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This assignment discusses the conflicting roles of the forensic mental health nurse as both caregiver and custodian. It will look at whether forensic mental health should be considered as a speciality service by examining how these apparently conflicting roles can (with the correct levels of skills, knowledge and attitude) provide quality services that are informed by a sound empirical knowledge base.
To achieve this we will look at how mental health care evolved from the Poor Law Act of 1601 through to the present day. We will consider the FMHN’s role in the protection of the public and look at how forensic mental health services are placed within a variety of settings to aid in achieving this aim. We will also examine the impact the role of the custodian can have on the therapeutic relationship between nurse and patient.
Firstly however we need to understand what is meant by the term ‘forensic’. Forensic means “of the law” (Kettles et al 2007:1) or “related to courts of law” (Baker et al 2011:400). Possibly, due to the misunderstanding of the word ‘forensic’, the term forensic mental health forensic mental health induces high levels of anxiety amongst the public (Baker et al 2011). Due to the forensic mental health services’ role in dealing with the more serious offenders and the stigma produced by the press this anxiety is not wholly surprising. Although the term forensic can be affiliated to any criminal activity it is important to recognise that not all forensic patients should be considered to be a danger to society.
The development of forensic mental health care.
Mental health care can be traced back to the Poor Laws of 1601. This introduced a responsibility for every Parish to support those incapable of looking after themselves (Sadiq et al 2011) and was possibly an early attempt in associating poverty and disability. Specific law pertaining to the mentally ill emerged in the 18th century when the power to incarcerate the ‘furiously mad and dangerous’ was enshrined in The Vagrancy Act 1714 (Moncrieff 2003) and the Regulation of Private Madhouses Act 1774 which required asylums to be licensed by the Royal College of Physicians (Miller et al 2011).
In 1843 Daniel M’Naughton was tried for murder. After a successful defence of mental incompetence, discussions within the House of Lords resulted in standards by which a person could be acquitted by reason of insanity (Vij 2008). McNaughton rules are still the standard test for criminal liability in relation to mentally disordered offenders today and allow courts to consider whether:
The party accused was labouring under such a defect of reason, from disease of the mind, as not to know the nature and quality of the act he was doing; or, if he did know it, that he did not know he was doing what was wrong.
Cowen et al (2012:723).
The Lunacy Act (Great Britain 1890), legalised the detention process by the use of monthly reports preventing patients staying longer than necessary and regulated treatment approaches which applied legal principles to incarcerate patients (Glover-Thomas 2002). The 1959 Mental Health Act (MHA) (Department of Health and Social Security (DHSS) 1959) repealed the Lunacy Act and marked a shift from emphasis from legal aspects of treatment to care becoming a medical responsibility (Warne et al 2010).
1863 saw the opening of Broadmoor Hospital (Forshaw 2008) followed by Rampton Hospital (1912) and Moss Side Hospital (1917). Ashworth Hospital opened in the early 1970’s after the merging of Moss Side and Park Lane Hospitals (Forshaw 2008).
The rudiments of forensic mental health nursing began with the opening of these state hospitals (Woods 2004). An enquiry into gross security lapses at Ashworth Hospital led to the Fallon Report (Fallon et al 1999) which recommended greater security such as the recording of phone calls, random searching of self and environment, and further improvements to the external and internal security (Tilt 2000) across all three special hospitals. This marked a shift back towards the onus being placed more on security than on care.
Services were further developed after the publication of the Glancy Report (DHSS 1974) and Butler Report (DHSS 1975) which focused on forensic need at a local level to provide care and security for the treatment of MDOs (Bartlett & Kesteven 2010). Both identified a lack of security in inpatient settings and the need for an interim service between high security hospitals and the community (Davies & Leech 2012). These influential reports paved the way for the development and construction of regional medium secure units (McMurran et al 2009).
As with the Glancy and Butler reports, the Reed Report (Department of Health & Home Office (DH & HO) 1992) also discussed the need for more secure beds (Dix 2005) and set out principles of secure care, stating that care should be provided according to individual need, near to the patient’s home or family, as far as possible in the community and in conditions of no greater security than is justified (DH & HO 1992).
Under The MHA 1983 (GB 1983) the mentally disordered offender’s (MDO) ‘health or safety’ as well as the ‘protection of others’ are considered. As an example the section 41 restriction order aims to protect the public from serious harm, and allows for compulsory supervision of a conditionally discharged patient (DH 1983) which shows a good balance between autonomy of the patient and the protection of the public.. The MHA 2007 (GB 2007) amalgamated the MHA 1983 and Mental Capacity Act 2005. It reinforced that MDOs should have the same right to assessment and treatment as people who have not offended (Ministry of Justice 2008). However, the act has been criticised for “placing public protection above the needs and rights of the patient” (Wrench & Dolan 2010:240) by introducing the concept of treatment availability as opposed to the treatability (Thomson 2008).
The publication of the NHS Plan 2000 highlighted the importance of providing treatment for prisoners with mental health problems (DH 2000) stating that no prisoner with mental illness will leave without a plan of care and care co-ordinator (DH 2000). This was reinforced by Changing the Outlook (DH 2001) which reminded us that the standards for mental health services apply equally within prisons as they do to the wider community (DH 2001) and prisoners that should have access to the “same range and quality of services appropriate to their needs as are available to the general population” (DH 2001:5). This was further echoed in the Bradley report which stated “prison may not always be the right environment for those with severe mental illness” (Bradley 2009:1) and MDOs “could, in appropriate cases, be diverted â€¦ to other services.” (Bradley 2009:8). Despite this the rates of MDOs still being held inappropriately in the prison system remains high (Berman 2012).
We now see FMHN’s working in many different areas such as high secure hospitals, medium and low secure units, prisons, young offender institutions, police stations acute wards, psychiatric intensive care units, court liaison schemes, outpatient departments, community care and rehabilitation services.
The role of the forensic mental health nurse in protecting the public.
Many aspects of the FMHN’s role in the management of MDOs are based around public safety such as escorting a patient in the community to assess their psychosocial functioning, informing the police should a patient fail to return from unescorted leave and writing reports for Mental Health Review Tribunals. Other areas connected to public protection are the completion of the Care Programme Approach (CPA) (DH 1990) and liaison with the multi-agency public protection arrangements (MAPPA) (Home Office 2001).
The CPA is a multi-disciplinary process, intended to provide a systematic assessment of a patient’s biopsychosocial needs, a plan of care (including the formulation of a risk assessment), the allocation of a key worker upon discharge and regular reviews of a person’s care (Earp & Byrt 2010). Its main intention is to plan for the patient’s future needs and keep the multi-disciplinary team aware of any concerns surrounding risk (Bartlett & Kesteven 2010). The results of an efficient CPA are the establishment of an effective care pathway, where all relevant agencies are made aware of their role with the MDO (Bartlett & Kesteven 2010), that “combines an understanding of both the patient’s mental health and their potential risk” (Gournay et al 2008:531). This is continued after discharge, within the community, to allow for a forensic community mental health nurse to be appointed to co-ordinate care by ensuring that the services identified within the patients care plan are put in place and continue to meet their needs. The CPA also applies within the prison system where it is used to “support improved throughcare and discharge planning” (Senior & Shaw 2008: 181) thus ensuring appropriate discharge with aftercare is provided.
The completion of a risk assessment, undertaken by the key-nurse, is a required component of the CPA process (Gournay et al 2008). It incorporates both static and dynamic risk situations that may lead to heightened future risk (such as refusal of medication, disengagement from services and other psychosocial issues). The ability to assess and manage risk is a skill forensic nurses must possess and refine to promote patients’ safe reintegration into the community (Encinares et al 2005).
It would appear from the above discussion that the CPA within forensic services is the cornerstone on which effective assessment and management of risks are based and effective aftercare is identified and provided.
Another aspect of the nurse’s role in public protection is involvement with MAPPA. Difficulties in achieving interagency care were recognised as far back as the Reed Report (DH & HO 1992). The introduction of MAPPA enabled agencies to work collaboratively in exchanging information and managing MDOs, thus ensuring potentially dangerous offenders are properly risk assessed and managed in the community. MAPPA placed a statutory duty to establish arrangements for the assessment and management of risk presented by offenders once leave or discharge have been considered (GB 2000, Home Office 2004, OBMH 2009). Health authorities have a statutory duty to cooperate with MAPPA (GB 2003, Thomson 2008) which may include the exchanging of patient information.
It is the professional duty of the nurse to share with MAPPA any information that they think is important to aid in the protection of the public. Therefore should a patient disclose any information that may pertain to risk to the public, the nurse has a duty to disclose this information (OBMH 2009). This information may be presented in the patients clinical team meetings (CTM) where discussion surrounding the risk can take place with the multi-disciplinary environment. If it is felt necessary this information can then be relayed to MAPPA via the key nurse or care co-ordinator (OBMH 2009). This sharing of information enables the relevant agencies to assess risk more effectively and make decisions on how to manage it (Ministry of Justice 2012) and is vital to inform risk assessment and any required aftercare (Snowden & Ashim 2008).
The practice of information-sharing between agencies can however have implications on patient confidentiality. Nurses owe a duty of confidentiality to their patients (DH 2003, Snowden & Ashim 2008) as well as a duty under the European Convention on Human Rights (ECHR 2004) and the Data Protection Act (GB 1998) which both convey support for the breaching of confidentiality only in the interests of preventing serious harm and public protection. The nurse must seek the consent of the patient before disclosing information (Snowden & Ashim 2008) albeit it the very nature of the information being disclosed may discourage the patient from consenting (Eastman et al 2010). However a breach of confidentiality would still be allowed where the law requires disclosure or where there is an issue of public safety (NMC 2008, RCP 2010, Bartlett & McGauley 2010).
Care versus Custody, the impact of the role of ‘custodian’ on the therapeutic relationship.
Since the Fallon Enquiry (Fallon 1999) and subsequent Tilt Report (2000) recommendations, the main emphasis of forensic mental health care has been on security.
Within secure mental health settings there are three distinct areas of security. Physical security in the form of locked doors, keys, fences and alarms; procedural security, such as policy and procedure, to maintain safety and security; and relational security which is the knowledge and understanding of the patient and the interpretation of this knowledge into appropriate responses and care (DH 2010). These security interventions are reflected in the National Institute for Clinical Excellence (NICE 2005) guidelines that set out guidance to improving security within secure settings.
Some of the largest dilemmas within forensic mental health nursing surround the challenges of maintaining ‘boundaried’ relationships, the tensions between disclosure of information versus patient confidentiality (Adlam et al 2012) and the need to provide holistic care against the need to contain the patient in order to provide public protection (care versus custody) (Chaloner 2000, Mason et al 2008, Rogers & Soothill 2008, Adlam et al 2012). These issues of care versus custody have been highlighted in a number of reports (Butler 1975, Reed 1992, Tilt 2000).
In the previous section we looked at how the sharing of information and breaching of confidentiality may be allowed in the interests of public safety, even if the nature of the information being disclosed may discourage the patient from consenting (Eastman et al 2010). As MAPPA is ultimately concerned with public protection, not healthcare, it may decide in circumstances of possible heightened risk to make a decision which impacts on a patient’s freedom (Snowden & Ashim 2008) which patients can perceive as punishment or forced containment (McCourt 1999, Aiyegbusi 2009). The disclosure of such information may be seen as a negative act by the patient, which in turn may produce barriers to the therapeutic relationship such as difficulties in trusting the nurse and seeing them more as a custodian as opposed to a carer, disengagement from therapeutic communication and rejection of treatment, opposition and hostility (Kettles et al 2006, Byrt 2010).
Knowledge, Skills, Attitudes and behaviours.
Forensic mental health nursing is multifaceted. Chaloner (2000) explains that the role of the forensic nurse has expanded the range of skills that are normally required the general mental health practitioner. The most obvious differences such as security, offence- specific risk assessment and management skills have already been discussed.
Less obvious features of the forensic nurse’s role are the differing diagnosis and categories of the patients (psychopath, sex offenders, paedophile and socio-political diagnosis’s such as dangerous and severe personality disorder) makes the role different from the general mental health nurse due to public perception and governmental interventions (Byrt & Dooher 2006, Kettles et al 2007). The forensic mental health nurse contributes to the therapeutic care and treatment of the patient as well as helping them to understand their own offending behaviour and recidivism (Kettles et al 2007, McMurran et al 2009, Coffey & Byrt 2010).
Whyte (1997, 2000) argued against the role as a speciality stating that FMHNs do no more than general mental health nurses and have the same duties. However Kettles et al (2007:7) counter this stating that FMHNs “certainly do have the same rolesâ€¦in terms of the provision of care…but with the added caveat that these persons do no harm to themselves or others”. This role of managing the patients’ multiple pathologies requires specific therapeutic competencies such as interpersonal skills, boundary management, the avoidance of negative custodial care, varying safety and security measures and responsibility towards public protection (Kettles et al 2007).
The ability to create and maintain a therapeutic relationship has been noted as “one of the most important competencies required by nurses working in secure environments” (Peternelj-Taylor & Schafer 2008:195). Scanlon & Adlam (2009) point out that FMHNs face continual challenges to abandon the therapeutic relationship in favour of custodial related tasks such as administrative duties and security related issues.
However it is important to remember:
In a forensic mental health setting… the maintenance of a safe and secure environment is the essential basis for all other psychotherapeutic work, rather than being in opposition to it
(Dale & Gardner, 2001: 256).
Therefore the FMHN needs to find solutions to the maintenance of the therapeutic relationships in cases of patient transference, disengagement and treatment refusal. As such they require a multitude of skills, capabilities and knowledge that start with the ten essential shared capabilities (DH 2004) (Appendix 1), which provide the starting point for education, training and continuing development of all mental health nurses, to achieve this, which could be argued, go beyond that needed by the mental health nurse in general ( DH 2004, Kettles et al 2008).
One of the skills needed is the ability to maintain boundaries within the therapeutic relationship. The issue of boundary maintenance is fundamental to the therapeutic process in order to not only protect the patient but also to provide protection of the staff (Dale 2001) through the creation of therapeutic spaces, thus keeping issues of care and custody apart. Within forensic settings boundary maintenance is important in providing safety for unregulated feelings, allowing the patient to express distressing thoughts and feelings in an appropriate manner (Adshead 2007) that do not overspill into the wider ward environment.
Nurses working with MDOs have a dynamic relationship that can hold both good therapeutic advantages as well as potential pitfalls (Blumenthall 2010). The fact that some MDOs have offended in severe ways brings about the need for staff to remain aware of their own views and feelings concerning patient offences (Byrt 2010) and to not let them overspill into the therapeutic relationship where they can affect the quality of care provided.
The FMHN needs a formidable knowledge base in order to deliver therapeutic interventions. They must able to promote the rights of patients whilst considering both the health care and legal systems. This includes extensive knowledge of the Mental Health Act 2007 (GB 2007) court-imposed sections, public protection issues, court proceedings and safeguarding. Along with this FMHNs need to obtain a higher level of risk assessment skills that are related to “risk to self or others in terms of serious violence” (Woods 2007) which allows for the completion and understanding of assessment tools such as the Historical, Clinical, Risk -20 Assessment. (HCR-20) (Webster et al 1997).
MDOs come into contact with both the healthcare and criminal justice system whose interests in public safety and individual care vary greatly. This means that the FMHN needs to consider both care and custodial aspects in their interactions with MDOs. However as a caring profession we need to be aware that the attempt to get the balance right between secure and caring environments presents the danger of missing the issue of caring for people in an effective, safe and holistic manner which should be the primary objective for all forensic mental health professionals.
The inclusion of restricted patients under MAPPA has led to better multi-agency management of the risk posed by such patients. Both the CPA and MAPPA have a common purpose of maximising public safety and the reduction of serious harm with the underlying principle of gathering and sharing of information between agencies in relation to risk. However they differ in that the CPA focuses on care and treatment to minimise the risk presented, whilst MAPPA focuses on the multi-agency management of risk.
Security within forensic mental health units should not solely rely on physical and procedural aspects. Relational security, built upon a sound therapeutic relationship, allows for both supportive and effective interventional work to occur and is the most important element in the maintenance of therapeutic progress. An awareness of the therapeutic importance of environmental, relational and procedural security is valuable in drafting safe and effective treatment plans for patients and working within these three auspices allows for the recovery process to continue.
FMHNs need a large skill and knowledge base in which to effectively work. The risk of recidivism within MDOs requires the FMHN to be able to effectively assess risk of violence to others as part of their nursing role. This appears to go beyond the DH’s ten essential shared capabilities and shows that FMHNs have to deal with a multitude of issues and interventions in their work with MDOs. Forensic mental health nursing differs in that it attempts to both de-stigmatise and de-criminalise the MDO as part of the recovery process which, in this author’s opinion, should come under the auspice of a speciality within mental health nursing.
Word Count 3287.
Ten Essential Shared Capabilities.
The Ten Essential Shared Capabilities (ESCs) framework provides the basic building blocks for the education, training and continuing development of all mental health workers.
Working in Partnership.
Developing and maintaining constructive working relationships with service users, carers, families, colleagues, lay people and wider community networks. Working positively with any tensions created by conflicts of interest or aspiration that may arise between the partners in care.
Working in partnership with service users, carers, families and colleagues to provide care and interventions that not only make a positive difference but also do so in ways that respect and value diversity including age, race, culture, disability, gender, spirituality and sexuality.
Recognising the rights and aspirations of service users and their families, acknowledging power differentials and minimising them whenever possible. Providing treatment and care that is accountable to service users and carers within the boundaries prescribed by national (professional), legal and local codes of ethical practice.
Addressing the causes and consequences of stigma, discrimination, social inequality and exclusion on service users, carers and mental health services. Creating, developing or maintaining valued social roles for people in the communities they come from.
Working in partnership to provide care and treatment that enables service users and carers to tackle mental health problems with hope and optimism and to work towards a valued lifestyle within and beyond the limits of any mental health problem.
Needs and Strengths.
Working in partnership to gather information to agree health and social care needs in the context of the preferred lifestyle and aspirations of service users their families, carers and friends.
Providing Service User Centred Care.
Negotiating achievable and meaningful goals; primarily from the perspective of service users and their families. Influencing and seeking the means to achieve these goals and clarifying the responsibilities of the people who will provide any help that is needed, including systematically evaluating outcomes and achievements.
Making a Difference
Facilitating access to and delivering the best quality, evidence-based, values-based health and social care interventions to meet the needs and aspirations of service users and their families and carers.
Promoting Safety and Positive Risk Taking.
Empowering the person to decide the level of risk they are prepared to take with their health and safety. This includes working with the tension between promoting safety and positive risk taking, including assessing and dealing with possible risks for service users, carers, family members, and the wider public.
Keeping up-to-date with changes in practice and participating in life-long learning, personal and professional development for one’s self and colleagues through supervision, appraisal and reflective practice.
Department of Health (DH) (2004) The Ten Essential Shared Capabilities: A Framework for the Whole of the Mental Health Workforce. London. Department of Health.
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