Forensic Psychiatric Nursing
Struggling to Happen, Failing to Thrive
By Colleen Carney Love, DNSc, RN, FAAN, and Eileen F. Morrison, PhD, RN
Editor's note: The views expressed herein are those of the authors and do not express the views of the California Department of Mental Health or the Commonwealth of Virginia Department of Mental Health, Mental Retardation and Substance Abuse Services.
Forensic psychiatric nursing may be defined as a subspecialty of nursing that has as its objective to assist the mental health and legal systems in serving individuals who have come to the attention of both. The majority of nurses who function in forensic psychiatric capacities work in public sector settings under the state departments of mental health or in psychiatric units in jails, prisons and juvenile detention centers under the state department of corrections or other state agencies.
Forensic psychiatric nurses also are found in a wide variety of unique and highly specialized practice capacities, including emergency rooms, case management and consultative functions in the private sector. While forensic psychiatric nurses may assist with legal questions emerging from the civil branch of law, they more commonly work with individuals and within systems linked to the criminal justice branch. Forensic psychiatric nursing is distinct from correctional nursing, which while being closely related, differs significantly in primary purpose, standards and regulations. 1
Despite the fact that forensic psychiatric nurses have provided services in the United States for more than a century, written material on forensic psychiatric nursing in this country is difficult to find. The subject rarely appears in nursing textbooks, nursing journals or nursing educational programs. In a sense, as far as nursing literature and nursing education are concerned, the specialty of forensic psychiatric nursing has been and remains virtually "invisible." Even in the decade-old International Association of Forensic Nurses (IAFN), the forensic psychiatric contingent is a tiny, far-flung minority among a vast and passionate majority of sexual assault nurse examiners (SANEs). The ANA Standards of Forensic Nursing Practice, developed largely by the IAFN membership,2 emphasizes SANE practice issues and care of victims of crime. This invisibility and professional isolation of forensic psychiatric nursing practice has had crippling effects on its development as a public service nursing specialty in the United States.
Causes and Effects of Professional Isolation
The virtual invisibility of forensic psychiatric nursing in nursing professional journals, textbooks and educational programs is curious and contrasts markedly from our neighboring disciplines. Both psychiatry and psychology have fully developed professional publications and texts, forensic subspecialties and postgraduate, university-based forensic fellowship programs. A high-quality body of literature is produced, characterized by valuable research trajectories, lively scholarly and philosophical debates and high profile involvement in shaping public policy (which significantly impacts forensic practice) and media coverage of forensic topics. Social work, too, has its own forensic journal and specialty organization.
In , Moritz3 reflected upon the lack of development of the nursing work with offenders. In , Bernier4 speculated about the slow professional development of correctional nursing which rings true for forensic psychiatric nursing as well: "... nurses who practice in the correctional system are a silent minority. It is rare that they publish in nursing journals and unusual for nurse educators to enlist their expertise in an effort to introduce this area as a practice option when considering career choices. The majority of these nurses are further limited in their scope of practice because they are not baccalaureate prepared."4
Little progress has been made in the development of forensic psychiatric nursing practice during the past 20 years.5 Forensic psychiatric nurses in the United Kingdom have contributed significantly to the growth of the field in the UK countries and, despite cultural and legal differences, serve as an important resource as the specialty develops in the United States.
The lack of baccalaureate- and graduate-prepared nurses working in forensic settings has severely limited its development as a specialty and left nursing at a disadvantage vis a vis other disciplines. Even if graduate programs were available for advanced practice forensic nurses, few incentives exist for administrators in public sector forensic settings to create positions for advanced practice forensic nurses.
Few published articles exist that demonstrate the cost effectiveness of advanced practice nurses in forensic settings. Additionally, even if there were readily accessible validation studies, most public sector environments are shaped by seriously outdated civil service systems that have no designation for advanced practice nursing roles. In situations where organizations have managed to allocate funding to hire advanced practice nurses, the salaries are often not competitive with other advanced practice nursing options, such as private practice, particularly when the hazards of forensic work are taken into consideration.
Smoyak6 noted that public sector psychiatric agencies tend to be battlegrounds for conflicting interests. While the first author was establishing a forensic psychiatric nurse practitioner program in a large forensic hospital, unforseen obstacles became apparent. Not only were there few incentives and mixed enthusiasm for the inclusion of advanced practice nurses, turf battles and defensive guild issues emerged (and persist) from other mental health disciplines.
Many restraining forces maintain nursing staff at an educational disadvantage in public sector agencies.The tendency for forensic and correctional agencies to be insular and regionally-shaped environments leads to a form of staff "institutionalization." Unless the forensic setting happens to be tied to a university and/or located in a major metropolitan area, forensic psychiatric environments tend to be colloquial organizations with direct care staff made up of local community members trained on the job. The staff develops and perpetuates idiosyncratic cultures with neither benchmarks from other forensic settings nor feedback from the larger profession. The challenges of the work, the relatively low salaries, and the conflicts with other disciplines are reality-based recruitment and retention problems for both the generalist and the advanced practice forensic psychiatric nurse.
The main unifying forces shaping forensic nursing practice come from external regulatory bodies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and state licensing which have the authority to enforce standards in forensic hospitals. The requirements put forth by JCAHO in particular have forced forensic psychiatric settings to hire additional registered nurses (rather than relying largely on orderlies, psychiatric technicians and aids), to use performance improvement principles, to manage seclusion and restraint use conservatively and to document practice outcomes and staffing by acuity. JCAHO and other regulatory agencies enforce sweeping regulations across diverse healthcare settings.
In many cases, these required standards seem unrealistic or only tangentially relevant to forensic psychiatric care while other needed standards are absent. For example, patient violence and behavior management are the top-ranked problems in forensic settings,7 yet JCAHO and other external regulatory agencies do not require comprehensive violence prevention or behavior management programs. In a recent consultation the first author conducted in an acute forensic psychiatric unit a staff member's remark, "JCAHO made us put flowerpots in the day room," illustrates a fairly widespread perception among direct care forensic staff that the JCAHO standards are not responsive to the hazards and unique challenges of the forensic environment. In spite of shortcomings encountered whenever standards are enforced widely,8 JCAHO has been a friend to nursing in forensic settings by emphasizing the importance of nursing care relative to treatment and evaluation of the forensic patient.
Forensic Psychiatric Nursing Has a Public Relations Problem
The stigma associated with the work is another reason forensic nursing has failed to develop. Goffman9 defines stigma as "a spoiled identity." The forensic psychiatric patient, due to the co-mingling of psychiatric disorder and criminality, is encumbered with a double barrel social stigma. This "mad-bad" stigma is not only part of the public's perception, it exists within the correctional environment. The mentally disordered inmate (MDO) is stigmatized among his otherwise socially undesirable prison inmates. In the California prison vernacular, the MDO is said to have a "nut jacket" In the Midwest, as noted by Hufft,5 the MDO is labeled a "bug" by fellow inmates.
Even among hardened prison cultures, a moral hierarchy of sorts exists. In most correctional settings, sex offenders, particularly child molesters, are considered inferior and deviant among their peers in prison. Sex offenders often experience sexual abuse and serious assault at the hands of inmates who view them with derision and contempt. Often sex offenders must be housed in secure segregation units for their own protection.
In a kind of guilt-by-association, the stigma that spoils the identity of the MDO rubs off on nurses caring for them. Nurses working in forensic environments encounter negative reactions to their work from a public that has low tolerance for crime. The status and public appreciation enjoyed by nurses in other settings is not available to forensic psychiatric nurses. In social settings, forensic psychiatric nurses may be asked with disdain and contempt, "How can you stand to work there?" Staff has noticed that community members often displace anger that actually stems from the offender's criminal behavior, aiming hostile reactions at staff that work with patients who are viewed as bad and deserving of punishment. Consequently, staff members sometimes do not disclose their place of employment in social settings and report drawing from their coworkers to create a social circle.
The social stigma also influences knowledge development. As much as we like to think that science is apolitical and unencumbered with subjective bias, it is not. Imagine sitting on the board of a grant-funding agency with resources to fund a limited number of studies. For the sake of illustration imagine that you have to select one study to fund among the following six proposals of comparable design quality: women with post-partum depression, latency-age children with attention deficit disorder, teens with a first psychotic break, support needs of unwed teen mothers, substance abuse in latency-age children or treatment approaches for incarcerated sexual violent predators. Which project is the least likely to be selected for funding and why?
The mad-bad stigma is likely part of the reason that a limited number of research studies (particularly biologically-based) are published relative to the disorders encountered by forensic nurses. The phenomenon of sex offending is particularly lacking in biologically-based evidence. The "best and the brightest" biological scientists are not being recruited to find a cure for MDOs. There are few, if any high profile pharmaceutical companies championing treatments specific to the forensic population. The effect of stigma on knowledge development and resource allocation becomes readily apparent when examined within the larger social context.
Beyond the stigma associated with the behavior of the patients, the general public has a very limited understanding of forensic science in general, and forensic psychiatric practice and treatment in particular. It is public policy, more so than science or consumer preference, that defines our practice and the populations we serve in the public sector.6 While public relations and visibility are important in all areas of nursing, the stigma associated with forensic psychiatric work and the legislative policy that influences practice and public safety, makes assertive public relations particularly important in our field. Explaining what exactly a nurse does, and explaining what a forensic psychiatric nurse does is difficult. Communicating the effectiveness of our work among ourselves, our colleagues and to our customers (the tax-paying public) is critical.
Characteristics of Forensic Psychiatric Nursing: A View from the Trenches
The tendency to describe nursing practice by resorting to lists of nursing interventions or describing attributes of the specific populations served is tempting. Unfortunately, this reductionist approach to defining practice yields gross oversimplifications and misses the essence of the work. Fuller10 suggests we reframe the question to explore nursing identity as follows: What are the needs of the forensic patient that can be met by nursing? This question can be explored in part by examining the central domain concepts of nursing including health, nursing, the patient, and the environment.
Health in Forensic Contexts
Health is one of the central domain concepts in nursing. Nurses profess to promote health and to assist patients to achieve and maintain health. The notions of health and health promotion are fairly straight-forward. However, in forensic practice decisions about what constitutes mental health and who is behaving in a mentally healthy manner involve a great deal of value judgment. Distinguishing between health and illness is very complicated in mental health contexts and is particularly complex in forensic psychiatric settings. Determinations of "health" are interlaced with complex legal and moral dimensions.
Health is more than the absence of disease. In correctional and forensic dialogue, health is often equated with "goodness" and illness is equated with "badness" or morally deficient behavior. Stone11 has been critical of certain aspects of forensic psychiatric practice where criminal behavior is labeled pathological and in need of treatment. He refers to this phenomenon as the "medicalization of morality." For example, if a person who is not psychotic has engaged in repetitive violent sexual acts, is he "sick" or "bad"? Were Jeffery Dahmer and Ted Bundy sick or simply morally deficient? Is a sexually violent predator, who experiences obsessive thoughts and compulsive drives to molest children, in need of treatment or punishment and incarceration?
Moore12 notes that there is a widely accepted perception that goodness equals mental health and that deviance equals mental disease. The concept of health as equivalent to virtue and happiness is an old notion that has stood up over time. Patients in forensic settings, psychosis and lifelong criminal histories not withstanding, often do not consider themselves as "unhealthy" and in need of treatment. There is a need for forensic psychiatric nurses to explore the practice -- specific dilemmas relative to the concept of health when nursing criminal offenders.
Forensic Psychiatric Nursing
A forensic psychiatric nurse functions as a therapeutic agent, employing the nurse/patient therapeutic alliance and milieu interventions to assist each forensic patient to manage the symptoms of his chronic mental illness until such time as he is able to manage them for himself. Our medical colleagues treat the underlying disease state, or biochemical pathology. Nursing, on the other hand, treats the human response to that disease state, which manifests itself in the patient's gross disturbances in thought, behavior and emotion. Forensic psychiatric nursing work is grounded in the thoughtful and purposive establishment and monitoring of the therapeutic alliance within a secure treatment milieu. All interactions with patients have the potential to be therapeutic and interactions that are built upon a solid therapeutic alliance are potentiated.
Functioning effectively as a therapeutic agent and establishing and maintaining a therapeutic alliance with forensic patients is a formidable undertaking fraught with potential pitfalls, pathological manipulation and deception. In highly psychopathic patients, forming an alliance in the traditional sense may not be possible or recommended. The interpersonal work in forensic nursing requires finely honed communication skills, advanced preparation in psychodynamic theory and adequate and ongoing self-monitoring and clinical supervision. The extreme character pathology, life long patterns of exploitation and perversion of interpersonal relations, deviant violent impulses and intractable psychotic symptoms encountered in the forensic patient population calls for a constellation of personal characteristics and specialized technical competencies including physical and emotional self protection strategies. Ideally, forensic psychiatric nurses think, train and act like an elite specialty force developed to treat the big leagues of mental illness.
In addition to the aforementioned clinical competencies, forensic psychiatric nurses must have intact ego boundaries, hardiness, insight, receptivity to feedback, self-confidence and a commitment to ongoing professional development. The unique and complex ethical issues that arise in practice call for ethical sophistication and the capacity for ethical reflectiveness.13 Because of their treatment orientation and exposure to patients, forensic psychiatric nurses have the potential to be major forces for change, yet because of limited educational preparation and lack of adequate clinical supervision, are vastly underutilized in this regard. Until nurses can convince the public that it is cost effective and desirable for advance practice nurses to function in public sector agencies, this situation is not likely to change any time soon.
The Forensic Patient
Patients who make their way to maximum-security forensic settings are among the most complex, dangerous and refractory to treatment. Most MDOs are treated in highly secure hospital environments, which may be a unit within a prison or the wing of a public mental hospital or a large freestanding facility serving the needs of an entire state. Forensic psychiatric patients may also be treated in the community in conditional release programs or be committed to outpatient treatment.
Severe and persistent mental illness combined with criminality distinguishes the forensic psychiatric patient from psychiatric patients in other involuntary, public sector institutions. The forensic psychiatric patient population presents with a variety of extremely complex clinical phenomena relative to the intermingling of severe mental illness, psychopathy, antisocial characteristics, and other forms of severe character pathology.
The forensic psychiatric population continues to grow and change to meet demands driven largely by public policy. For example, the policies leading to de-institutionalization and the subsequent "criminalization of the mentally ill," are blamed for the increasing numbers of forensic patients. The trend toward the sexual violent persons/predator (SVP) commitment is another example of how policy shapes patient population and practice. The legislatures in 15 states thus far, have articulated commitment criteria for this select group of inmates/parolees that use the civil commitment provision or a variation of the future dangerousness police power of the state to divert sex offenders considered high risk for re-offending to involuntary forensic treatment settings. This rapidly growing population has dramatically changed the face of the inpatient milieu in settings housing and treating SVPs. Treatment of the SVP is a pressing challenge facing forensic psychiatric nursing in the 21st century.
The Forensic Treatment Environment
The treatment settings for adjudicated mentally disordered offenders are a heterogeneous mix of public sector entities with complex administrative and treatment implications. Maximum-security forensic facilities are the end of the line in terms of security and referral. Therefore, there is a "downward drift" of violence and illness severity from other settings leaving forensic facilities with the most disturbed and intractably violent patients.
Patients often experience a dramatic cultural transition when admitted to a forensic hospital from jails and corrections. Correctional settings are often oppressive total institutions with their own subculture shaped by predation, violence and gang activity. In many states, prisons are the last strongholds of sanctioned racial segregation. Admission to the hospital from corrections can be a taxing initiation.14 As one patient described it, "You have to drop the prison mask when you come here."
In spite of the efforts of treatment staff to establish a therapeutic environment, a well-defined pecking order, strong-arming, racial and gang influences and territoriality crop up from time to time. The potential for violence and weapon manufacture is always present.15 Provision of a therapeutic milieu in a forensic environment calls for maintenance of a high level of security within the least restrictive environment.16 The hospital or forensic unit is likely to have a high security (locked and guarded) periphery with a relatively open inner environment designed to create, to the extent possible, a least restrictive "demonstration model"17 where patients can practice skills needed to "make it on the outside." Often a behavioral privileging program is in place with provision for patients to complete high school and or learn a trade such as printing, shoe repair, janitorial or maintenance skills cooking, art or music.
Essentially, forensic settings exist first and foremost to protect the public from the dangerous mentally ill. The additional mission is treatment and evaluation of patients and evaluation for community placement or return to various correctional and legal systems.
Nursing practice in forensic settings shapes and is shaped by the public sector demands. Forensic nurses have many customers. Custody and treatment can and does occur simultaneously, but not without constant tensions and challenges. The intensity of the forensic milieu, which has been referred to as a "polarity inducing" environment, does arouse strong feelings in both staff and patients. 18,19 Staff splitting and "set-up" processes are ever present.20
Schaefer21 stresses the importance of attention to boundaries. She notes that the nurse works in the patient's living space where boundaries are therefore blurred by the physical setting. Additionally, the patient's life-long patterns of exploitation, intimidation, pathological manipulation and perverted intimacy further stress boundary formation and maintenance. The structure of the nurse-patient relationship must communicate and maintain the boundaries of the relationship.21 While forensic settings are technically healthcare settings, many vestiges of the prison culture infuse the forensic milieu. Violence is a pressing reality, 14 as are suicide, criminal activity and interpersonal boundary problems.22
The authors express appreciation to Mel Hunter, Jeff Elliot and Julie Heriford for reviewing drafts of the manuscript.
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Colleen Carney Love, DNSc., RN, FAAN, is director of the Clinical Safety Project at Atascadero State Hospital and is on the adjunct faculty of California State Long Beach School of Nursing. |
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Eileen F. Morrison, PhD, RN, is a nurse consultant at Central State Hospital in Richmond, Va.
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