FORENSIC PSYCHIATRY

The many roles of nurses continue to increase with the ever expanding health service delivery
system. Forensic nursing is an example of a nursing role that is an example of a nursing role that
is rapidly increasing in its scope of practice. Nurses practising in this field may apply their skills
to the care of both victims and perpetrators of crime and in a variety of settings including
primary care facilities, hospitals and correctional institutions. Forensic nursing has its roots in
Alberta, Canada around 1975 where nurses served as investigators for medical examiners in the
field of death investigations.

 The International Association of Forensic Nurses (IAFN) and the American Nurses
Association (ANA) define forensic nursing as,

“The application of forensic science combined with the bio-psychological education of the
registered nurse, in the scientific investigation, evidence collection and preservation, analysis,
prevention and treatment of trauma and/or death related medical-legal issues”

 Hancock (2005) suggests that,

“Forensic nursing is the application of clinical and scientific knowledge to question of law and the
civil or criminal investigation for survivors of traumatic injury and /or patient treatment involving
court related issues.”

Context of Forensic Nursing

The forensic nursing service (FNS) (1999) has identified a variety of aspects within which the
forensic nurse may work.

1. Interpersonal violence – Domestic violence, sexual assaults, child & elder abuse/neglect,
psychological abuse, drug/alcohol abuse.
2. Public health & safety – Food & drug tampering, holistic health investigation,
epidemiological issues, environmental hazards.
3. Emergency/ trauma nursing – Traumatic injuries, suicide attempts, work related
injuries.
4. Patient care facilities – Accidents/injuries/neglect, inappropriate treatment
5. Police & corrections – Custody, abuse

Forensic Nursing specialties

 Clinical Forensic Nursing Speciality

 The Sexual Assault Nurse Examiner (SANE)
 Forensic Psychiatric Nursing Speciality
 Correctional/Institutional Nursing Speciality
 Nurses in General Practice

Forensic Psychiatric Nursing Speciality

Forensic Psychiatric Nurses integrate psychiatric/mental health nursing philosophy and

practice with knowledge of the criminal justice system and assessment of the sociocultural
influences on the individual client, the family and the community to provide comprehensive
psychiatric/mental health nursing.

Forensic psychiatric nurses work with mentally ill offenders and with victims of the crime. They
help the victim to cope with their emotional wounds and assist in the assessment and care of
perpetrators. They focus on identification and change of behaviours that link criminal offenses
or reactions to them.

Functional applications of Forensic psychiatric nursing include assessment of inmates for

physical fitness, criminal responsibility, disposition and early release. In the criminal justice
system Forensic Psychiatric Nurses deal with destructive, aggressive and socially unacceptable
behaviours. These nurses provide interventions that encourage individuals to exercise self-
control, foster individual change in behaviour and in the process protect other members of the
society and property.

Application of the nursing process in forensic psychiatric nursing in correctional

facilities

Care of a mentally ill offender population is a highly specialized area of nursing practice. The
rationale of imprisonment for criminal behaviour has been identified as – retribution to society,
deterrence of future crimes, rehabilitation and repentance, protection of society.

 Nursing Assessment
Common psychiatric behaviours to be identified include hallucinations, suspiciousness,
thought disorders, anger/agitation and impulsivity. Denial has been observed as the
most common behaviour among this population. Use of substances and medication non-
compliance are common obstacles to rehabilitation.

Special concerns-

Overcrowding and violence - Numerous studies have shown that crowding affects the
level of violence in prison. Inmate violence towards prison staffs is also a common
occurrence. Actual or implied verbal threats and swearing are the common everyday
language of most offender clients. Nurses who work in correctional facilities must be
able to adjust to the commonality of physical and verbal aggression if they are to prevail
in this chosen area of specialization.

Sexual assault- Rape in prison is viewed as an act of dominance and power. Severe
physical injury is often the result in most of these cases.

 Nursing Diagnosis
Common nursing diagnoses relevant to forensic clients in correctional facilities include-
Defensive coping
Dysfunctional grieving
Anxiety/ fear
Powerlessness
Acute confusion
  Plan of care

Development of a therapeutic relationship

1. Pre-orientation phase – During this phase the nurse must examine his/her feelings, fears
and anxieties about working with prisoners and in particular violent offenders-perhaps
murderers, rapists and pedophiles. This is the phase where the nurse must determine that
he/she will be able to separate the person from the behaviour and provide the
unconditional positive regard.
2. Orientation phase – This is the phase where nurse starts to establish rapport with the client.
This is a lengthy and intense process with the prisoner population. Empathy is a commonly
used tool to manipulate the nurse. Touch and self-disclosure, two elements used in the
establishments of trust are most commonly unacceptable with the prisoner population. A
handshake may be appropriate but any other form of touch is unacceptable in most of the
settings. Nurse must maintain awareness of the situation and ensure that personal
boundaries are not being violated. Communication within the correctional facility may
prove to be a challenge for the nurses.
3. Working phase – Nursing skills are implemented during the working phase of relationship
and promotion of behavioural change is the primary goal. This is extremely difficult with
offenders who commonly deny problems and resists change. Issues are discussed in the
treatment team meetings and on going modifications are made as required. The following
interventions can be done –
3.1. Counselling and supportive psychotherapy-
 Nurses may work with inmates who are experiencing feelings of powerlessness and
grief.
 Nurses may also counsel rape victims of sexual assault. Victims of sexual assault in
prison often experience the symptoms (feeling of helplessness & vulnerability, coupled
with shame, humiliation, embarrassment) associated with rape-trauma syndrome.
These individuals often become withdrawn and isolated and are at high risk for suicide.
The nurse can recognise these symptoms and intervene as required.
3.2. Crisis intervention-
 Behaviours such as self-mutilation, aggression, suicide attempts, acute psychotic
episodes and post-trauma responses require that the nurse be proficient in crisis
intervention.
 Non-compliance to prison rules, feelings of hopelessness, psychopathology, substance
use, overcrowded conditions tribute to potential for violence. Threatening behaviours
are to be reported immediately to all the members of treatment team.
3.3. Education-
 Opportunities for teaching abound in the correctional facility.
 Teaching plan must be individualised.
 Many have no desire or motivation to learn and resist cooperating with these efforts.
Important educational endeavours with these clients include:
- Health teaching to provide information to achieve optimum wellness based on poor
diets, rough lives of smoking, substance abuse and minimal health care.
- Stress management techniques can be demonstrated to the inmates to reduce
anxiety.
 - Nurse can participate in substance abuse treatment programs by providing client
education (the effects of substances on the body, the consequences of sharing
needle).
4. Termination phase – Ideally the termination phase of the nurse-client relationship ensures
therapeutic closure. This is not always possible in the correctional environment. Prisoners
are transferred from one institute to another for various reasons. When possible it is
important for nurses to initiate termination with clients so that at least some semblance of
closure can be achieved and review of goal attainment can be accomplished.

 Evaluation
Evaluation of the psychiatric forensic nursing process in the correctional environment
involves ongoing measurement of the diagnostic criteria aimed at resolution of
identified real or potential problems. Modification of the treatment plan as required is
part of the ongoing evaluation process.

***Forensic issues in Child Psychiatry

Forensic child & adolescent psychiatry is a sub-speciality of psychiatry involving the

relationships between psychiatry and law.

 Child custody
The evolution of child custody decision making has been influenced by increasing
awareness and recognition of the rights of children and women as well as by a
broadening perspective on the developmental and psychological needs of the children
involved. A psychiatric evaluator must maintain his/her role as an advocate for the best
interest of the child. The age and developmental needs of the child are considered in
making a judgement regarding which parent may better serve the child’s interests.

 Juvenile offenders
Youth in juvenile justice system are at extremely high risk for psychiatric disturbance
and unmet mental health needs are of public health concern. Adolescents in juvenile
justice residential facilities not only have higher rates of psychiatric disorders, including
depression, substance abuse and suicidal behaviour but they are also significantly more
likely to have been victims of physical and sexual abuse, educational failure and family
conflict.
A psychiatrist may be asked to evaluate a juvenile to make recommendations about
appropriate diversion plans. Psychiatric evaluations also may be requested when the
court is considering a waiver to adult court. In some cases such decisions are based in
part on the juvenile’s psychiatric history and current mental status.

Conclusion

Forensic nursing which is a growing area within the profession is composed of variety areas of
expertise. Forensic nurse take care of both victims and perpetrators of crime in a variety of
settings, including primary care facilities, hospitals and correctional institutions.