, and theoretical framework. The researchers reported that the forensic psychiatric nurses who took part in this study felt significant apprehensions about their roles as custodian and therapeutic agent (Rask & Brunt 2006).
It is important that FMHNs feel effective enough to execute their therapeutic mandate in the delivery of care. Therapeutic efficiency is associated with the aspect of upholding control of patients who sought to disrupt a hated system. The therapeutic relationship between patient and nurse, and especially the orientation phase tend to be long and tense, with some patients usually viewing a nurse's genuineness and sincerity as qualities worth of exploitation. Accordingly, developing a therapeutic relationship between FHMNs and patients in secure psychiatric settings, though crucial, is not without its fair share of difficulties. Peternelj-Taylor and Johnson (1995) describe the ensuing relationships as questionable, in that the offender “regard the professional as a friend or con?dant when requests are approved, and as a member of the establishment or the system when requests are denied’ (p. 16). FHMNs are often faced with an uphill task of overcoming the difficult barrier facing them namely, being seen by the patients as part of the criminal justice system. On the other hand, Peternelj-Taylor and Johnson (1995) argue that this context is vital so that patient might stop viewing the nursing staff ‘as a dumping ground for their hostility’ (p. 16). certain strategies are important to enable FMHNs circumvent such barriers to relationship development, including skills in multidisciplinary working, team work, competing and boundary invasion, communication, and proficiency in avoiding splitting (Martin & Daffern 2006). Secure psychiatric institutions subscribe to a cultural mosaic which views nurses as having the capability to negotiate an intricate area of human relations (Moran & Mason 1996). The nursing staff could be viewed as 'targets' with the offender who manages to 'catch' a nursing staff enjoying social advancement within his/her inner circle (McMurran, Khalifa & Gibbon 2008). This is likely to yield a stressful experience among the FMHNs who must endeavour to operatinalise their practice in the face of a likely renouncing from contact. Nurses under these environments are constantly fearful of being abused, outmanoeuvred, and used. Various strategies have been provided to enable FMHNs overcome such challenges, including understanding issues of authority and power, professional identity, territoriality, and professional identity (Peternelj-Taylor & Johnson 1995).
FMHNs’ skills, attitudes, and knowledge in fulfilling their roles
As noted earlier, most FMHNs are at times expected to provide care treatment and care to patients who are at risk of offending or have an offending history. In the event that the patient has committed an offence and on account of their mental health state, the FMHN is expected to apply the fundamental skills, attitudes and knowledge of nursing as well as the enhanced skills needed in working effectively with forensic patients (McMurran et al. 2008). FMHNs should ideally apply such skills, attitudes and knowledge while providing treatment and care to forensic clients in diverse healthcare settings, such as prisons, police custody centres, the community, and forensic mental health hospitals. The FMHN usually undertakes extensive risk assessment processes when dealing with forensic clients in order to identify aspects of risk to the forensic client and to others, as well as potential protective factors that if adopted, might reduce such risk (McMurran et al. 2008). Towards this end, prevention and management of offending, and more so violence, is now the focal point of modern-day risk assessment in as far as forensic mental health is concerned. Once assessment of the likely risk has been done, the FMHN then executes evidence-based interventions as a means of managing such risk, and to help the forensic patients self-manage their risk behaviours (National Forensic Nurses' Research and Development Group 2008). Such a dynamic process calls for continuous risk assessment and to ensure that the interventions are adapted to the patient's changing risk status (Elder, Evans & Nizette 2012). Risk assessing and managing risk hinges on a structured professional judgement on the part of the FMHN consisting of a three-stage sequential process. The process involves collection of accurate information, understanding the client’s pathway to violence, and as well as developing a safety pathway (Evans et al. 2006).
In gathering accurate information, the FMHN should be fully conversant with the client's pattern of violence (Durcan 2008). This can only be realised by collecting accurate information on the client’s past incidents (Bartlett & McGauley 2010). This entails identifying the events that took place, their frequency, the context, nature of violence, victims, and weapon use (Durcan 2008). Various scholars have expressed divergent views on the skill set of a FMHN in comparison with the skill set required of other mental health nurses. Some have argued of a significant difference in skill set and hence advocate that forensic mental health nursing be regarded as a speciality area in psychiatric nursing (Cashin 2006). Lyons (2009) opines that even as the knowledge base of the FMHN is undoubtedly significant and encompasses mental health, criminal justice and nursing systems, the ability of the FMHN to use their skills under stressful and onerous circumstances (risk, patient behaviours, environment) is the key difference between mental health nursing and forensic mental health nursing. Other scholars (for example, Rask & Brunt 2006) are of the view that the ability of the FMHN to use confrontation skills is a key tool of intervention. This is yet another distinguishing factor between FMHN and other health mental health nursing. Moreover, the FMHN must possess special skills that enable them to work with clients characterised by challenging personality disorders (Martin 2008). Dale and Storey (2004) conducted a survey to assess the relationships between FMHNs and their clients in secure mental health service setting in the UK. Participants to the survey intimated that their relationship with clients was “...highly charged and emotionally intense with high levels of anger and hostility” (p. 177). According to Martin (2008), FMHNs are expected to demonstrate “competence in mental health nursing and then needing to develop additional knowledge and skills” (p. 27). Elsewhere, Kettles and Walker (2007) report that the FMH nursing is “not restricted to basic competency level, but included advanced practice.” (p. 38). Bowring-Lossock (2006) has confirmed the distinction of FMHNs by noting that this profession calls for skills that are highly focused on danger and risk. This is realised by dealing with elements of evaluating and managing risk, managing aggression and violence, knowledge of the culture of detention, as well as offending behaviour. Moreover, FMHNs are expected to possess high levels of skills in defining, de-escalating and calming in order to make interventions under tense situations (Fluttert et al. 2009; Mason et al. 2008). More importantly, the FMHNs has to maintain respect, dignity, and privacy for the client.
FMHNs work in very dynamic settings. The key concerns of FMHNs entail managing violent and dangerous clients, and ‘security versus therapy’. In executing their duties, FMHNs encounter conflicting roles such as “therapy versus security” and how to enhance therapy efficacy. FMHNs work under diverse and oftentimes dangerous settings, including prisons, young offender institutions, and hospitals. The FMHN also comes under increasingly higher pressure to ensure public safety by protecting them from risky behaviour by the client. FMHNs interact with patients at times under very stressful conditions. The issue of whether the FMHN should pay more attention to caring for the mental health patient or ion matters of custody is also a key source of conflict in the role of the FMHN. The FMHN also faces the challenge of being seen as part of the criminal justice system by the patient. To overcome such barriers and in an effort to enhance the nurse-client relationship, the FMHN is expected to possess skills in working with a multi-disciplinary team, ability to participate in team work, avoiding boundary invasion, and proficiency in avoiding splitting.
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