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Forensic Psychiatric Nursing

Thayel Notes

Forensic psychiatric nursing is slowly gaining momentum as a way to bridge the gap between the criminal justice system and the mental health system.

Forensic nursing, jail nursing, correctional nursing, and forensic psychiatric nursing are terms used to describe nursing with forensic populations.

Forensic nurse- one who practices in a facility or program where the primary mission is the evaluation and treatment of mentally ill offenders.

As crime and violence continue to escalate in society, all psychiatric nurses, regardless of setting will need forensic knowledge and skills.

Today, the setting in which forensic psychiatric nursing occurs are many and varied. Forensic settings include hospitals for the criminally insane, state hospitals, and locked units in general hospitals; however, the traditional practice site has been jails and prisons.

Currently, the US has the highest rate of incarceration in the western world.

Many individuals are unable to access appropriate treatment and ultimately experience the "revolving door syndrome" that includes the courts, jails and prisons.

Coupled with de institutionalization is the problem of homelessness. These individuals are especially vulnerable to the influence of, and exploitation by, criminals and drug abusers.

Factors to be taken into account when working with the forensic population include prevalence of mental disorder, cultural and demographic variations, and the needs of special at risk groups, including women.

The forensic clientele, as a group, demonstrate poor judgment, limited reasoning abilities, and a history of not learning from past mistakes. There is also a high level of substance abuse.

Nurses need to be informed regarding the laws and legal provisions governing the jurisdiction in which they find themselves.

A review of the research suggests that in any prison or jail population, at least 6% to 15% of those incarcerated will be designated as mentally disordered.

Schizophrenia, mood disorders, and organic syndromes with psychotic features are common and complicated by the coexistence of personality disorder and substance abuse.

In forensic settings, nurses work with clients with a proven capacity for violence.

Studies of violence among prison inmates reveal two major categories of violent offenders- those with expressive violence and those with instrumental violence.

1. Expressive violence- interpersonal altercations, usually with people who are known to the assailant and are of similar age, ethnicity, and cultural background.

2. Instrumental violence- premeditated and unusually motive driven, committed to acquire property or for economic gain, and usually involve people who are unknown to each other and have dissimilar backgrounds.

A third type is gang violence.

Trends among women offenders indicate increased incidence of those with personality disorders, substance abuse, and post-traumatic stress disorder.

Elderly forensic clients in many ways are no different from their nonforensic counterparts and have many life issues that need to be addressed.

The incidence of HIV and AIDS is higher in the correctional system than in the general public. Often lower functioning clients have limited understanding of how to keep themselves safe and are vulnerable to exploitation by other, higher functioning clients.

Palliative care of clients with HIV and AIDS in the prison setting is a growing trend.

Cultural implications need to be considered when providing mental health care. Impact of the controlled environment can create many barriers to care, and nurses must be cognizant of the problems unique to the clients with whom they are working.

In addition to offenders who enter the correctional system with a mental disorder, forensic psychiatric nurses care for individuals who become mentally ill while incarcerated.

The physical setting, client population, and authoritarian interpersonal environment result in forensic settings being identified as the most extreme and stressful known to society.

The safety of these vulnerable populations presents ongoing dilemmas for prison administrators, who often find it necessary to confine individuals to segregationís or protective custody units.

Nurses working in correctional institutions have 2 primary responsibilities: health care provider and correctional officer.

In 1985, the ANA published Standards of Nursing Practice in Correctional Facilities. Much of the nurseís time is spent attending to issues related to the therapeutic milieu and security.

The correctional environment is not suited to all nurses, nor is it appropriate for all student nurse placements.

Problems are related to assessing clients in isolation for their support systems, home environments, and daily routines because in the forensic setting, the client is closely supervised, and behavior is restricted and mandated by the institutional policies. Assessment is further complicated by the physical environment and lack of privacy.

Security concerns affect every aspect of nursing function on the practice of nursing and can often complicate the creation of a therapeutic relationship. Interview rooms are completely glassed in and are soundproof, but all can see inside, conflicting the right to privacy and confidentiality.

Many clients may not want to be identified with the forensic psychiatric nurse because of the stigma associated with mental illness in prisons.

Assessments in the forensic setting should include at the minimum:

1. History of psychiatric illness

2. Hospitalization and outpatient treatment

3. Current psychotropic medication

4. Suicidal ideationís

5. History of suicidal behavior and drug or alcohol use

Crime histories and history of aggression are essential components of the assessment of the offender. The most critical skill of the forensic psychiatric nurse is the ability to estimate the risk of violence.

Incidence of self-violence and suicide in correctional settings is higher at least six times. Unrestricted access to psychiatric care must be available for any offender presenting with suicidal ideation or at-risk behaviors.

Regardless of the length of the sentence, the first 6 months after sentencing represent a particularly high-risk period. Suicide in the forensic setting must be followed by a full debriefing.

Nursing Diagnoses

Ineffective Individual Coping

Fear

Post Trauma Response

Social Isolation

Risk for Violence: self and others

Planning short-term goals, which frequently involve completion of tasks and the practice of selected communication or self-care skills.

In many settings, group therapy is in conflict with the work assignments mandated by the prison. Work details, lock-ups, formal counting of offenders, and endless security procedures makes planning difficult.

Long term goals must be consistent with the reality of the client's circumstances. It is unrealistic to plan for re-entry to the community for a client with a life sentence. Often it is important to acknowledge that long-term goals, such as developing trusting relationships with peers and staff, may be totally unrealistic.

Recurring themes of power and control, trust building, and negotiating the relationship dominate therapeutic interventions in this setting.

Clients in forensic settings have in varying degrees learned to adapt to an environment that rewards distrust, manipulation and deceit. Relationships are often dubious at best and easily broken.

In the forensic setting, issues and problems surrounding transference and countertransference are an occupational hazard. There are issues of boundary violation and exploitation. Nurses may not know how to respond to come on's. "Thank you for that compliment, but I would appreciate that from this point on, you keep your comments to yourself. Your remarks are irrelevant to my purpose with working with you."

Clients often incorrectly perceive the nurse's warmth and concern as love and intimacy. No response or a silent response is interpreted as approval of the compliment or gesture. Excessive familiarity is out of line.

 

Nurses in forensic settings are also responsible for mental health and wellness promotion. Women offenders, in particular, are interested in their own health and a discussion about contraception and birth control can be an opportunity to express feelings related to abuse, powerlessness, or social awkwardness.

In correctional settings, the security personnel are also a part of the team, and information sharing is vital. Correctional personnel need to be informed when suicidal, homicidal or out of control behavior is suspected or of concern.

Community of care is virtually non-existent for offenders once they leave the forensic or treatment setting. Dvoskin and Broaddus have proposed a mental health care model for the efficient and systematic treatment of the mentally ill offender.

Nurses need to acquaint themselves with policies that affect the forensic population and society as a whole.

To assess the effectiveness of the nursing process in the forensic setting, the nurse must measure client behaviors that indicate resolution or change.

Evaluate the client's outcome in terms of small succeses, often "giant steps" for many clients.

The goal of mental health treatment is to address a mental disorder, whereas the goal of correctional treatment is to decrease the likelihood of recidivism.

Forensic science is relevant to nursing curricula and the forensic nursing is the most important effort nurses can provide to break the cycle of interpersonal violence.

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