Risk & Risk
Management:
in
Forensic Psychiatric/Mental Health Nursing:
A
Brief Annotated Bibiliography
-General
Role & Education In The Literature Re. Forensic Psychiatric/MH
Nursing
- Risk Assessment & Managment In the
Literature Re Forensic Psychiatric/MH Nursing
-Intervention and Therapy in the Litererature
-Refererences & Further Reading
-Author's
Acknowledgement's
Forensic
psychiatric nurses work with offenders who have been deemed mentally
disordered and thus have no place in the judicial/ penitentiary
system. Within secure psychiatric settings, they must provide
care for and maintain custody of these patients, a paradoxical
role that makes this type of nursing unique. Although coinciding
with psychiatry, psychology and clinical criminology in some
respects, this nursing discipline is nonetheless distinct. In
the literature, there exists a debate over the true status of
forensic psychiatric nursing as a specialty: some declare it
a distinct role with unique requirements and responsibilities,
while others believe that the profession needs to further define
its nurse-patient relationship and develop more standardized
formal training.
Risk assessment and management have become increasingly important in forensic
psychiatric nursing, as nurses work with patients who have a high probability
of displaying violent behaviour. However, as an emerging practice, no standardized
universal training or instruments exist, and there has been much recent research
into the development of risk assessment and management models.
Although not exhaustive, this annotated bibliography is a collection
of recent literature regarding forensic psychiatric nursing and
aims to highlight the
particulars of this practice. It is divided into three sections: role/ education,
interventions/ therapy, and risk assessment and management, with a particular
focus on the nursing perspective. It was compiled by a third year student enrolled
in the Bachelor of Health Sciences program at McMaster University in Hamilton,
Ontario. My research began as an interest project and has continued as an independent
study required by the course, Health Sciences 3H03: Inquiry Project. The project
was completed under the direction of Dr. Chris Webster, Senior Research Consultant,
Forensic Services, St. Joseph’s Healthcare, Hamilton.
The
literature search was conducted between Spring 2003 and Spring
2004, using Ovid Medline and combinations of search words such
as: ‘forensic nursing,’ ‘forensic psychiatry,’ ‘forensic
psychiatric nursing,’ ‘job description,’ ‘nurse’s
role,’ ‘psychiatric nursing,’ and ‘risk
assessment.’ A variety of nursing and mental health journals
were accessed electronically or through McMaster University libraries,
most frequently: the Journal of Psychiatric and Mental Health
Nursing, the Journal of Psychosocial Nursing and Mental Health
Services, Nursing Times, and the Journal of Psychosocial Nursing.
Papers were included on the basis of apparent pertinence to the
topic and currency. Within my research, I found that the same
points were often made by different authors, but no effort was
made to determine primacy as all information was simply summarized
and categorized by content.
Role
and Education of Forensic Psychiatric/Mental Health Nursing In
the Literature (General)
As
an emerging specialty, the role of the forensic psychiatric nurse
is not yet universal, and the term “forensic” has
expanded to include nurses working with both victims and perpetrators
in a variety of settings. The articles in this section discuss
the emerging role of the forensic psychiatric nurse, the debate
over the existence of a specialty, role tensions, and training
issues.
Role – forensic
nursing – with perpetrators
Barton, S. (1995). Investigating forensic nursing. Kansas Nurse, 70(6): 3-4
-
Kansas: Focuses on forensic nurses who care for victims of
crime
- Nurses also use their therapeutic abilities to work with the perpetrators
of criminal acts. In correctional facilities, forensic psychiatric nurses
assess, evaluate, and use therapeutic interventions while working with criminal
defendants. Other practitioners working in private offices manage therapeutic
regimens with either victims or offenders
Education/
training – burnout
Ewers, P., Bradshaw, T., McGovern, J. M., & Ewers, B. (2002).
Does training in psychosocial interventions reduce burnout
rates in forensic nurses? Journal
of Advanced Nursing, 37(5): 470-6
-
UK: Mental health nurses working in secure environments with
patients suffering from serious mental illness have been
shown to be at risk of clinical burnout syndrome
- Clinical burnout has been described as a syndrome occurring in staff working
in the care professions which results in emotional exhaustion, depersonalization
and reduced personal accomplishment
- Clinical burnout has been shown to have a negative effect on the well-being
of staff, the quality of interactions between staff and clients, and undesirable
consequences for the organizations in which staff work
- Psychosocial Intervention Training (PSI) is a relatively
new innovation that helps clinicians to conceptualize
their patients’ problems within
a more empathetic framework and trains them in the skills to intervene effectively
- Study: aimed to evaluate the effect of PSI on the knowledge, attitudes
and levels of clinical burnout in a group of forensic mental health nurse
- Found that staff in the experimental group showed significant improvements
in their knowledge and attitudes about serious mental illness and a significant
decrease in burnout rates
Role – forensic
community nurse – developing
Friel, C., & Chaloner, C. (1996). The developing role of
the forensic community nurse. Nursing Times, 92(29): 33-5
-
UK: Generic mental health teams face anxieties and pressures
in caring for/ managing difficult/ dangerous patients, which
is reflected in the number of requests for forensic specialist
opinion
- The Care Program Approach (CPA) has raised standards of aftercare and increased
the accountability of key community mental health personnel
- Evolving role of the forensic community mental
health nurse (FCMHN): being asked to offer independent
advice and recommendations re: care/ management
of forensic psychiatric patients – these recommendations may form the
basis of the clinical team’s plan for treatment and management in the
community
- Need for education/ preparation of nurses as they are increasingly required
to conduct formal assessments and produce comprehensive/ influential clinical/
managerial reports
- Emphasis placed upon examining the patient’s
history of, and potential for, offending
- There are few, if any, definitive assessment instruments available specifically
for nurses
- Chiswick (1995): 5 useful indicators are: index of behaviour or event and
antecedents, use of alcohol and other substances, psychosexual behaviour
and interests, mental state examination, and attitude to treatment received
Role – forensic
nursing – caring
Hammer, R. (2000). Caring in forensic nursing: Expanding the
holistic model. Journal of Psychosocial Nursing & Mental
Health Services, 38(11): 18-24
-
United States: Forensic nursing brings together the disciplines
of nursing, forensic science, medical science, sociology,
and psychology with law enforcement and the criminal justice
system
- Until the IAFN recently designated forensic nursing as a unique specialty,
nurses had practiced forensic nursing for many years without formal recognition
of the domain as a sub-discipline for specialized study
- Such recognition requires that the specialty define
and explicate its major conceptual base – must
remember that caring remains the hallmark of professional
nursing practice
- Complex role in providing caring encounters for
victims of violence as well as the perpetrators of
criminal acts – some difficulty may arise
because of the dichotomy of roles that presents itself in many forensic situations
and the need to avoid conclusions of innocence or guilt; further, the nurse’s
need to protect and preserve human dignity may seem to be in conflict with
the objectives of the other members of the forensic team
- Article provides recurring themes in the definition of caring as well as
an instrument developed to measure caring
Role – forensic
nursing – debate
Maeve, M. K., & Vaughn, M. S. (2001). Nursing with prisoners:
The practice of caring, forensic nursing or penal harm nursing?
Advances in Nursing Science,
24(2): 47-64
-
United States: This article critically analyzes three philosophic
stands toward nursing care with prisoners and suggests their
philosophic commensurability within traditional nursing practice
- The idea of providing decent, sound health care for prisoners is not always
popular
- It is widely reported/ accepted that incarcerated men and women have increased
rates of serious and chronic physical and mental illnesses (diabetes, hypertension,
depression)
- If one accepts the idea that criminal behaviour is unhealthy behaviour,
the potential scope of health care needs becomes exponentially greater
- Nurses may be licensed practical nurses (LPNs) with about one year of vocational
training or registered nurses (RNs) with varying levels of education/ preparation
- The pool of available nurses and physicians for prison settings is somewhat
limited due to the nature of the job, the pay, and the setting/ location
? there is a professional stigma associated with working in correctional
health care
- Ethical problems: maintaining confidentiality, using chemical restraint
for security rather than medical purposes, working with under-qualified personnel
providing care outside their scope of practice, caring for addicted prisoners,
caring for the mentally ill, caring for incarcerated mothers and their newborns,
managing for the visitation rights of children whose parents are incarcerated,
dealing with violence, coping with prolonged isolation/ segregation of inmates,
and providing appropriate planning for released prisoners
From a caring perspective:
- Caring associated as the fundamental core of nursing, and caring always
involves relationship (even with an offender)
- When feelings of natural caring are distorted, nurses must find a way to
respond to and overcome obstacles through ethical caring
From a forensics perspective:
- In 1995, the American Nurses Association officially recognized forensic
nursing as a specialty
- The International Association of Forensic Nurses (IAFN) recognizes varying
roles: nurse coroner, nurse investigator, forensic psychiatric nurse, legal
nurse consultant, and the forensic correctional/ institutional nurse
- Inconsistencies of definitions lead to role ambiguity
- Adding the term ‘forensic’ assured a formalized interface with
the criminal justice system = new set of expectations for the outcomes of
psychiatric nurses’ evaluations and treatment interventions
- Forensic psychiatric nurses are increasing their
involvement in the transition between institutionalization
and community living; they can affect patients’ re-institutionalization
so as to maintain safety in the community
From a penal harm perspective:
- In general, penal harm medicine and nursing exist when any health care
provider supports and enforces penal harm through nursing and/ or medical
actions
- During orientation processes at jails and prisons,
nurses are substantively ordered not to care – this type of occupational socialization is intended
to protect nurses but some may ‘forget’ their healing/ caring
role
Role – forensic
psychiatric nursing – developing
Mahony, C. (1997). Managing the risk. Nursing Times, 93(18): 73-6
-
Wales: Spectrum of care for forensic psychiatric nursing
encompasses special hospitals, medium- and low-security hospitals,
and community nursing
- In 1996, the Special Hospitals Service Authority
was abolished and replaced with the High Security
Psychiatric Services Commissioning Board – prisons,
police stations, probation teams, secure units and mainstream mental health
services will all come under the Board’s scrutiny
- Nurse Ray Rowden, appointed first director of the
board, wants “to
see people writing more about their work, a vibrant research programme in
forensic mental health nursing, and nurses acting as consultants and trainers
to colleagues in mainstream mental health services” (p. 75)
- Ged McCann, county development officer for mentally
disordered offenders in North Yorkshire, predicts
that the future will see more forensic psychiatric
nurses working in a range of community settings. McCann says: “The
biggest training challenge is that health-service staff haven’t a clue
how criminal justice works and vice versa. There is a big role for forensic
CPNs in educating other professionals” (p. 76)
Role – forensic
psychiatric nursing – debatable specialty
Martin, T. (2001). Something special: forensic psychiatric nursing. Journal
of Psychiatric and Mental Health Nursing, 8: 25-32
-
Australia: This paper refutes the claims that forensic psychiatric
nursing has achieved the status of a specialist area of nursing
- There is a lack of consensus regarding the stage
of development of forensic psychiatric nursing as
a specialist area. Lynch (1996); Peternelj-Taylor & Johnson
(1995); Burnard (1992); and Burrow (1993) concur with the view that it is
a specialist area, while Mason & Mercer (1999); Whyte (2000); and Doyle
(1998) disagree
- Author suggests that the claim of working in a specialized area of nursing
practice is not supported in the literature or by evidence of specialist
practice. Forensic psychiatric nursing will remain a subspecialty of psychiatric
nursing until what is distinct and therapeutic about the practice is made
clear
- Three requirements are necessary if forensic psychiatric nurses wish to
achieve specialty status. First, forensic nurses have to consolidate their
role in the containment and care of patients. Second, they have to return
to the nurse-patient relationship as the foundation of psychiatric nursing
practice. Third, within that relationship, nurses must expand their practice
to include dealing with offence issues
- At present, discussion of the offence is often avoided due to a lack of
education or because of their attitude to the offending behaviour. Exploring
the offending and risk behaviours allows nurses to contribute to the decisions
that will determine ongoing detainment, leaves or discharge. Expansion of
their role would require education in criminology, substance use, grief issues
and counseling skills
Role – tensions – literature
review
Mason, T. (2002). Forensic psychiatric nursing: a literature review and thematic
analysis of role tensions. Journal of Psychiatric and Mental Health Nursing,
9: 511-520
-
UK: The aims of this literature review were to analyze the
existing literature on forensic psychiatric nursing, to undertake
a thematic analysis for emerging themes, and to construct
a theoretical framework for further research
- In the UK, there exist four main areas of concern
regarding secure psychiatric provision: 1. Treatment
efficacy of secure psychiatric settings, 2. Tension
created through the political move towards community care provision, 3. The
complexity surrounding personality disorder, 4. The ‘prisonization’ of
the secure psychiatric wards
- The results of this literature review were the identification of a series
of major issues, which were broadly categorized as negative and positive
views, security vs. therapy, management of violence, therapeutic efficacy,
training, and cultural formation.
- Negative views have been located within socialized
values of distaste for particular types of offences
and these values may lead to the contamination
of professional practice. Negative views are also noted in nurses’ commentary
regarding the effectiveness of their skills to treat mentally disordered
offenders
- Positive views are often expressed in relation to the extent to which forensic
psychiatric nurses feel that they are in control of particular situations,
and when they feel that their efforts are appreciated
- Security versus therapy is the central dilemma for forensic psychiatric
nurses. In the UK the role of security falls to nursing staff, while in the
USA and Canada most units have security personnel to undertake those tasks
(Day 1983)
- Management of violence is necessary as the potential for violence among
an offender population with mental disorder is ever present
- Therapeutic efficacy is of central importance in the delivery of care;
however, the formation of a therapeutic relationship in secure psychiatric
settings is difficult, as the patient views the nurse as being part of the ‘system’ of
detention
- Training to undertake forensic nursing in secure psychiatric services has
become a growing concern internationally. Byrt (1990) found that nurses required
training in nurse-patient relationship, listening skills, personal qualities
and self-awareness
- Culture has an impact on the delivery of care; the ward culture can be
negative or positive as a result of the difficulty of establishing the fine
balance between security and therapy
- From here, domains of practice emerged as a framework for further research:
medical vs. lay knowledge, transference vs. counter-transference, win vs.
lose, success vs. failure, use vs. abuse, and confidence vs. fear
Role – community
psychiatric nursing
Parish, C. (2002). Carers in court. Nursing Standard (Harrow-on-the-Hill),
16(41):12
-
UK: Court diversion schemes designed to intercept people
with mental health problems staffed by community psychiatric
nurses whose job it is to ensure that people are properly
assessed and diverted to appropriate services
- The criminal justice mental health liaison service
at the Mersey Care NHS Trust in Liverpool provides
a ‘safety net’ at each stage of the
criminal justice system – intervene to get more appropriate sentencing
- Nurses use knowledge/ expertise to perform risk
assessment and decide what the patient needs – hospitalization,
medication, etc.
Role – forensic
psychiatric nursing
Peternelj-Taylor, C. (1999). Forensic psychiatric nursing: The paradox of custody
and caring. Journal of Psychosocial Nursing and Mental Health Services, 37(9):
9-11
-
Features the contributions of forensic psychiatric nursing
experts from Canada, the United States, and the United Kingdom
- Forensic psychiatric nursing bridges gap between the mental health care
system and the criminal justice system; it is defined as the integration
of mental health nursing philosophy and practice within a sociocultural context
that includes the criminal justice system to provide comprehensive care to
individual clients, their families, and their communities
- These nurses face a dual obligation of custody (legal system; community)
and caring (health system; individual) ? this paradox is the single factor
that most differentiates forensic psychiatric nursing from forensic nursing
in general
- The protection of society is seen as a direct consequence of the processes
of control and custody
- The health consequences of violence are of concern to both the health care
system and the criminal justice system and require a coordinated multidisciplinary
approach
- Forensic nursing described as a contemporary area of nursing practice that
is still in its development stage
Role/
Education – improving care/ training needs
Rask, M., & Aberg, J. (2002) Swedish forensic nursing care: nurses’ professional
contributions and educational needs. Journal of Psychiatric and Mental Health
Nursing, 9: 531-539
-
Sweden: Utilizing content analysis, this report analyzes
data regarding how nursing care could contribute to improved
care and the organizational changes needed, as well as what
knowledge the nurses need to meet future demands
Niskala (1986):
- There are several roles/ skills that forensic psychiatric nurses must be
knowledgeable about to be able to meet the needs of the patients in their
care
- The types of competence rated most important by nurses: effective communication,
the maintenance of security, the performance of the nursing process, and
the maintenance of a professional role
- The skills nurses stated they needed most often include: to initiate relationships,
to listen effectively, to document in a clear and concise manner, to maintain
confidentiality, and to cope with institutional and environmental stressors
- Nurses reported a need for more training on 66 of the 162 skills/ competencies
items
Study:
- Nurses working in five Swedish forensic psychiatric units filled in a questionnaire
designed for general psychiatric nursing, but modified for forensic
use
- How nursing care could contribute to improved care and the organizational
changes needed:
- Analysis of issues resulted in four different categories: humanistic basis
in nursing care, organization of care, nurses’ need of knowledge, and
essence in the nurses’ work
Findings:
- An interpersonal nurse-patient relationship based on trust, empathy, respect
and responsibility for the patients’ personal resources and knowledge
is the essence of nursing care and a way to improve care
- The organization needs to be more influenced by/ based on nursing care
where clinical supervision and the patient’s social networks have more
distinguished roles
Knowledge
the nurses need:
- Analysis developed 10 categories with specific content: Nursing care, Developing
relationships, Humanistic and basic human values, Theoretical models and
treatment techniques, Psychopathology and medication, Basic and further training,
In-service training adapted to the ward-specific problems, Documentation
and evaluation, Clinical supervision, and Knowledge about other caring professions
Findings:
- The nurses’ educational needs emanate from different treatment modalities,
how to perform different treatments, how to establish developing relationships,
and in-service training adapted to the ward-specific problems
Role – forensic
psychiatric nursing – developing
Sekula, K., Holmes, D., Zoucha, R., Desantis, J., & Olshansky, E. (2001).
Forensic psychiatric nursing: Discursive practices and the emergence of a specialty.
Journal of Psychosocial Nursing & Mental Health Services, 39(9): 51-57
-
North America: Describes the concept of forensic nursing and
questions its existence as a specialty. Much debate and
controversy has accompanied the development of specialty practices
in nursing. Traditionally, nurses have been trained as generalists
and nurses with extensive clinical experience in a particular
area of practice are considered specialists – by this
definition, no formal education beyond the entry level is required
to call oneself a specialist
- The International Council of Nurses (ICN) defined specialization in nursing
as a level or knowledge and skill beyond basic nursing education; in 1992,
the National Council of State Boards of Nursing further defined the requirements
by stipulating that in addition to basic nursing education, advanced practice
nursing requires a graduate degree in nursing with a concentration in the
identified area of practice
- Two models for specialization in nursing are used in practice: the first
is the collaborative model (similar to the medical model in that it views
patients within disease categories); the second is the clinical nurse specialist
model (based on nursing models of practice which views patients within nursing
theories of care)
- While Whyte (1997) argues that forensic nursing is not a legitimate specialty
within nursing, Lynch (1993, 1995) and Burrow (1993), among others, believe
that forensic nursing is a specialty of its own with unique responsibilities
created by the intersection of the mentally ill person as both the patient
and the criminal
- The development of forensic nursing has been attributed to the increased
rate of incarceration and the failure of deinstitutionalization
- However, inconsistent definition of role makes it more difficult to identify
forensic nursing as a specialty, as well as to provide education and set
standards. The acceptance of this specialty could facilitate further development
of a knowledge base, accelerate the development of assessment and intervention
skills, encourage research in the area, and promote a sense of identity for
nurses working in this marginalized domain of practice
Role – multidisciplinary
team-work – ethical references
Mason, T., Williams, R., & Vivian-Byrne, S. (2002). Multi-disciplinary
working in a forensic mental health setting: ethical codes of reference. Journal
of Psychiatric and Mental Health Nursing, 9: 563-572
-
UK: Reports on a research project on multidisciplinary team-working
within a medium secure forensic unit
- In healthcare settings, teams will comprise individuals
from differing professional groups whose roles within the
team also differ; each must have
some understanding of other members’ roles to maximize the functioning
of the overall team. Team-working is central to effective healthcare delivery
- The focus of forensic mental healthcare is the delivery of service through
a systemic structure incorporating mental health and criminal justice issues.
Individuals involved in these multidisciplinary clinical teams come from
professions such as psychiatry, clinical psychology, social work, nursing,
occupational therapy, and probation. Each professional group brings their
own profession’s value system, normative practices, ideological framework,
and code of conduct
- A review of the literature reveals definitional difficulties and different
proposed typological frameworks applied to multidisciplinary team-working
- Brooker & Whyte (2000): aimed to assess the extent to which professions
working in forensic settings were clear about their role in teams, and agreed
about the core skills needed by all team members. Referring to overall identification,
55% of subjects identified with both their profession and the team – indicates
that these two areas of identification are interacting with each other, although
multidisciplinary tensions were also noted across professional groups
- Robinson & Kettles (1998): forensic nurses feel they provide a link
between disciplines in a pivotal role central to communication; however,
some have difficulties contributing to the team and feel they have low status
within it
Study:
- Two questionnaires were developed, one delivered to groups/ teams and one
to individuals, with the aim of obtaining feedback from a wide range of workers
regarding the systems, processes, and structures in place to support their
practice
- The results highlight a three-level ethical code referencing system employed
by both groups and individuals: (a) a reference system within their own ideological
framework; (b) a reference to the local unit’s/ Trust’s ethical
codes; and (c) each profession’s general code of conduct
- When these codes of reference differ, tension is created in deciding which
to follow
- Further, within this referencing system exists three polarized continua
labeled: (a) individual versus group accountability; (b) local versus national
policies; and (c) informal versus formal reference points – multidisciplinary
decision-making must be made within this complex structure
Education/
training – leadership
Pullen, M. L. (2003). Developing clinical leadership skills in student nurses.
Nurse Education Today, 23: 34-9
-
UK: Need for strong leadership within the NHS: The NHS Plan
(2000) states that nurses need to take a lead role in the
running of local health services
- The literature identifies a number of skills deemed to
be essential for clinical leadership – four skills
discussed in the article are self-knowledge, communication
skills, risk taking, and keeping informed
- Self-knowledge: it is important that a leader develops an awareness of
the messages that their own body conveys to others; also must know own strengths
and weaknesses so as to help the team achieve desired goals
- Communication skills: these are encouraged throughout pre-registration
nurse education; communication is a two-way process and students are taught
active listening skills
- Risk taking: risk taking is one of the defining characteristics of leadership,
however the culture of the NHS is one of risk aversion
- Keeping informed: the need to know what is happening both locally and globally,
in order to ensure that actions taken are synchronized with other events
- This paper analyzes the ways these skills are currently developed in
one University’s pre-registration nursing curriculum and concludes
that although many opportunities are available to develop these skills
in the
classroom environment, there are many pressures that prevent use of these
skills in a practice environment
Therapeutic
tool/ nursing skill – leadership – education/ training
Scheick, D. M. (2002). Mastering Group Leadership: An Active Learning Experience.
Journal of Psychosocial Nursing, 40(9): 30-9
-
United States: Leading therapeutic groups is an underused
by viable treatment role for nurses in all specialty areas – it
is a skill that can increase nurses’ repertoire of
therapeutic responses
- Learning results from both passive reception and active processing of
information
- Active learning encompasses a range of teaching-learning strategies
emphasizing students’ involvement, investment, and responsibility
to learn
- Learning how to lead a group begins by being in a group; each year
nursing students are given more of a leadership role accompanied
by journal writing
to internally process and self-evaluate – students self-teach and
expand the therapeutic repertoire of responses
- Recognition that the skills required to produce good group work are different
than those required to produce good individual work
- Psychoeducational group model is used in clinical setting
- Structured exercises are used to help facilitate group progress and to
help determine the level of self-exploration or intensity
Role/
Education – training issues in forensic practice – multidisciplinary
Mason, T., & Gerry, C. (2002). Towards a ‘forensic lens’ model
of multidisciplinary training. Journal of Psychiatric and Mental Health Nursing,
9: 541-551
-
UK: Paper reports on research undertaken to identify if common
areas of multidisciplinary training in forensic mental health
practice exist in the literature; review of literature and
curriculum documents
- Multidisciplinary working is central to forensic practice
- Professional training has taken a diffused approach – each profession
has formulated areas of study for appropriate ‘forensic’ expertise,
usually involving basic training pertaining to the profession followed by
postgraduate studies
- This method of training is unclear and may not be appropriate, so it is
necessary to identify what the required skills are to care for/ manage this
patient population, as well as establishing whether they are evidence-based
and to what extent they can be measured
- Debate, particularly in forensic nursing, is centred on two points:
first, whether generalist principles of professional working practices
are merely
being applied to a specific patient population; second, whether there is
a unique body of knowledge known as ‘forensic’
Forensic Psychiatric Nursing:
- The term ‘forensic’ nursing was generally accepted in the literature
in the mid-1980s to denote those who work with mentally disordered offenders
in secure psychiatric services
- Difficult to define, but the disparate nature of the inchoate profession
is highlighted – the contrasting aims of caring and custody
- Dale et al (1995): failure to address the inadequacies of syllabi to skill
a nursing workforce to manage and treat mentally disordered offenders is
a major concern
-
Brooker & Whyte (2000): report aimed at multidisciplinary
team-working in secure psychiatric settings; argued that
inter-professional training should take place at the clinical
interface, and that it should focus on client-centred, problem-based
learning exercises that allow for reflexive learning
- An important finding of this review is that process is just as important
as content in the care/ management of mentally disordered offenders. The
process is assisted by a knowledge base that is related to forensic practice
and constructed from 13 broad multidisciplinary training areas: legal, assessment,
treatment, evaluative, research, management, multidisciplinary, service development,
risk, forensic, other, security, and ethical issues
- Forensic practice is at an early stage of development, and the process
requires facilitation in order for a specific knowledge to emerge. This process
involves developmental work in the 13 areas and specific training is required
for staff to take action in these areas. This modeling provides evidence
to support
common areas of multidisciplinary forensic training
Role – forensic
nursing – definition
Whyte, L. (1997). Forensic nursing: a review of concepts and definitions. Nursing
Standard, 11(23): 46-7
-
UK: Considers the evidence for the existence of forensic
nursing as a sub-specialty in mental health care; the author
argues that forensic nursing as a distinctive branch of nursing
does not exist
Lynch 1993, 1995:
- forensic nursing is the application of forensic science to nursing
- differentiated between 4 areas of forensic nursing:
- 1. clinical forensic nursing: application of clinical and scientific knowledge
to questions of law and criminal/ civil investigation of survivors of traumatic
injury and for patient treatment involving court-related issues
- 2. sexual assault nurse examiner: clinical examination of victims and therapeutic
interventions
- 3. forensic psychiatric nurse: involved in the assessment of, and interventions
with, criminal defendants before court hearings
- 4. forensic correctional/ institutional nurse: specializes in the care,
treatment, and rehabilitation of individuals who have violated criminal law
and have been committed for therapy to hospitals
- In the US and Canada, the term forensic psychiatric nurse can be used in
the same sense as forensic correctional/ institutional nurse
- The emphasis of Lynch’s work in the US is much more upon the issues
surrounding the victim, compared with the UK emphasis which is predominately
perpetrator centred – author believes there is a clear distinction
between the roles/ responsibilities of forensic nurses in relation to the
victims and perpetrators (care versus control)
- Author believes that a nurse must contribute to
assessment in the justice process to be called ‘forensic’
– also
states that the work of all mental health nurses is being influenced
increasingly by the forensic aspect of mental health care; mental
health nursing is simply evolving as mental health and justice
systems come into contact more frequently to become more forensic
in nature
Risk
Assessment and Risk Management
Risk
assessment and management are important in both secure psychiatric
settings and outpatient services, in which patients are reintegrated
into the community. The papers in this section discuss the theory
behind risk assessment and management, some approaches to their
implementation, and their central importance in forensic psychiatric
nursing. More specifically, instruments that have been developed
for use in practice are described and evaluated for their predictive
ability.
Assessment – research – developing
tools
Belfrage, H., & Fransson, G. (2000). Swedish Forensic Psychiatry:
A field in Transition. International Journal of Law and Psychiatry,
23(5-6): 509-514
- Sweden:
New legislation of 1992 required risk assessments in forensic
psychiatric examinations; although the body of knowledge
in this field was poor, at present (2000) there is no area
in the field of forensic psychiatry or the correctional system
that is subject to more research projects than risk assessment
and risk management
- Sweden has been influenced by international researchers,
mainly from Canada, in the area of risk assessment.
There is a trend in favour of structured
risk assessments, and Canadian instruments like the HCR-20 Violence Risk
Assessment Scheme (Webster, Douglas, Eaves, & Hart, 1997), the Spousal
Assault Risk Assessment Guide (Kropp, Hart, Webster, & Eaves, 1995),
the Sexual Violence Risk-20 (Boer, Hart, Kropp, & Webster, 1999), and
the Psychopathy Checklist-Revised (PCL-R)/ PCL-Screening Version (PCL:SV)
(Hare 1991; Hart, Cox, & Hare, 1995), are implemented into clinical practice
- The Swedish National Board on Forensic Medicine
is responsible for the forensic psychiatric assessments,
which take place during a trial, before
a sentence is given. A team consisting of a psychiatrist, a psychologist,
and a social worker work together to complete the assessment within four
weeks, and although it is up to the court to make the final decision, the
team’s suggestions are usually followed
- Risk management procedures (within Sweden’s civil psychiatric and
special forensic psychiatric hospitals) are introduced at the beginning of
the treatment, focusing on the individual’s risk factors and on the
establishment of risk management models to minimize them. Swedish law requires
that patients participate in planning for all forms of compulsory treatment
- To meet the requirements for final discharge, the court must decide that
there is no longer a risk for relapse into serious criminality as a function
of the mental disturbance and that there is no need for the patient to be
held at a psychiatric hospital - these requirements are rarely fulfilled
Assessment
and management – risk escalators
Heyman, B., Buswell Griffiths, C., & Taylor, J. (2002). Health risk escalators
and the rehabilitation of offenders with learning disabilities. Social Science & Medicine,
54: 1429-1440
-
UK: This paper presents a study of risk management in a hospital
within the UK National Health Service (NHS) which attempts
to rehabilitate offenders with learning disabilities. Analysis
is based on the metaphor of a ‘risk escalator’ with
a focus on emergent properties of a downward risk escalator
- The concept of a risk escalator provides a way of understanding how the
dilemma of balancing patient safety against autonomy is dealt with by hospital
staff
- Health and social care systems can be characterized as risk escalators
if they possess three attributes: first, risk managers (health professionals)
should agree upon the ordering of the severity of a set of related risks;
second, a range of responses should exist that can be calibrated against
risk severity and which provide different balances between autonomy and safety;
third, it should be possible for individuals to be propelled up or down a
risk escalator by positive or negative feedback
- Positive and negative risk feedback can occur because risk identification
changes behaviour and/ or because the emotional impact of a risk assessment
itself affects risk indicators
- In rehabilitation systems, risk escalators may bring patients downward
towards greater autonomy if justified by negative feedback, but this trajectory
may be blocked or reversed; ideally, behavioural management and therapeutic
systems work together to facilitate movement down the risk escalator
Study:
- Designed to illuminate patient and staff experiences of the rehabilitation
of offenders within a mental health care system. The research focuses
primarily on patient experiences and the obtained data relates more
to the behavioural management system than to biennial progress reviews
or psychotherapy
- Decisions to move a patient depend on communication
between different groups of health professionals – interviews
highlighted the gap in risk assessment which could
open up between front-line staff who shared their
lives with
patients and more distant senior colleagues empowered to decide their progress
- Four major issues were identified in the present study:
- 1. The smooth running of the downward risk escalator was compromised by
organizational complexities; further, patients did not necessarily seek to
move down the risk escalator
- 2. The slow-moving downward risk escalator towards rehabilitation was counter-balanced
by a rapid transit up escalator which swiftly moved those judged unable to
manage a given degree of autonomy into a more controlled environment. This
privileged safety over rehabilitation and created a tendency towards under-achievement
- 3. Travelers may actively manage their journeys on risk escalators; some
patients and staff identified inherent tensions between behavioural compliance
and therapeutic openness, and the ability to act in an expected manner in
order to gain autonomy
- 4. Riskiness may, like other nebulous attributes, be seen as a general
trait of individuals, indexed by any domain
Risk
assessment/ management – community release
Kelly, T., Simmons, W., & Gregory, E. (2002). Risk assessment
and management: A community forensic mental health practice
model. International Journal of
Mental Health Nursing, 11: 206-213
-
Australia: Risk assessment and management are central to
mental health practice; professionals must consider the probability
that their patient will act in a destructive manner and intervene
to prevent such behaviour (Mullen 2001)
- In Victoria, the Crimes (Mental Impairment and Unfitness to be Tried) Act
(1997) reformed the detention, management and release of persons found by
a court to be not guilty on the grounds of insanity by providing a legal
structure for such forensic patients to move from secure inpatient facilities
into the wider community
- Under the Crimes Act 1997, the court can impose a range of orders including
custodial and non-custodial supervision orders as well as unconditional release
- This new legislation has created challenges for all stakeholders by significantly
changing the lifestyle and life opportunities of this client group and their
carers (Martin et al. 2001)
- Responsibility regarding outcomes may extend from the forensic patient,
carers, courts, and wider community. Although ultimately a Supreme Court
decision to release forensic patients, it is clinicians who manage the risk
on a daily basis
Forensicare Risk Management Model:
- The challenges have necessitated development of the Forensicare risk assessment
and management practice model, with the objective to provide a framework
that optimizes community safety while acknowledging the rights of the individual
- Mental health nurses developed the model to work with mentally ill offenders
who have committed homicide in the past and are now living in the community.
It is based on the practical experience of mental health care practitioners,
risk assessment research, and literature
- The model is a three-pronged approach to risk assessment and management:
- 1. Risk Profile
- Serves as a tool to collate information pertaining to the offence and to
the patient’s total experience, and to provide a historical overview
of the illness-related factors, contextual circumstances, and dispositional
factors that have been associated with past violence
- 2. Risk Assessment
- Process of assessing the individual patient against his or her specific
risk factors as well as against other known general risk factors, such as
substance abuse (Mullen 2001)
- The function is to determine whether the clinician needs to take action
for the protection of the patient or community by activating the risk management
plan
- Risk is a dynamic factor, and assessment is more accurate at predicting
violence in the short term (Tardiff 1989); frequent risk assessment is therefore
essential
- 3. Risk Management Plans
- A collaborative and proactive exercise developed by the clinician in consultation
with the patient, their carers, and other relevant agencies
- The plan documents strategic directions for immediate response in patient
management in times of increased risk, and serves as a communication tool
- Distinguishes between two levels of response – after
identification of increased risk and assessment,
it may be decided that the patient can
remain in the community with additional support, or that the patient must
be recalled to hospital
Management – intervention – issue
of restriction
Kozub, M. L., & Skidmore, R. (2001). Least to
most restrictive intervention: A continuum for mental health
care facilities. Journal of Psychosocial Nursing & Mental
Health Services, 39(3): 32-38
- United States: The article reviews current research/
literature to formulate a usable continuum of interventions
in response to violent/ aggressive client behaviour AND hopes
to help hospital staff meet requirements of standards
- Responses must be proactive, effective in meeting patient needs at the
time, satisfy ethical/ regulatory requirements
- Public interest in the use of seclusion/ restraint has led to the revision
of regulatory standards such that seclusion/ restraint only to be used as
a last resort; the Health Care Financing Administration (HCFA) and the Joint
Commission on Accreditation of HealthCare Organizations (JCAHO) each have
released a set of revised standards to guide health care organizations in
the acceptable use of these interventions
- Two main levels of response to escalating patient behaviour exist: 1. least
restrictive interventions; 2. seclusion/ restraint. The less restrictive
end of the continuum provide a greater number of options for interventions,
and include verbal techniques, time out, medications, and therapeutic holding
for children. Interaction and redirection is a method of resolution at earliest
intervention level in which early detection of the escalating situation is
key. The patient is provided with consequences of escalation vs. de-escalation:
self-control and choice decreases as emotional response escalates. Seclusion/
restraint used together is the most restrictive intervention in the continuum.
Patients who need to be controlled at this level have been determined to
be unsafe in all of the less restrictive levels of intervention, and they
must be constantly monitored.
- Two constants of intervention are “processing out” and medication.
Processing out, or debriefing, is important at all levels. The second constant
involves patients’ ability to request medications and staff’s
responsibility to offer them at any point in the intervention process
- Strategies for implementation of less restrictive interventions include
education (prevention and management of disruptive behaviour, least restrictive
interventions, and assessment), training in the proper/ safe use of seclusion/
restraint, and support/ leadership from management
Assessment – risk
factors – rehabilitation
Lindqvist, P., & Skipworth, J. (2000). Evidence-based rehabilitation
in forensic psychiatry. British Journal of Psychiatry, 176:
320-323
-
Britain: This paper discusses some essential features of
a forensic psychiatric rehabilitation system to create a
conceptual framework for research and practice
- The assessment of the probability of mentally disordered offenders committing
violent and criminal acts continues to be subject to extensive research
- Research must be grounded in clinically-based
studies linking risk assessment to management
if it is to be applicable; studies should be
both qualitative
and quantitative, with a focus on the questions of whether or not, to what
extent and when forensic psychiatric rehabilitation alters the individual’s
level of risk
- Actuarial risk assessment tools, developed to further define which groups
of people with mental illness show/ have an increased risk of violent behaviour,
are largely based on static and historical factors that cannot hope to be
targeted or changed by rehabilitation; this may lead to inaccurate evaluations
- Risk assessment can be linked to at least four dynamic features of the
individual patient and their treatment setting: the disorder itself, family
problems and poor sociocultural circumstances, substance misuse, and anti-therapeutic
system dynamics
- There has been insufficient analysis of external factors and their influence
on prognosis; it is essential to focus therapeutic rehabilitative efforts
on factors both within the patient and their rehabilitative environment.
Such external factors include: shared values and goals, staff continuity,
timing of the initiation of the rehabilitation process, family relationships,
social networking/ peers, process insight, and future plans
- Research aimed at analyzing the effects of forensic psychiatric rehabilitation
is fraught with difficulty, whether quantitative or qualitative, and will
be hampered by such problems as: the complexity of forensic treatment systems,
the problems of constructing randomized-controlled studies (RCTs) with patients
in treatment systems, and the inability of current risk assessment tools
to assist reliably in rehabilitation
- To conduct a natural experiment, it is suggested that a number of separate
forensic psychiatry services be organized into a joint collaboration; this
would preserve a true clinical rehabilitative environment and allow for
comparative research
Risk
Management – forensic psychiatric nursing – workplace
violence
Morrison, E., Morman, G., Bonner, G., Taylor, C., Abraham,
I., & Lathan,
L. (2002). Reducing staff injuries and violence in a forensic psychiatric setting.
Archives of Psychiatric Nursing, 16(3): 108-117
-
USA: Little progress has been made towards improving understanding
of violence by the mentally ill, and programs aimed at the
prevention of such violence are rare
- This report describes the administrative and clinical efforts of the staff
in a maximum security psychiatric facility when addressing an alarming increase
in violence and serious staff injuries
- At the study hospital, the administrative team
developed a plan examining strategies for supporting/
protecting staff during violent crises – strategies
included a more lenient definition of ‘emergency’ for the use
of seclusion/ restraint, new restraint products, the implementation of a
Security Management Team (SMT), and Aggression Management Plans (AMP) on
selected high risk patients. A nurse consultant with knowledge in violence
was also hired to work with the staff in forensic psychiatry – short-term
goal was to be an advocate for staff and to decrease violence, and long-term
goal was the education of staff related to violence
- AMP: developed and implemented for managing the nine identified high-risk
patients. They provided for a means of early physical intervention, which
included seclusion and restraint (under a more targeted definition of emergency)
for the safety of staff. The AMP identified the appropriate clinical interventions
for three stages of escalation
- Data suggests that the units in the study hospital successfully reduced
staff injuries as well as the overall amount of aggression and violence;
use of seclusion/ restraint also decreased overall
- Several implications can be drawn for nurses: first, organizational issues
affecting quality of care in forensic psychiatric settings should be addressed
such as mandatory overtime, staff injuries, and violence. Second, staff injuries
and violence are not necessary in forensic psychiatric settings; violence
can be reduced. Third, staff morale is an issue that also must be addressed
because of its relationship with the quality of care
Risk
assessment – tools – VRAG & HCR-20
Tengstrom, A. (2001). Long-term predictive validity of historical factors in
two risk assessment instruments in a group of violent offenders with schizophrenia.
Nordic Journal of Psychiatry, 55(4): 243-249
-
Sweden: Studies have shown that individuals with a major
mental disorder (MMD) have an increased risk of committing
a violent crime. As most individuals with MMD do not commit
crimes, the crucial question is which mentally disordered
individuals have a higher risk of committing or recidivating
in violent crimes
- The literature points to historical variables as the best predictors of
future violence among all offenders, regardless of mental health status:
previous criminality, start of criminality at an early age, and childhood
conduct problems
- Several risk assessment guides/ checklists have
been developed during recent years (Borum 1996) – two
of the best-known are the HCR-20, Assessing Risk
for Violence (Webster et al. 1997), and the Violence
Risk Appraisal
Guide (VRAG) (Harris et al. 1993; Webster et al. 1994)
- The HCR-20 is a 20-item checklist for prediction of future violence among
personality-disordered or mentally disordered violent offenders. H refers
to historical, of which there are 10 items. C refers to clinical, and R to
risk; each comprises 5 items. No specific weighting procedure was adopted;
all items are rated from 0 to 2, 0 indicating absence and 2 indicating definite
presence of an item
- The VRAG is a 12-item actuarial risk assessment guide for prediction of
violent recidivism among violent offenders. To optimize prediction, this
tool utilizes a weighting procedure in which the items most strongly related
to recidivism are given a wider range of scores and more degrees of freedom
Study:
- Investigation of the long-term predictive validity of the VRAG and the
historical part (H-10) of the HCR-20 in predicting violent recidivism in
a sample of violent offenders with schizophrenia
- Results indicated that both H-10 and VRAG had a
moderate ability to predict violent recidivism and
that H-10 had a slightly better accuracy – most
of the items in H-10 but only half of those in VRAG correlated significantly
with violent recidivism
- It is concluded that historical factors seem to play an important role
for the long-term prediction of future violence among a group of severely
mentally ill individuals
Management – intervention – attitudes
re: restriction
Terpstra, T. L., Terpstra, T. L., Pettee, E. J., & Hunter, M. (2001). Nursing
staff’s attitudes toward seclusions & restraint. Journal of Psychosocial
Nursing & Mental Health Services, 39(5): 20-28
-
United States: Although there is a large body of literature
on the use of seclusion and restraint, only a few studies
have focused on the attitudes of staff toward their use.
The perceptions and attitudes of nursing staff will influence
not only their interactions with patients but also their
choice of interventions when responding to an identified
need or problem
- Seclusion and restraint use has received increased attention in recent
years; society has demanded that people with mental illness be treated with
the least restrictive methods possible. Guidelines issued by different nursing
and mental health associations suggest that seclusion and restraint be considered
emergency interventions aimed at protecting patients in danger of harming
themselves or others, and that they should be used as infrequently as possible
- Nurses are often on the front line, interacting with patients who may be
violent or who display disruptive behaviours and choosing to use these as
interventions
- Among physicians and therapists, attitudes have polarized over time
- Objections to seclusion and restraint use have
been based on ethical grounds, with the use of these
interventions being viewed as punitive and as a violation
of patients’ basic rights of freedom and dignity. Some also believe
these interventions are counter-therapeutic and induce dependency on staff
- Steele (1993) surveyed 28 employees in four inpatient psychiatric facilities
regarding attitudes: found that although 60% saw the use of restraint or
seclusion as therapeutic, many also expressed concerns about potential abuse
of rights, loss of dignity, and control over persons who are at a power disadvantage
- Study examined attitudes of 65 neuropsychiatric hospital staff members
in the Midwestern United States
- Pro-restraint: decreased physical injury, greater control over violent
behaviour, physical reassuring contact by staff, immediate feedback
- Pro-seclusion: more freedom of movement, decreased external stimuli, patient
has greater control
- Pro-medication: less restrictive, calming effect, greater control
- Staff must be educated about the therapeutic value of seclusion and restraint
as well as alternatives. Kozub and Skidmore (2001) discussed a variety of
least restrictive approaches which include interaction and redirection, setting
limits, using time outs, and safe physical escort techniques
Risk
assessment – institutional violence – dynamic factors
Wang, E.W., & Diamond, P.M. (1999). Empirically Identifying
Factors Related to Violence Risk in Corrections. Behavioral
Sciences and the Law, 17: 377-389
-
United States: Correctional violence is a large problem in
modern America. Because of problems associated with predictions
involving human judgment, formal (actuarial, mechanical,
algorithmic) have been proposed as alternatives to informal
(clinical) prediction models for all domains, including violence
(Grove & Meehl, 1996; Monahan & Steadman, 1994; Quinsey
et al., 1998)
- Actuarial violence prediction literature has focused almost exclusively
on community violence, typically of individuals (offenders or psychiatric
patients) following institutionalization, as opposed to institutional violence.
- Risk factors are different for community and institutional violence
- Institutional research may have some advantages over community research:
first, short-term may be more accurate than long-term predictions; second,
violent behaviour can be more accurately assessed because it is more likely
to be detected; third, environmental variability is constrained in institutions
- Methodological problems have plagued community research: criterion variables
have been weak and predictor variables have been narrow and not linked to
theory, and are usually static as opposed to dynamic (which can be targeted
for clinical intervention)
Study:
- Structural modeling was used to predict institutional aggression among
male mentally ill offenders using the predictors of anger, antisocial personality
style, current violent offense, ethnicity, and impulsivity. Measures included
the Barratt Impulsiveness Scale, the Buss-Perry Aggression Questionnaire,
the Personality Assessment Inventory, age, ethnicity, current violent offense,
victim injury from current offense, and institutional incidents of physical
and verbal aggression
- Results indicated anger, antisocial personality style, and impulsivity
are stronger predictors of institutional aggression than are ethnicity and
current violent offense, with anger being the best predictor
- Results suggest dynamic variables (such as anger) can be targeted for clinical
intervention to reduce institutional violence; the contribution of dynamic
indicators to the prediction model offers the possibility of linking prediction
and management models of risk assessment, intervening to manage the risk,
and assessing the relative risk of an individual at different points in time
Risk
assessment – corrections-based psychiatric hospital -
PAI
Wang, E.W., Rogers, R., Giles, C.L., Diamond, P.M., Herrington-Wang,
L.E., & Taylor,
E.R. (1997). A Pilot Study of the Personality Assessment Inventory (PAI) in
Corrections: Assessment of Malingering, Suicide Risk, and Aggression in Male
Inmates. Behavioral Sciences and the Law, 15: 469-482
-
United States: Provision of mental health services to correctional
populations demands that clinical staff efficiently and effectively
screen patients for severe mental disorders and other conditions
that require immediate intervention
- Screening instruments used in corrections should: be short, easy to read,
assess response sets and response styles, assess severe Axis I disorders,
assess problematic Axis II disorders, and assess violence potential
- An important consideration in assessing the treatment needs of mentally
disordered offenders is the selection of versatile clinical measures that
address a broad range of psychopathy and problematic behaviours
Study:
- An archival study
- Examined the usefulness of the Personality Assessment Inventory (PAI) in
assessing problematic behaviours in a corrections-based psychiatric hospital.
The problematic behaviours studied/ assessed were forms of acting out (suicide
and aggression towards others) and response style (motivations to malinger)
- As evidence of criterion validity, selected PAI scales were compared to
evidence of malingering on the Structured Interview of Reported Symptoms
(SIRS), suicidal threats and gestures, and ratings of aggression on the Overt
Aggression Scale (OAS)
- Results supported the continued examination of the PAI in assessment of
malingering, suicide risk, and aggression in male inmates receiving or requesting
psychiatric treatment
Risk
assessment – instruments – HCR-20
Uncorrected Proof
Watt, A., Topping-Morris, B., Rogers, P., Doyle, M., & Mason, T. (2003).
Pre-admission nursing assessment in a Welsh Medium Secure Unit (1991-2000):
Part 2 – comparison of traditional nursing assessment with the HCR-20
risk assessment tool. International Journal of Nursing Studies
-
Wales: This study assessed the quality of nursing risk assessments
through comparison with the HCR-20 (Webster, Douglas, Eaves, & Hart,
1997)
- The need for nurses to account for their actions and decision-making has
increased with the movement towards evidence-based practice. Developed in
1991, pre-admission forensic nursing assessment is a tradition that has no
research evidence base, little documentary support and is an expensive drain
on nursing resources from clinical environments
- Evaluation is possible through comparison of the information obtained in
pre-admission nursing assessments with a well-established and validated risk-assessment
tool: HCR-20
- The HCR-20 was developed as a broad-band violence risk assessment tool
and identifies markers for previous, current, and future risk. Evidence suggests
that the HCR-20 demonstrates good predictive validity and it is recommended
for use as a professional guideline to structure clinical assessments. One
historical item of the instrument (psychopathy) was omitted because it required
administration of the Psychopathy Checklist Revised (Hare, 1991a, b)
- The information traditionally collected by forensic nurses to aid risk
assessment at the Caswell Clinic was found to be sufficient to rate over
80% (n=16) of the 19 rateable items of the HCR-20
- Although the issue of evidence-based practice is important to nurses, not
every aspect of clinical practice has an evidence base. In such cases, some
traditional practices (nursing attempts to validate experiential and intuitive
practice) may have greater use
Risk
assessment and management
Woods, P. (2001). Incidents: reporting and management. In:
Dale, C., Thompson, T., & Woods, P. (Eds.), Forensic Mental
Health: Issues in Practice. London: Bailliere Tindal in association
with the Royal College of Nursing, pp. 99-107
-
UK: Violence in the workplace is a real problem, particularly
in forensic mental health settings. Although research has
been undertaken in relation to all aspects of violent incidents,
it is difficult to generalize from the literature as differing
definitions and measurements of violence are used
- It is important that incident monitoring is maintained on a regular basis.
Health service guidelines indicate that reporting systems should: be simple
to use, be based on a standard definition of incidents, allow for the timely
collection of data and investigation, and be able to record detailed/ complete
information regarding the incident (NHSE 1997)
Incidents:
- Definitions range from the vague to the more complete; a suitable definition
may be: ‘any behaviour which could be physically or psychologically
damaging to the individual, another individual or property’ (p. 100)
- There is agreement within the literature that high priority should be given
to a number of factors which are related to violence: factors predisposing
to violence, environmental factors, and the nature of the incident
1. Factors predisposing to violence:
- Generally, these factors form the actuarial base of any risk assessment
and management strategy. Individual characteristics of age; gender; ethnicity;
length of stay; and previous history of violence are important. For instance,
it is reported in the literature that younger patients tend to be involved
in more violent incidents
2. Environmental factors:
- The importance of environmental factors such as type of ward, location
of incident, patient density, time of day, day of the week and seasonal variation
often overlooked. These factors can assist in monitoring the occurrence of
violent incidents
3. Nature of the incident:
- It is important to record the nature of the incident, such as the victim
and the severity of incident. Nursing staff appear to take the brunt of most
violent incidents, although they are involved in direct patient care and
are more likely to be available for attack.
Reporting:
- A few authors have published incident-reporting systems which have been
empirically examined in order to determine their usefulness
- The best known of these is the Staff Observation
Aggression Scale, SOAS (Palmstierna & Wistedt
1987), with a recently revised version, SOAS-R (Nijman
et al 1999). The main variables measured when aggressive
behaviour
occurs are: provocation; means used by the patient; target of aggression;
consequence(s) for the victim(s); and measure(s) to stop aggression
- The SOAS can be used in conjunction with the Broset
Violence Checklist (Almvik & Woods 1998, 1999)
to measure violence in the first three days following
admission by assessing confusing, irritability, boisterousness,
verbal threats, physical threats and attacks on objects
Management:
- It is necessary for information to be reported or collated in order for
an incident-reporting system to feed into the management of incidents from
the organizational perspective
- Collection of information allows analysis of the incidents which occur
Risk
assessment and management
Woods, P. (2001). Risk assessment and management. In: Dale,
C., Thompson, T., & Woods,
P. (Eds.), Forensic Mental Health: Issues in Practice. London: Bailliere Tindal
in association with the Royal College of Nursing, pp. 85-97
-
UK: This chapter explores key issues of risk assessment and
management within forensic mental health care from both the
individual patient and organizational perspectives, with
an emphasis on clinical context
Risk Assessment:
- Risk can be defined as the probability of a bad consequence or as the likelihood
that a particular adverse event will recur (Prins 1996); within forensic
mental health care, risk assessment is concerned with three interrelated
components: the risk posed in the past, now, and in the future
- Assessments need to be systematic and based on
the population undergoing assessment (Pollock & Webster, 1990; Monahan & Steadman,
1994). Literature points to three foci for the future
of risk assessment research: first, there
should be an actuarial focus; second, there are situational variables; third,
attention should be on varied populations upon which predictions are made
(Monahan 1984)
- The Royal College of Nursing (1998) suggest that the aims of risk assessment
are to: identify the hazards, identify who is at risk, evaluate the risks,
make a record of the findings, and review and revise the assessment
Approaches to risk assessment:
- There are two main approaches: actuarial or statistical, and clinical
- The actuarial approach is based on the assumption
that an individual coming from a population within
which a certain type of bevahiour is common is more
likely to display this form of behaviour (Pollock & Webster, 1990)
- The clinical approach is based upon professional opinion; it looks for
explanation of specific violent behaviour and is concerned with how individuals
behave. Some researchers are opposed to this approach because it may be contaminated
by assessor bias
Good practice in risk assessment:
- Little effort has been made to develop frameworks for clinical usage in
making risk assessments (Borum 1996); however, factors can be identified
that predispose an individual to behave dangerously (McClelland 1995) and
that may serve as indicators for good practice in risk assessment
- Commonly recognized, although static, actuarial variables are: previous
history of violence, age under 30, male gender, concurrent drug/ alcohol
abuse, and active psychotic symptoms. An important point to emphasize is
that these actuarial risk markers only provide a guide for risk management
planning and any assessment must be individualized to the particular person
through inclusion of individual risk factors
Assessment
- prediction of recidivism - variables
Bonta, J., Hanson, K., & Law, M. (1998). The prediction
of criminal and violent recidivism among mentally disordered
offenders: A meta-analysis. Psychological
Bulletin, 123(2): 123-142
-
Ontario: Results of the study showed that the major predictors
of recidivism were the same for mentally disordered offenders
as for nondisordered offenders; criminal history variables
were the best predictors, and clinical variables showed the
smallest effect sizes
- The findings suggest that the risk assessment of mentally disordered offenders
can be enhanced with more attention to the social psychological criminological
literature and less reliance on models of psychopathology
- Psychopathological theories focus on psychological dysfunction, biological
dysfunction, or both as the basis for criminal behaviour; in contrast, the
theories of rational offenders have viewed criminal behaviour as a predictable
consequence of learning histories, values, and social structures
- 2 general camps within theory of rational offenders: sociological criminology
and social psychology
- Meta-analysis examined 4 domains of predictors: personal demographics,
criminal history, deviant lifestyle-history, and clinical
- In general, the predictors of recidivism among mentally disordered
offenders were almost identical to the predictors found among nondisordered
offenders – for
both general and violent forms of recidivism
- Most of the clinical variables were either unrelated or inversely related
to recidivism
- In studies that compared the recidivism of mentally disordered offenders
with nondisordered offenders, the mentally disordered offenders were less
likely to recidivate
- Assessments of dangerousness by clinical staff have not been very accurate;
in contrast, objective, empirically derived risk assessment measures proved
to be the best predictors of recidivism
Risk
assessment and management – mental health nursing
Crowe, M., & Carlyle, D. (2003). Issues and innovations
in nursing practice: Deconstructing risk assessment and management
in mental health nursing. Journal
of Advanced Nursing, 43(1): 19-27
-
New Zealand: Paper aims to critically examine the concept
of risk in mental health nursing practice through the historical,
clinical, cultural, political and economic structures that
underline contemporary understandings of risk and its management
- Assessment and management of risk are necessary in mental health nursing;
they protect the welfare of consumers of mental health services and the community,
and also play a role in protecting nurses against potential litigation. Despite
its emphasis in clinical practice, there exists very little mental health
nursing literature providing a critical analysis of the topic
- Historical: There is a long historical association of risk and mental
disorder. Responsibility of those classified as mentally disordered shifted
between legal, medical and administrative practitioners until the mid-19th
century, when psychiatrists took control. This process of medicalization,
the application of scientific principles to the mind and its mental health,
has introduced psychiatric diagnosis and the concept of risk inherent in
prognosis
- Clinical: Clinical risk assessment and management occurs in the context
of broader risk management – organizational, financial, political,
legal (Mental Health Commission, 1998)
- While an actuarial process is an integral part of the assessment process,
reliance upon statistical generalizations is not recommended. There is no
fixed or essential risk that reveals itself through observation, but rather
meaning is attributed to some characteristics and not others through a process
of aggregation. Individuals are thus evaluated based on their likeness or
difference from aggregated norms and this evaluation determines the amount
of surveillance and discipline required
- Cultural: Risk is defined in a way that reflects the values of dominant
culture, and what is attributed to normality. According to Beck (1999), risk
is always culturally constituted and as such is always imbued with culturally
determined values
Risk
assessment – mental health patients
Doyle, M. (1998). Clinical risk assessment for mental health nurses. Nursing
Times, 94(17): 47-9
-
UK: successive governments since the 1950s have continued
the policy of providing care for people with mental health
problems in the community – results in a heightened
public anxiety about the risks associated with people with
mental illness
- Recurring themes in tragedies involving mental health
patients: failure of clinicians to obtain sufficient
knowledge about a service user’s
history, poor communication between disciplines, lack of collaboration between
agencies, lack of resources and failure adequately to assess and manage risk
- The care program approach (CPA) was introduced in 1991 to provide a framework
for the care of mentally ill people outside hospital
- Supervised discharge legislature came into effect April 1, 1996 under
section 117 of the Mental Health Act 1983 – ensures that a service
user who has been detained in hospital for treatment receives aftercare
services
- Need for connection between available literature/ research and practical
frameworks for risk assessment and management
- Risk management cycle of 6 stages to reflect the dynamic characteristics
of risk assessment and management: 1. Identify the potential for harm, 2.
Risk assessment, 3. Rate risk, 4. Implement risk management measures, 5.
Monitoring of risk management measures, 6. Review
- Methods of risk assessment may include: record review, interview, observation,
rating scales or psychometric tests, and physical investigations – then
risk can be rated
Assessment – impulsivity
Fish, K. (2002). Assessment of impulsivity among psychiatric inpatients. Journal
of Psychosocial Nursing & Mental Health Services, 40(6): 30-35
-
United States: Impulsivity can be defined in many ways; the
general consensus is that the term is usually reserved for
maladaptive behaviour, which typically results in undesirable
consequences
- Important to nurses due to their close contact with patients and their
responsibility for modifying and managing behaviour
- Webster and Jackson (1997): impulsive individuals can be well described
by five categories: interpersonal dysfunction, lack of plans, distorted self-esteem,
rage/ anger/ hostility, and irresponsibility
- Impulsivity is one of the defining characteristics of many adult psychiatric
disorders and is also a key component in the clinical risk assessment of
anger and aggression
- Understanding the effect of impulsivity on personality, behaviour, and
coping abilities is essential for assessment and care/ management of impulsive
patients
- By assessing impulsivity, it may be possible to identify those patients
at high risk for suicide, self-destructive acts, violence, or other unpredictable
behaviours
- Assess impulsivity to be able to see strengths/ weaknesses, coping skills,
and to provide support and design interventions for particular patients
Risk
assessment – general nursing
Harrison, A. (2003). A guide to risk assessment. Nursing Times, 99(9): 44
-
UK: Risk assessment is linked to risk management, whereby
a mutually agreed plan, aimed at reducing identified risks,
is negotiated with the individual concerned
- Although risk assessment is a core nursing skill, it needs to occur within
the multi-professional context and involves other relevant disciplines
- Risk assessment provides useful information when devising care plans
- Key principles:
- The nursing goal is the minimization of risk and the prevention of harm
or further harm
- Risk management plans must be constantly evaluated and amended as risk
is a dynamic process
- ‘Risk factors’ are based on population studies and do not
necessarily allow practitioners to identify risks in a particular individual
- Research suggests engagement and psychological support are key nursing
strategies for reducing risk – empathy, active listening and involvement
in care planning can reduce self-harming behaviour
- Training, continuing education and clinical supervision increase the effectiveness
of clinical work and risk assessment practice
Risk
management – intervention – detention and nurses’ rights
Houlihan, G. D. (2000). The nurses’ power to detain informal
psychiatric patients: a review of the statutory and common
law provisions in England and
Wales. Journal of Advanced Nursing, 32(4): 864-870
-
UK: Mental Health Act (1983) developed to improve the rights
of patients, especially with respect to consent to treatment
and the care of mentally disordered offenders
- Patients who are admitted informally to psychiatric hospitals are not subject
to the statutory restrictions; they have two basic rights under common law:
may leave hospital whenever they like and may refuse to accept any form of
treatment which they do not want
- Concern regarding rights of informal patients – some believe
the rights may not exist in reality for certain patients
- Section 5(4) of the MHA (1983) introduced statutory powers for nurses
of the ‘prescribed class’ to detain, for up to 6 hours, a
patient who is receiving treatment for mental disorder as a hospital
in-patient ?
attempt to clarify the legal position of nurses when dealing with a psychiatric
emergency
- Under 5(4), the nurse may use the minimum force necessary to prevent
the patient from leaving – minimum medical or physical intervention
- Important: effective risk assessment of the patient by the nurse before
invoking 5(4) at the time of emergency – adequate training vital
- Criminal Law Act (1967) – under section 3(1) a person may use
such force as is reasonable in the circumstances in the prevention of
crime, or
in affecting or assisting the lawful arrest of offenders or suspected offenders
or persons unlawfully at large
- This may include physical restraint or seclusion, and the power does not
apply when the patient is insane and by definition not capable of committing
a crime
- The Police and Criminal Evidence Act (1984) – under section 24(4)
a person has the power to arrest without warrant anyone who is in the act
of committing an arrestable offence or anyone who has reasonable grounds
for suspecting someone to be committing such an offence
Management/
intervention – psychiatric patients – entitled
Kerr, N. (2002). Clinical Management of “Entitled” Clients.
Journal of Psychosocial Nursing, 40(12): 40-5
-
United States: Entitled clients harbour excessive and unrealistic
expectations about what the world owes them – a mismatch
exists between what they desire, need, and expect from others
(expectations), and what is feasible given the prevailing
circumstances (reality)
- Internal and external factors will influence this process of misguided
entitlement, which can be situational or characterological
- Traits common to entitled psychiatric patients: aggression, sociopathy,
and paranoia, although narcissism and depression have also been pointed to
- Once aroused (after goal attainment fails due to mismatch), they tend
to discharge their emotions through action – will avoid reflection,
realization of feelings and imperfection, dependency on others
- The use of empathetic mirroring is necessary to establish rapport by making
clients feel understood, and to prevent aggressive outbursts by decreasing
their frustration level
- Confrontation can be a useful therapeutic tool by drawing a patient’s
attention to the negative consequence of his or her dysfunctional behaviour,
but often occurs out of exasperation
- After rapport established, the goal is to identify entitled thought
patterns/ behaviours and to explore the irrational nature of the underlying
assumptions – interventions
aimed at uncovering the irrational beliefs and at strengthening ego functions
Risk
assessment – instruments – various forensic professionals
McGregor Kettles, A., Robinson, D., & Moody, E. (2001).
A review of clinical risk and related assessments in forensic
psychiatric units. Journal of Psychiatric
and Mental Health Nursing, 8: 281-283
-
UK: Providing care for mentally disordered offenders presents
clinicians with difficult decisions regarding risk, and there
is a need for evidence-based methods of risk assessment;
the aim of this study was to identify the nature and extent
of clinical risk assessments (CRA) in use in forensic settings
- The term CRA refers to the concept of risk assessment, while Risk Assessment
Instrument (RAI) refers to tools and instruments used for risk assessment
purposes
- A questionnaire developed by the authors was distributed to a sample of
qualified forensic professionals (forensic consultant psychiatrists, forensic
psychologists, social workers and nurses)
- Responses highlight the diversity of instruments in use; although every
forensic secure unit is attempting to use some form of CRA and to structure
their individual assessments, there is little coordination or uniformity.
Respondents identified a total of 124 tools currently in use: 67 locally-developed
RAIs and 57 individually named RAIs, such as the HCR-20
- There is a need for communication between professionals about the types
of risk and related assessment they are using and about the use of appropriate
instruments in the assessment of people moving between units; co-ordination
is needed as currently there exists much overlap and inconsistency
Risk
assessment and management - editorial
Mullen, P.E. (2000). Forensic mental health. British Journal of Psychiatry,
176: 307-311
-
Britain: Editorial
- Forensic psychiatrists within the court process must maintain the dignity
of a medical expert against pressures (institutional and fiscal) of manipulation
by lawyers
- Forensic mental health involves the assessment and treatment of those who
are both mentally disordered and whose behaviour has led, our could lead,
to offending
- Risk assessment and risk management have emerged as central elements in
all of mental health practice, but particularly in forensic practice; this
emergence has coincided with an expansion of the role of the forensic psychiatrist
- Mental health services have a responsibility to provide care and support
to those mentally disordered people with an increased probability of acting
violently. Although highly problematic, the aim is to identify in advance
and manage such risks before they manifest in violence. The challenge for
forensic mental health professionals is to move from risk assessment to the
therapeutics of risk management.
Risk
assessment – mental health patients
Noak, J., & House, M. (1997). Assessment of the risks posed
by people with mental illness. Nursing Times, 93(1): 34-36
-
UK: Judgments about the dangers people pose to themselves
or others are commonplace in psychiatric practice
- Move to community care and open wards has meant unavoidable risks for people
with mental health problems
- The common factors associated with violence and dangerousness appear to
be past history of violence, past history of crime, alcohol misuse and dependence
disorder, being male, young age and economic status
- Individuals have different definitions of dangerousness; there is the need
for a systematic, objective approach to assessing dangerousness
- MacArthur Risk Assessment Study: four main categories upon which to base
risk predictions are dispositional/ individual, historical, contextual, and
clinical
- Many variables are involved in a comprehensive assessment of risk; however,
there are no direct indicators and each may become more important when other
factors are present or may be neutralized by them
- Risk assessments should take place regularly because individuals’ circumstances
change
- Inter-agency collaboration plays an important part in assessment – need
for communication between agencies and individuals
- Monahan and Steadman (1994) make recommendations: risk must be treated
as a probability estimate that changes with time according to context; managing
risk as well as assessing it must be a goal
Risk – violence
against psychiatric nurses
Quintal, S. A. (2002). Violence against psychiatric nurses:
An untreated epidemic? Journal of Psychosocial Nursing & Mental
Health Services, 40(1): 46-55
-
United States: This article explores possible precipitants
and risks associated with episodes of violence
- Health care workers, especially psychiatric nurses, continue to be victims
of assaultive behaviour from their clients. However, the importance of this
assaultive behaviour has been minimized by clients, hospital staff management,
and society
- The ways clients cope with personal crisis depends on the resources available
and can be positive or negative; part of negative crisis resolution includes
violence against others
- The standard definition of employee injury used in reporting to the
Occupational Safety and Health Administration (OSHA) includes injuries
resulting in lost
work days, loss of consciousness, restriction of work or motion, termination
of employment, transfer to another job, or medical treatment – excludes
the assaults suffered by nursing staff
- An interaction of individual, socio-psychological, interpersonal, situational,
and sociocultural factors led to increased rates of workplace assaults by
clients
- Individual characteristics that were found to be correlated highly
with violent behaviour include the client’s diagnosis, history
of violent behaviour, young age, neurobiology, and genetic predisposition.
A previous
diagnosis of psychosis, substance abuse, organic brain disorders, dementia,
mental retardation, or personality disorder were correlated highly with assault.
- Interpersonal, situational, and environmental factors include the communication
between nursing staff and clients. Factors that may have an influence on
communication include nursing staff attitudes, educational and experience
levels of staff, and limit setting and communication styles of nursing staff.
Socio-cultural factors include the desensitization to violence by hospital
management, the legal system, the public, and especially client assaulters.
This has led society to assume that people with mental illness are not accountable
for their actions.
- There are actions that can be taken by nursing staff to address this
growing concern, including: performing complete assessments on every
client on admission
to inpatient psychiatric units; educating health care workers (non-violent
self defense and communication) and clients (coping skills); advocating for
legislation to protect health care workers; introducing the Occupational
Safety & Health Administration (OSHA) Guidelines for Preventing Workplace
Violence for Health Care and Social Service Workers (1998); providing emotional
support to health care workers who have been assaulted
Current assessment instruments available:
- HCR-20 (Webster et al 1997):
- Consists of a mixture of static historical variables and dynamic clinical
and risk management variables; each of the 20 items is measured on a three-point
scale, with a lower score indicating less risk
- Extensive research has focused on the instrument’s predictive ability,
which looks promising
- Violence Prediction Scheme (Webster et al 1994):
- Combines both an actuarial and a clinical component. The actuarial component
is the Violence Risk Appraisal Guide, VRAG (Rice & Harris 1995); research
indicates promising predictive validity. The clinical component is a mnemonic,
the ASSESS-list
- Behavioural Status Index (Robinson et al 1996, Woods et al 1999):
- Developed to assist in the clinical assessment of social risk and in construction
of meaningful and measurable intervention strategies
- Consists of three related subscales: behaviours which are associated with
risk in a forensic context; the degree of insight into causality and current
status shown by an individual; and assessment of current communication and
social skills. Each item is measured on a five-point ordinal scale
Risk Management:
- A risk management plan focuses on the likelihood of the probability or outcome
occurring; it is the link between risk assessment information and the known
or potential interventions
- The plan should state the nature or level of the anticipated risk and how
it can be avoided, and must be continuously reviewed if it is to be effectively
evaluated – ‘dynamic risk assessment’
- The individual must be informed of the risk(s) which have been identified,
what will happen if they occur and why; this may involve the individual being
given the opportunity to select from a range of alternative management strategies
An organizational risk management strategy:
- This strategy aims to create a more coordi
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