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Perspectives in Psychiatric Care
ISSN 0031-5990
Caring Science and the Development of Forensic Psychiatric Caring Ulrica Hörberg, RPN, PhD Ulrica Hörberg, RPN, PhD, is an Associate Professor, Faculty of Health and Life Sciences, Department of Health and Caring Sciences, Lifeworld Centre for Health, Care and Learning, Linnaeus University, Växjö, Sweden.
Search terms: Caring attitude, caring science, forensic psychiatric caring, health process Author contact: [email protected], with a copy to the Editor: [email protected] First Received February 6, 2014; Final Revision received September 19, 2014; Accepted for publication October 1, 2014. doi: 10.1111/ppc.12092
PURPOSE: This study aimed to discuss how caring science can contribute and provide a theoretical foundation for the development of caring within forensic psychiatric care. CONCLUSIONS: It is not only a challenge but also a great opportunity to use caring science theory within forensic psychiatric care when caring for the patients and supporting their health processes. PRACTICE IMPLICATIONS: There is a need for more knowledge about, understanding of, and willingness to care for patients within forensic psychiatric settings in a “true caring” way. In order to achieve this, a caring culture is required, one that supports carers and provides them with opportunities to further develop a caring attitude.
In this article, the need for developing forensic psychiatric care in the direction of “true caring” that meets and understands the patients as existential human beings is illustrated. The purpose is to discuss how caring science, based on a lifeworld approach (Dahlberg, 2011; Dahlberg & Segesten, 2010), can contribute and provide a theoretical foundation for the development of caring in forensic psychiatric care. There is a belief that this is possible without jeopardizing the safety of the patients or the staff. Caring science as a basis for caring could contribute to the promotion of patients’ health processes and in the long run contribute to the patients having greater possibilities to live and function better in the community and with others. This article addresses staff who have responsibility for patients’ daily care, that is, registered nurses, nurses specializing in psychiatric care (registered psychiatric nurses [RPNs]), and other nursing staff. These professionals are referred to as “carers” or staff in this article on the grounds that the professional status of the various staff categories is not significant in caring science theory and thus includes all the staff, irrespective of their level of education. A choice has been made to name the care that carers provide as caring, which thus also includes nursing.
tions where patients experience having no choice. Furthermore, forensic patients frequently suffer from severe mental disorders and most of them have committed a crime. The patients often receive care for long periods of time within institutional environments with high levels of security (Hörberg, Sjögren, & Dahlberg, 2012). To be referred to forensic psychiatric care can thus be seen as one of the most comprehensive encroachments society can impose upon a person’s life. The staff have the ambiguous task of both providing care, to improve the patients’ health and quality of life and to guard and contain the patient. The overall purpose for forensic psychiatric care is for the patient to return to a normal, independent life (Swedish Government Official Report, 2006:91). As such, forensic psychiatric caring is complex in nature due to the dilemma of providing custodial care, which implicitly implies a contradictory mandate of providing care in a custodial manner. This has been highlighted in several studies in the past two decades (Austin, 2001; Burrow, 1991, 1998; Gildberg, Elverdam, & Hounsgaard, 2010; Holmes, 2002, 2005; Hörberg, 2008; Hörberg et al., 2012; Jacob, 2014; Maroney, 2005; Peternelj-Taylor, 1999, 2004). Holmes (2002, 2005) and Hörberg (2008) state that forensic psychiatric care is often based on correction and discipline, and as a result, there is thus a need to develop the care with a more caring foundation.
Forensic Psychiatric Care
Patient Perspective
Forensic psychiatry is a complex field of care, which includes carrying out caring actions of a compulsory nature in situa-
Gildberg et al. (2010) point out that few studies have been performed focusing on forensic psychiatric care from the per-
Introduction
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spective of patients, and Coffey (2006) emphasizes the need for more research findings from this perspective in order to enable the development of this care. Some negative aspects of care provided in forensic psychiatric settings from patients’ points of view have, however, been presented. An example of this is the care being experienced as non-caring due to the absence of caring encounters and conversations. In a study by Hörberg et al. (2012), patients described how they are exposed to the exertion of authority, power, and punishment. According to Meehan, McIntosh, and Bergen (2006) patients experienced empty and unstructured days, and Farnworth, Nikitin, and Fossey (2004) and O’Connell, Farnworth, and Hanson (2010) report that patients’ everyday lives are spent on “killing time.” Sturidsson, Turtell, Tengström, Lekander, and Levander (2007) studied time use for patients in a forensic psychiatric clinic, which showed that most of the time was used for sleeping and resting, unstructured activities, and daily routines. Approximately one and a half hours was spent on structured activities such as physical exercise and sociotherapy, and less than 20 min per day on treatment, including pharmacotherapy, psychotherapy, consulting with the psychiatrist and nurses, and occupational therapists. There is, therefore, no shortage of time in the daily life on the ward, which means that there is also enough time, for example, for conversations and companionship between patients and their carers. Schafer and Peternelj-Taylor (2003) describe, from the patients’ perspective, experiences of what promotes or hinders the therapeutic relationship in forensic psychiatric settings. The results of their study on boundary violations show that the relationship is influenced by the carers being or not being there for patients and by the patients having or not having a voice, being or not being heard, feeling or not feeling objectified, and receiving or not receiving feedback. This indicates the great importance of the carers’ attitudes toward the patients and how they experience the care given. In recent years, studies have reported patients’ experiences of what they perceive as supportive in their recovery process. Tapp, Warren, Fife-Schaw, Perkins, and Moore (2013) have investigated how patients, who were considered “ready” to be discharged from a high-security forensic hospital, experienced what had helped or hindered their progress. The results illustrate that supportive alliances such as trusting and caring relationships were important. Supportive alliances of this nature could include peers and family as well as professionals. The results also demonstrated that collaboration in care between patient and professional, learning from others, maintaining a safe and secure environment, and psychotherapies were important for the recovery process. Olsson, Strand, and Kristiansen (2014) describe how forensic patients with a history of a high risk of violence experienced the turn toward recovery as “a long and arduous journey with many pitfalls where the participants had experiences of failure and disease 278
relapse” (p. 510). Maguire, Daffern, and Martin (2013) investigated nurses’ and patients’ perspectives of “limit setting” in forensic psychiatric settings. They concluded that an authoritative limit-setting style characterized by emphatic responding, which accounts for fairness, respect, consistency, and knowledge, is to be preferred before an authoritarian style characterized by control and indifference. In short, there is a need for a greater degree of humanization of the care and that patients need a great deal of support in their recovery process. Staff/Nurses Perspectives Research based on the perspective of staff/nurses indicates a number of difficulties that carers encounter in forensic psychiatric care. Several studies describe nurses’ vulnerability in the care of patients in forensic psychiatric settings. This may relate to dealing with one’s own fear and the patients’ potentially violent behavior in nurse–patient interactions (Jacob & Holmes, 2011), and to the difficulties in approaching the patient in a respectful way despite the implicit constraints and power (Rose, Peter, Gallop, Angus, & Liaschenko, 2011). Forensic psychiatric settings are stressful to work in and where experiences of hostile behavior by patients are not uncommon (Tema, Poggenpoel, & Myburgh, 2011). In a study by Gildberg, Bradley, Fristed, and Hounsgaard (2012), staff members’ interactions with patients in forensic psychiatric settings is characterized by “trust and relationshipenabling care” and/or “behaviour and perception-corrective care.” In essence, the staff are striving to change, halt, or support patient’s behavior based on what they (staff) perceive as normal. “The intention is to support and teach the patient normal behaviour, to protect the patient from becoming embarrassed by correcting their behaviour, and at the same time maintaining control and security by staying abreast of potential conflicts” (Gildberg et al., 2012, p. 111). Jacob (2012) has concluded that it is difficult for nurses to combine the correctional and health imperatives in the forensic psychiatric environment into caring acts. The nurses have a dual role that includes being both “agents” of care and “agents” of control. Nurses thus have to balance the demands from both the patients and from the health authorities and the legal system in their assessment of and interventions with patients in custodial activities by doing this from a therapeutic standpoint. Furthermore, Jacob observes that this has more to do with a humanization of these care environments than the application of their unique knowledge in caring for mentally ill offenders. Jacob and Foth (2013), in their article on sovereign power with references to the philosophers Foucault and Agamben, maintain that there is a dual purpose in enlisting nurses in forensic psychiatric environments. Nurses have to provide mental health care for patients as well as giving “the appearance that approach to the treatment of fellow human beings is taking place” (p. 184). They also point Perspectives in Psychiatric Care 51 (2015) 277–284 © 2014 Wiley Periodicals, Inc.
Caring Science and the Development of Forensic Psychiatric Caring
out that there is a risk that nurses engage in practices that do not comply with a therapeutic framework and are instead engaged in what the authors term as “sovereign displays of power,” which can entail the existence of exclusion in the care environment that can enable the use of “legitimate” violence and punishment. The aforementioned studies from the perspective of staff/nurses demonstrate the difficulties in caring for patients. Thus, there appears to be a need to enhance and empower nurses’ caring potential, which could contribute to a kind of care that these patients need. “True Caring” in Forensic Psychiatric Care From a Caring Science Perspective The literature review highlights the complexity and duality of forensic psychiatric care both from a patient and staff/nurse perspective. This complexity forms the challenge that forensic psychiatric care has to deal with. Compulsory care can be found in various psychiatric settings, but forensic psychiatric care is different due to the patients having committed crimes adjudged to be carried out under the influence of a severe mental disorder and consequently transferred to a forensic psychiatric unit. Questions arise such as: How can forensic psychiatric caring be based on a caring science foundation rather than on a correctional and custodial foundation? How can staff/nurses acquire caring tools based on caring science and ethics in this context of care? How can caring science contribute to forensic psychiatric care? Caring science based on a lifeworld approach (Dahlberg, 2011; Dahlberg & Segesten, 2010) is grounded in the phenomenological philosophy of Husserl (1970/1936, 1977/ 1929) and Merleau-Ponty (1968/1964, 2002/1945). From a caring science perspective, patients cannot be separated from their lifeworld because they live in and through the lifeworld in the form of experiences, traditions, culture, relationships, surroundings, and so forth. Caring science is thus interested in “the lived experiences” and the patients’ perspective is the starting point for caring. The central concepts in caring science are lifeworld, lived body, health and well-being, suffering, and caring relationships (Dahlberg, Segesten, Nyström, Suserud, & Fagerberg, 2003). The aim of caring science is to develop knowledge in order to attain a greater understanding of patients and their life situation. The carers must thus work to gain an understanding of the patient’s lifeworld in order to be able to understand and meet the patients’ needs and life situations (Dahlberg, 2011; Dahlberg & Segesten, 2010). The meaning of health and well-being as well as caring is paramount for caring science. The theory on health and caring that is described by Dahlberg and Segesten (2010) and Dahlberg, Todres, and Galvin (2009) can serve as a theoretical foundation for caring and nursing in the forensic psychiatric context. This theory of health and caring is founded on a lifeworld perspective and has its roots in the phenomenologiPerspectives in Psychiatric Care 51 (2015) 277–284 © 2014 Wiley Periodicals, Inc.
cal philosophy mentioned previously. It is within the daily life on a forensic psychiatric ward that the time and opportunity exist for establishing caring relationships that can help forensic patients move toward health. Caring, however, requires an environment where the individual’s lifeworld is given attention. Ranheim (2009) maintains that it is possible to connect ethical caring science theories into practical everyday care. In order to do so, nurses need to acquire both an increasing selfawareness and a deepened theoretical knowledge in relation to lived experiences of care. However, nurses need to incorporate the concepts of caring science in order to apply these in practice. When caring for patients in forensic psychiatric settings, the understanding and incorporation of the following concepts grounded in caring science could be of pivotal help. Specifically, the need of a patient perspective; the need for a caring attitude; dimensions of health—vitality, rhythm of life, and coherence; and learning instead of being corrected. The Need of a Patient Perspective Caring science is characterized by a patient perspective, which means that the patient’s needs are the focal point for caring and that the patients should be understood as being experts about themselves. In addition, a patient perspective should be understood as an ethical approach in caring. This entails that carers provide good care, where the patient’s perspective is taken into account (Dahlberg & Segesten, 2010). A patient perspective in caring can be understood as a “caring for insiderness,” which entails striving toward understanding another person as much as possible, and to act on this in a “true caring” way. This requires that carers are open minded in the caring moment (Todres, Galvin, & Dahlberg, 2014). The carer thus needs to start from the patient’s lived experience (i.e., in the patient’s lifeworld) in order to attempt to understand how the patient perceives their own situation. According to Dahlberg and Segesten (2010) the goal of caring is health, which could be further described by its essential meanings such as well-being—“to feel well” and a quality of “being able to,” which means to carry out things in life that are considered to be valuable for the person. Health should be the goal of caring even if the patient is suffering from severe mental illness. Caring for forensic patients should focus on well-being and a quality of “being able to”in a healthy way and not on cultivating their illness. An example of this is when a patient with drug problems wants to visit friends, who have similar problems,on his first permission from the ward,and he justifies his desire by claiming that it will be good for his wellbeing.In situations such as this,the carer needs to pay attention to the patient’s outspoken needs not always being beneficial to him and discuss the issue of the possible negative effect of meeting friends with drug problems.The carer thus challenges the patient in a caring way and they can together work on solutions that can contribute to his well-being in the longer term. 279
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The aim of caring is to support and strengthen the patient’s health processes, and the carer’s role is therefore not “to produce” something for the patient, rather to support the patient’s own capability (Dahlberg & Segesten, 2010). This requires that carers adopt a patient perspective, and in order to do this the carer needs to view and meet the patient as a subject and with Merleau-Ponty’s (2002/1945) words as a “personal bodily communicator,” and not as an object. In order to adopt a patient perspective when caring for patients, this understanding is of significance for the carers in forensic psychiatric settings. This may help the caregivers to understand the individual patient’s life situation and his or her point of view, for example, what it is like for this patient to live with the crimes committed. This can be crucial for the patient’s recovery process and to achieve successful care. If the carer fails to adopt patient perspective when caring for the patient, there is a risk that they do not understand each other, thereby preventing the establishment of a caring relationship. The Need for a Caring Attitude A basic prerequisite is that the carers incorporate a caring attitude when caring for patients to provide good and safe care of high quality (Dahlberg & Segesten, 2010). This means that the carers incorporate an increased awareness and a reflective attitude implying a holding back of their natural attitude, that is, the everyday attitude. This caring attitude has its roots in Husserl’s (1977/1929) description of a phenomenological attitude. Dahlberg (2006) clarifies that this entails challenging and problematizing the whole process of understanding and not taking any meanings for granted. In this more reflective attitude, the process of reflection (understanding) is slowed down in order to become more aware of one’s own actions that can increase the quality of care.An example of a caring attitude is when patients are asking for something then they should never need to be approached in a bad way by a carer who for example has “a bad day” or is tired and thus reacts in an unreflective way. Carers always need to reflect on the care provided in each encounter with patients and also need to reflect on the care provided by their colleagues. It is thus the healthcare environment as a whole that is of significance for the patient’s opportunity to achieve better health and well-being. This caring approach requires an openness to the patients’ lifeworld and to meet them as unprejudiced as possible. This entails understanding as much as possible about how the patients understand their life situation, which can contribute to identifying both what brings health and what causes illness in their lives. It can thus contribute to a discovery of something new and important that can be used when caring for the patient. Dahlberg and Segesten (2010) point out that the carer must develop his or her own “caring style” from an ethical point of view. This means that the carers in forensic psychiat280
ric settings need to develop an ethical sensitivity and reflect on how the care given affects the patients as well as themselves as carers. Austin, Goble, and Kelecevic (2009) emphasize a relational ethic that focuses on “being with,” as well as “being for” patients. This could provide a perspective that deepens the understanding of how to interact with patients in forensic psychiatric care. The ethical approach should include a “sensitive wakefulness” that is characterized by integrity and dignity where the carer reflects on how his or her caring is experienced by the patient (Sivonen & Kasén, 2003), for example, in a situation where the carer denies the patient the opportunity of going outside the ward due to the lack of staff on the ward. A carer with a sensitive wakefulness can try to understand how the patient experiences the situation and ask himself or herself questions such as: In what way does the patient experience my approach in the situation? What does it mean for the patient not to be able to go outside the ward this day? How can I support the patient in this situation? Ranheim and Dahlberg (2012) emphasize that carers need to develop an expanded awareness in order to meet patients in a way that provides space for existence and that supports the patients’ health processes. This means that carers need to cultivate and widen their experiential horizon. Carers thus need acuity of the senses, self-awareness, and self-confidence in order to be able to recognize the patients’ unspoken needs (Ranheim & Dahlberg, 2012). For example, a carer is caring for a patient who is a mother to a 5-year-old daughter she is not able to take care of and she is only allowed to meet her daughter once a month while being supervised by a carer in a visiting room on the ward. In this caring relationship, the carer has to try to really understand what it means to be cared for on a forensic psychiatric ward and at the same time to be a mother. The carer also needs to give the patient the opportunity to articulate her feelings, thoughts, and existential vulnerability in order to be able to support the patient’s health processes. It is thus with the help of a caring attitude the carer has the opportunity to gain insight into the patient’s lifeworld and to create a true caring relationship. This perspective could support carers in forensic psychiatric settings to really understand how the patients perceive themselves, their life situation, and enable them to meet the patient’s existential thoughts. The caring relationship is an interpersonal encounter and must be characterized by a carer’s professional commitment, focusing on the patient’s needs for care and that the carer consistently reflects on what is happening in the relationship (Dahlberg & Segesten, 2010). Dimensions of Health: Vitality, Rhythm of Life, and Coherence Health could be described as finding one’s own place in existence and a way to live both with oneself and with the surrounding world (Dahlberg & Segesten, 2010). This could be Perspectives in Psychiatric Care 51 (2015) 277–284 © 2014 Wiley Periodicals, Inc.
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an overall goal when caring for patients in forensic psychiatric care. According to Heidegger (1978/1927), we can understand what it means to live in an authentic way, to handle our lives, and take responsibility in order to make the best of our lives. The opposite is to live in a non-authentic way, which means losing oneself and failing to take responsibility for one’s life (Dahlberg & Segesten, 2010), which could be the case for the patients in forensic psychiatric settings. Health could be further described in relation to vitality and life rhythm. Vitality is put forward as a human being’s driving force or engine in order to cope with life that could bring both opportunities and obstacles or difficulties. The challenge when caring for patients in forensic psychiatric settings is to identify their vitality and support them to use it in a healthy way, for example, to choose a life without drugs and criminality. Health in terms of life rhythm means finding harmony and balance in life where both experiences of stillness and movement are important from an existential (thoughts and feelings) point of view and from a biological (physical) point of view (Dahlberg & Segesten, 2010; Dahlberg et al., 2009). There is a risk that the patient’s life rhythm becomes imbalanced due to feeling that their life situation lacks meaning and the restrictions to activities on and outside the ward. Patients in forensic psychiatric settings are more or less limited in their freedom of movement both literally and metaphorically.There is thus a challenge for the carer to support the patients to use time in a proper and meaningful way. It also entails the carers using all available time in the everyday life on the ward to support and encounter patients in a “true caring” way, for example, by performing meaningful activities together. The need for meaning and for coherence is a deep human desire that is related to how health can be strengthened or weakened.Both disease and suffering affect a human being’s experience of meaning and coherence. Even the care environment can affect a patient’s sense of meaning and coherence. Based on Heidegger’s thinking (1978/1927), Svenaeus (2013) outlines the difference between a homelike (healthy) versus an unhomelike (unhealthy) “being-in-the-world” for human beings. In forensic psychiatric care, this could entail both patients’ illnesses and the fact that they are incarcerated in a ward that contributes to feelings similar to homelessness in an unhomelike existence. Meaning and coherence are both interdependent and intertwined and it is of utmost significance for human beings to lead a healthy life,even for patients in forensic psychiatric settings. It can, however, be difficult to achieve this in the forensic psychiatric environment,and whether it is difficult or not,the patients need support to live and to express their vitality in a healthy and balanced way. Learning Instead of Being Corrected There is a great need for patients “to learn” in forensic psychiatric settings. Patients’ learning to live with illness can be Perspectives in Psychiatric Care 51 (2015) 277–284 © 2014 Wiley Periodicals, Inc.
viewed as a movement toward a change of understanding of one’s access to the world (Berglund, 2014). Learning can thus not be based on pure correction and discipline if it is at the same time to be a true caring, that is, a caring that is founded on correction and discipline is not caring. Hörberg (2008) showed that learning based on discipline and the use of the dual system of “punishment—rewarding” cannot alleviate the patients’ experiences of suffering. Within such a framework the patients have to conform and adapt to the rules and requirements of the carers, which cannot be considered as a health-promoting learning from a caring science perspective. How can the caring be designed in forensic psychiatric care to be a health-promoting learning for the patients? In the studies by Hörberg and Hörberg et al. (2012), it is maintained that a basis for caring other than that of correction and discipline is needed and that carers need primarily to adopt a reflective attitude when caring for forensic patients. The promotion of patients’ learning should be based on a patient perspective, and this kind of learning is described by Ekebergh (2007, 2009) and Hörberg, Ozolins, and Ekebergh (2011) as a lifeworld-led learning. There is a clear distinction between learning based on a lifeworld perspective and learning based on correction and discipline. The former focuses on the patients “learning themselves,” that is, the carers support the patients in their learning. On the other hand, a learning based on correction and discipline concerns “teaching you,” which entails the carer dictating the rules for the patient and how the patient has to behave (cf. Berglund & Källerwald, 2012; Hörberg, 2008; Hörberg et al., 2012). The problem within this latter framework is that the patient could learn to adapt to prescribed rules and behavior without really understanding why this is important to them and their relation to the world around them. Correction and discipline appear to be related to the exercise of power and destructive relationships based on inequality and can be devastating in a caring context as they can divert from what could be a breeding ground for true caring. Without any effective caring, the correctional and disciplinary activities lead to care that is experienced as meaningless (Hörberg, 2008; Hörberg et al., 2012). Based on Heidegger’s (1978/1927) philosophy, open, responsible, and responsive carers will join with the patients and assist them with their knowledge and show the way by not running too far ahead and taking over (Dahlberg & Segesten, 2010). The caregiver must therefore be where the patient is and highlight their possibilities. Berglund and Källerwald (2012) state that teaching and information for patients on an “admonishing level” entails telling the patients what they are expected to do. This kind of learning is not the same as genuine learning for the patients, and these authors maintained that genuine learning takes place on a deeper level and can be transformed into knowledge. Genuine learning means that the learning is incorpo281
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rated into life as a whole. This requires carers adopting a patient perspective when providing support for the patients’ learning. For example, when you are caring with a lifeworld perspective you are not only saying “no” to patients who are asking for something they are not allowed to do. You are also asking,“Why do you think that you are not allowed to do this? What could happen if we allowed you to do this?” You also explain in a caring way why the patient is not allowed to do this. A caring that contributes to genuine learning for the patients in forensic psychiatric settings could be a “new” and authentic caring way of encountering patients who have both problems and possibilities. The patients should be cared for without using methods that include correction and discipline and embrace the concept of lifeworld-led learning. Implications for Nursing Practice In this article the need for greater knowledge, understanding, and willingness to care for patients in forensic psychiatric settings in a “true caring” way is highlighted. In order to achieve this, a caring culture and environment is required; however, this also requires that the managers in forensic psychiatry seriously grasp and understand this need in order to support and provide opportunities for carers to further develop a caring attitude. Such support could include: • A customized educational program founded on caring science that focuses on how to provide “true caring” within a forensic psychiatric context, one that includes the aspects of risk and security. This “true caring” should contain a focus on a genuine learning for the patients. • Supervision from a caring science perspective that focuses on existential and ethical issues and starts from patients’ perspectives in relation to illness and their whole life situation. • A daily forum for the staffs’ reflections on the care given and the opportunities and barriers for achieving a common caring culture and environment. • Highlighting the advantages of having time to spend on, for example, caring conversations in order to use the time well in the everyday life on the ward as a complement to therapy. This may both enhance the possibility of getting through to the patients and of establishing or furthering the development of a caring relationship. Conclusion Forensic psychiatric care must be questioned and challenged by scientifically based theories and concepts of what true caring is. This article demonstrates the possibilities for using caring science theory in forensic psychiatric care when caring for patients in supporting the patients’ health processes. The preconditions for creating a caring environment where “true caring” can be provided are that the prevalent care culture 282
needs to be made visible, questioned, and discussed. Hard work is necessary at all levels in such institutions, but the most important is that the basic values, the understanding about human beings, the concepts of caring, and its aim, means, and methods should be brought forward and discussed by those who have a responsibility and a caring assignment within forensic psychiatric care. There appears to be possibilities to implement a caring science perspective based on a lifeworld approach in forensic psychiatric units. Staff/nurses need caring science tools to use when caring for patients. They also need support to transform the caring science theory into practice. In order to know if and how caring science can support staff/nurses in the care for patients, it is necessary that such an implementation is investigated and evaluated from the perspective of both staff/nurses and patients. An important area for future research is the relationship between the content of received care and patients’ ability to be rehabilitated and to live in society.
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(Eds.), Qualitative research in midwifery and childbirth, phenomenological approaches (pp. 19–34). London: Routledge. Dahlberg, K., & Segesten, K. (2010). Hälsa och vårdande i teori och praxis [Health and caring in theory and practice]. Stockholm: Natur & Kultur. Dahlberg, K., Segesten, K., Nyström, M., Suserud, B.-O., & Fagerberg, I. (2003). Att förstå vårdvetenskap [Understanding caring science]. Lund: Studentlitteratur. Dahlberg, K., Todres, L., & Galvin, K. (2009). Lifeworld-led healthcare is more than patient-led care: An existential view of well-being. Medicine, Health Care, and Philosophy, 12, 265–271. doi:10.1007/s11019-008-9174-7 Ekebergh, M. (2007). Lifeworld-based reflection and learning: A contribution to the reflective practice in nursing and nursing education. Reflective Practice, 8(3), 331–343. doi:10.1080/14623940701424835 Ekebergh, M. (2009). Developing a didactic method that emphasizes lifeworld as a basis for learning. Reflective Practice, 10(1), 51–63. doi:10.1080/14623940802652789 Farnworth, L., Nikitin, L., & Fossey, E. (2004). Being in a secure forensic psychiatric unit: Every day is the same, killing time or making the most of it. British Journal of Occupational Therapy, 67(10), 430–438. Gildberg, F. A., Bradley, S. K., Fristed, P., & Hounsgaard, L. (2012). Reconstructing normality: Characteristics of staff interactions with forensic mental health inpatients. International Journal of Mental Health Nursing, 21, 103–113. doi:10.1111/j.1447-0349.2011.00786.x Gildberg, F. A., Elverdam, B., & Hounsgaard, L. (2010). Forensic psychiatric nursing: A literature review and thematic analysis of staff—patient interaction. Journal of Psychiatric and Mental Health Nursing, 17, 359–368. doi:10.1111/j.1365-2850.2009.01533.x Heidegger, M. (1978/1927). Being and time (J. Maquarrie & E. Robinson Trans.). Oxford: Blackwell. Holmes, D. (2002). Police and pastoral power: Governmentality and correctional forensic psychiatric nursing. Nursing Inquiry, 9(2), 84–92. doi:10.1046/j.1440-1800.2002.00134.x Holmes, D. (2005). Governing the captives: Forensic psychiatric nursing in corrections. Perspectives in Psychiatric Care, 41(1), 3–13. doi:10.1111/j.0031-5990.2005.00007.x Hörberg, U. (2008). Att vårdas eller fostras. Det rättspsykiatriska vårdandet och traditionens grepp [To be the subject of care or the object of correction. Forensic psychiatric care and the power of tradition]. [Dissertation in Swedish]. Växjö University Press. Hörberg, U., Ozolins, L.-L., & Ekebergh, M. (2011). Intertwining caring science, caring practice and caring education from a lifeworld perspective: Two contextual examples. International Journal of Qualitative Studies on Health and Well-being, 6, 10363. doi:10.3402/qhw.v6i4.10363 Hörberg, U., Sjögren, R., & Dahlberg, K. (2012). To be strategically struggling against resignation: The lived experience of being cared for in forensic psychiatric care. Issues in Mental Health Nursing, 33, 743–751. doi:10.3109/01612840.2012.704623
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Husserl, E. (1970/1936). The crisis of European sciences and transcendental phenomenology (D. Carr, Trans.). Evanston, IL: Northwestern University Press. Husserl, E. (1977/1929). Cartesian meditations (D. Cairns, Trans.). The Hague: Martinus Nijhoff. Jacob, J. D. (2012). The rhetoric of therapy in forensic psychiatric nursing. Journal of Forensic Nursing, 8, 178–187. doi:10.1111/j.1939-3938.2012.01146.x Jacob, J. D. (2014). Understanding the domestic rupture in forensic psychiatric nursing practice. Journal of Correctional Health Care, 20(1), 45–58. doi:10.1177/1078345813505444 Jacob, J. D., & Foth, T. (2013). Expanding our understanding of sovereign power: On the creation of zones of exception in forensic psychiatry. Nursing Philosophy, 14, 178–185. doi:10.1111/nup.12017 Jacob, J. D., & Holmes, D. (2011). Working under threat: Fear and nurse–patient interactions in a forensic psychiatric setting. Journal of Forensic Nursing, 7, 68–77. doi:10.1111/j.1939-3938.2011.01101.x Maguire, T., Daffern, M., & Martin, T. (2013). Exploring nurses’ and patients perspectives of limit setting in a forensic mental health setting. International Journal of Mental Health Nursing, 23(2), 153–160. doi:10.1111/inm.12034 Maroney, M. K. (2005). Caring and custody: Two faces of the same reality. Journal of Correctional Health Care, 11(2), 157–169. doi:10.1177/107834580401100204 Meehan, T., McIntosh, W., & Bergen, H. (2006). Aggressive behaviour in the high-secure forensic setting: The perceptions of patients. Journal of Psychiatric and Mental Health Nursing, 13, 19–25. doi:10.1111/j.1365-2850.2006.00906.x Merleau-Ponty, M. (1968/1964). The visible and the invisible (A. Lingis, Trans.). Evanston, IL: Northwestern University Press. Merleau-Ponty, M. (2002/1945). Phenomenology of perception (C. Smith, Trans.). London: Routledge. O’Connell, M., Farnworth, L., & Hanson, C. E. (2010). Time use in forensic psychiatry: A naturalistic inquiry into two forensic patients in Australia. International Journal of Forensic Mental Health, 9, 101–109. doi:10.1080/14999013.2010.499558 Olsson, H., Strand, S., & Kristiansen, L. (2014). Reaching a turning point: How patients in forensic care describe trajectories of recovery. Scandinavian Journal of Caring Sciences, 28(3), 505–514. doi:10.1111/scs.12075 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. Peternelj-Taylor, C. (2004). An exploration of othering in forensic psychiatric and correctional nursing. Canadian Journal of Nursing Research, 36(4), 130–146. Ranheim, A. (2009). Caring and its ethical aspects: An empirical philosophical dialogue on caring. International Journal of Qualitative Studies on Health and Well-being, 4, 78–85. doi:10.1080/17482620902727300 Ranheim, A., & Dahlberg, K. (2012). Expanded awareness as a way to meet the challenges in care that is economically driven and
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focused on illness: A Nordic perspective. Aporia: The Nursing Journal, 4(4), 20–24. Rose, D. N., Peter, E., Gallop, R., Angus, J. E., & Liaschenko, J. (2011). Respect in forensic psychiatric nurse-patient relationships: A practical compromise. Journal of Forensic Nursing, 7, 3–16. doi:10.1111/j.1939-3938.2010.01090.x Schafer, P., & Peternelj-Taylor, C. (2003). Therapeutic relationships and boundary maintenance: The perspective of forensic patients enrolled in a treatment program for violent offenders. Issues in Mental Health Nursing, 24, 605–625. doi:10.1080/01612840305320 Sivonen, K., & Kasén, A. (2003). Enheten människa—kropp, själ och ande [The human unit—body, soul and spirit]. In K. Eriksson & U. Å. Lindström (Eds.), Gryning II: klinisk vårdvetenskap [Dawn II: Clinical caring science] (pp. 75–96). Vasa: Institutionen för vårdvetenskap, Åbo akademi. Sturidsson, K., Turtell, I., Tengström, A., Lekander, M., & Levander, M. (2007). Time use in forensic psychiatry: An exploratory study of patients’ time use at a Swedish forensic psychiatric clinic. International Journal of Forensic Mental Health, 6(1), 79–86. doi:10.1080/14999013.2007.10471251
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Perspectives in Psychiatric Care
ISSN 0031-5990
Caring Science and the Development of Forensic Psychiatric Caring Ulrica Hörberg, RPN, PhD Ulrica Hörberg, RPN, PhD, is an Associate Professor, Faculty of Health and Life Sciences, Department of Health and Caring Sciences, Lifeworld Centre for Health, Care and Learning, Linnaeus University, Växjö, Sweden.
Search terms: Caring attitude, caring science, forensic psychiatric caring, health process Author contact: [email protected], with a copy to the Editor: [email protected] First Received February 6, 2014; Final Revision received September 19, 2014; Accepted for publication October 1, 2014. doi: 10.1111/ppc.12092
PURPOSE: This study aimed to discuss how caring science can contribute and provide a theoretical foundation for the development of caring within forensic psychiatric care. CONCLUSIONS: It is not only a challenge but also a great opportunity to use caring science theory within forensic psychiatric care when caring for the patients and supporting their health processes. PRACTICE IMPLICATIONS: There is a need for more knowledge about, understanding of, and willingness to care for patients within forensic psychiatric settings in a “true caring” way. In order to achieve this, a caring culture is required, one that supports carers and provides them with opportunities to further develop a caring attitude.
In this article, the need for developing forensic psychiatric care in the direction of “true caring” that meets and understands the patients as existential human beings is illustrated. The purpose is to discuss how caring science, based on a lifeworld approach (Dahlberg, 2011; Dahlberg & Segesten, 2010), can contribute and provide a theoretical foundation for the development of caring in forensic psychiatric care. There is a belief that this is possible without jeopardizing the safety of the patients or the staff. Caring science as a basis for caring could contribute to the promotion of patients’ health processes and in the long run contribute to the patients having greater possibilities to live and function better in the community and with others. This article addresses staff who have responsibility for patients’ daily care, that is, registered nurses, nurses specializing in psychiatric care (registered psychiatric nurses [RPNs]), and other nursing staff. These professionals are referred to as “carers” or staff in this article on the grounds that the professional status of the various staff categories is not significant in caring science theory and thus includes all the staff, irrespective of their level of education. A choice has been made to name the care that carers provide as caring, which thus also includes nursing.
tions where patients experience having no choice. Furthermore, forensic patients frequently suffer from severe mental disorders and most of them have committed a crime. The patients often receive care for long periods of time within institutional environments with high levels of security (Hörberg, Sjögren, & Dahlberg, 2012). To be referred to forensic psychiatric care can thus be seen as one of the most comprehensive encroachments society can impose upon a person’s life. The staff have the ambiguous task of both providing care, to improve the patients’ health and quality of life and to guard and contain the patient. The overall purpose for forensic psychiatric care is for the patient to return to a normal, independent life (Swedish Government Official Report, 2006:91). As such, forensic psychiatric caring is complex in nature due to the dilemma of providing custodial care, which implicitly implies a contradictory mandate of providing care in a custodial manner. This has been highlighted in several studies in the past two decades (Austin, 2001; Burrow, 1991, 1998; Gildberg, Elverdam, & Hounsgaard, 2010; Holmes, 2002, 2005; Hörberg, 2008; Hörberg et al., 2012; Jacob, 2014; Maroney, 2005; Peternelj-Taylor, 1999, 2004). Holmes (2002, 2005) and Hörberg (2008) state that forensic psychiatric care is often based on correction and discipline, and as a result, there is thus a need to develop the care with a more caring foundation.
Forensic Psychiatric Care
Patient Perspective
Forensic psychiatry is a complex field of care, which includes carrying out caring actions of a compulsory nature in situa-
Gildberg et al. (2010) point out that few studies have been performed focusing on forensic psychiatric care from the per-
Introduction
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spective of patients, and Coffey (2006) emphasizes the need for more research findings from this perspective in order to enable the development of this care. Some negative aspects of care provided in forensic psychiatric settings from patients’ points of view have, however, been presented. An example of this is the care being experienced as non-caring due to the absence of caring encounters and conversations. In a study by Hörberg et al. (2012), patients described how they are exposed to the exertion of authority, power, and punishment. According to Meehan, McIntosh, and Bergen (2006) patients experienced empty and unstructured days, and Farnworth, Nikitin, and Fossey (2004) and O’Connell, Farnworth, and Hanson (2010) report that patients’ everyday lives are spent on “killing time.” Sturidsson, Turtell, Tengström, Lekander, and Levander (2007) studied time use for patients in a forensic psychiatric clinic, which showed that most of the time was used for sleeping and resting, unstructured activities, and daily routines. Approximately one and a half hours was spent on structured activities such as physical exercise and sociotherapy, and less than 20 min per day on treatment, including pharmacotherapy, psychotherapy, consulting with the psychiatrist and nurses, and occupational therapists. There is, therefore, no shortage of time in the daily life on the ward, which means that there is also enough time, for example, for conversations and companionship between patients and their carers. Schafer and Peternelj-Taylor (2003) describe, from the patients’ perspective, experiences of what promotes or hinders the therapeutic relationship in forensic psychiatric settings. The results of their study on boundary violations show that the relationship is influenced by the carers being or not being there for patients and by the patients having or not having a voice, being or not being heard, feeling or not feeling objectified, and receiving or not receiving feedback. This indicates the great importance of the carers’ attitudes toward the patients and how they experience the care given. In recent years, studies have reported patients’ experiences of what they perceive as supportive in their recovery process. Tapp, Warren, Fife-Schaw, Perkins, and Moore (2013) have investigated how patients, who were considered “ready” to be discharged from a high-security forensic hospital, experienced what had helped or hindered their progress. The results illustrate that supportive alliances such as trusting and caring relationships were important. Supportive alliances of this nature could include peers and family as well as professionals. The results also demonstrated that collaboration in care between patient and professional, learning from others, maintaining a safe and secure environment, and psychotherapies were important for the recovery process. Olsson, Strand, and Kristiansen (2014) describe how forensic patients with a history of a high risk of violence experienced the turn toward recovery as “a long and arduous journey with many pitfalls where the participants had experiences of failure and disease 278
relapse” (p. 510). Maguire, Daffern, and Martin (2013) investigated nurses’ and patients’ perspectives of “limit setting” in forensic psychiatric settings. They concluded that an authoritative limit-setting style characterized by emphatic responding, which accounts for fairness, respect, consistency, and knowledge, is to be preferred before an authoritarian style characterized by control and indifference. In short, there is a need for a greater degree of humanization of the care and that patients need a great deal of support in their recovery process. Staff/Nurses Perspectives Research based on the perspective of staff/nurses indicates a number of difficulties that carers encounter in forensic psychiatric care. Several studies describe nurses’ vulnerability in the care of patients in forensic psychiatric settings. This may relate to dealing with one’s own fear and the patients’ potentially violent behavior in nurse–patient interactions (Jacob & Holmes, 2011), and to the difficulties in approaching the patient in a respectful way despite the implicit constraints and power (Rose, Peter, Gallop, Angus, & Liaschenko, 2011). Forensic psychiatric settings are stressful to work in and where experiences of hostile behavior by patients are not uncommon (Tema, Poggenpoel, & Myburgh, 2011). In a study by Gildberg, Bradley, Fristed, and Hounsgaard (2012), staff members’ interactions with patients in forensic psychiatric settings is characterized by “trust and relationshipenabling care” and/or “behaviour and perception-corrective care.” In essence, the staff are striving to change, halt, or support patient’s behavior based on what they (staff) perceive as normal. “The intention is to support and teach the patient normal behaviour, to protect the patient from becoming embarrassed by correcting their behaviour, and at the same time maintaining control and security by staying abreast of potential conflicts” (Gildberg et al., 2012, p. 111). Jacob (2012) has concluded that it is difficult for nurses to combine the correctional and health imperatives in the forensic psychiatric environment into caring acts. The nurses have a dual role that includes being both “agents” of care and “agents” of control. Nurses thus have to balance the demands from both the patients and from the health authorities and the legal system in their assessment of and interventions with patients in custodial activities by doing this from a therapeutic standpoint. Furthermore, Jacob observes that this has more to do with a humanization of these care environments than the application of their unique knowledge in caring for mentally ill offenders. Jacob and Foth (2013), in their article on sovereign power with references to the philosophers Foucault and Agamben, maintain that there is a dual purpose in enlisting nurses in forensic psychiatric environments. Nurses have to provide mental health care for patients as well as giving “the appearance that approach to the treatment of fellow human beings is taking place” (p. 184). They also point Perspectives in Psychiatric Care 51 (2015) 277–284 © 2014 Wiley Periodicals, Inc.
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out that there is a risk that nurses engage in practices that do not comply with a therapeutic framework and are instead engaged in what the authors term as “sovereign displays of power,” which can entail the existence of exclusion in the care environment that can enable the use of “legitimate” violence and punishment. The aforementioned studies from the perspective of staff/nurses demonstrate the difficulties in caring for patients. Thus, there appears to be a need to enhance and empower nurses’ caring potential, which could contribute to a kind of care that these patients need. “True Caring” in Forensic Psychiatric Care From a Caring Science Perspective The literature review highlights the complexity and duality of forensic psychiatric care both from a patient and staff/nurse perspective. This complexity forms the challenge that forensic psychiatric care has to deal with. Compulsory care can be found in various psychiatric settings, but forensic psychiatric care is different due to the patients having committed crimes adjudged to be carried out under the influence of a severe mental disorder and consequently transferred to a forensic psychiatric unit. Questions arise such as: How can forensic psychiatric caring be based on a caring science foundation rather than on a correctional and custodial foundation? How can staff/nurses acquire caring tools based on caring science and ethics in this context of care? How can caring science contribute to forensic psychiatric care? Caring science based on a lifeworld approach (Dahlberg, 2011; Dahlberg & Segesten, 2010) is grounded in the phenomenological philosophy of Husserl (1970/1936, 1977/ 1929) and Merleau-Ponty (1968/1964, 2002/1945). From a caring science perspective, patients cannot be separated from their lifeworld because they live in and through the lifeworld in the form of experiences, traditions, culture, relationships, surroundings, and so forth. Caring science is thus interested in “the lived experiences” and the patients’ perspective is the starting point for caring. The central concepts in caring science are lifeworld, lived body, health and well-being, suffering, and caring relationships (Dahlberg, Segesten, Nyström, Suserud, & Fagerberg, 2003). The aim of caring science is to develop knowledge in order to attain a greater understanding of patients and their life situation. The carers must thus work to gain an understanding of the patient’s lifeworld in order to be able to understand and meet the patients’ needs and life situations (Dahlberg, 2011; Dahlberg & Segesten, 2010). The meaning of health and well-being as well as caring is paramount for caring science. The theory on health and caring that is described by Dahlberg and Segesten (2010) and Dahlberg, Todres, and Galvin (2009) can serve as a theoretical foundation for caring and nursing in the forensic psychiatric context. This theory of health and caring is founded on a lifeworld perspective and has its roots in the phenomenologiPerspectives in Psychiatric Care 51 (2015) 277–284 © 2014 Wiley Periodicals, Inc.
cal philosophy mentioned previously. It is within the daily life on a forensic psychiatric ward that the time and opportunity exist for establishing caring relationships that can help forensic patients move toward health. Caring, however, requires an environment where the individual’s lifeworld is given attention. Ranheim (2009) maintains that it is possible to connect ethical caring science theories into practical everyday care. In order to do so, nurses need to acquire both an increasing selfawareness and a deepened theoretical knowledge in relation to lived experiences of care. However, nurses need to incorporate the concepts of caring science in order to apply these in practice. When caring for patients in forensic psychiatric settings, the understanding and incorporation of the following concepts grounded in caring science could be of pivotal help. Specifically, the need of a patient perspective; the need for a caring attitude; dimensions of health—vitality, rhythm of life, and coherence; and learning instead of being corrected. The Need of a Patient Perspective Caring science is characterized by a patient perspective, which means that the patient’s needs are the focal point for caring and that the patients should be understood as being experts about themselves. In addition, a patient perspective should be understood as an ethical approach in caring. This entails that carers provide good care, where the patient’s perspective is taken into account (Dahlberg & Segesten, 2010). A patient perspective in caring can be understood as a “caring for insiderness,” which entails striving toward understanding another person as much as possible, and to act on this in a “true caring” way. This requires that carers are open minded in the caring moment (Todres, Galvin, & Dahlberg, 2014). The carer thus needs to start from the patient’s lived experience (i.e., in the patient’s lifeworld) in order to attempt to understand how the patient perceives their own situation. According to Dahlberg and Segesten (2010) the goal of caring is health, which could be further described by its essential meanings such as well-being—“to feel well” and a quality of “being able to,” which means to carry out things in life that are considered to be valuable for the person. Health should be the goal of caring even if the patient is suffering from severe mental illness. Caring for forensic patients should focus on well-being and a quality of “being able to”in a healthy way and not on cultivating their illness. An example of this is when a patient with drug problems wants to visit friends, who have similar problems,on his first permission from the ward,and he justifies his desire by claiming that it will be good for his wellbeing.In situations such as this,the carer needs to pay attention to the patient’s outspoken needs not always being beneficial to him and discuss the issue of the possible negative effect of meeting friends with drug problems.The carer thus challenges the patient in a caring way and they can together work on solutions that can contribute to his well-being in the longer term. 279
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The aim of caring is to support and strengthen the patient’s health processes, and the carer’s role is therefore not “to produce” something for the patient, rather to support the patient’s own capability (Dahlberg & Segesten, 2010). This requires that carers adopt a patient perspective, and in order to do this the carer needs to view and meet the patient as a subject and with Merleau-Ponty’s (2002/1945) words as a “personal bodily communicator,” and not as an object. In order to adopt a patient perspective when caring for patients, this understanding is of significance for the carers in forensic psychiatric settings. This may help the caregivers to understand the individual patient’s life situation and his or her point of view, for example, what it is like for this patient to live with the crimes committed. This can be crucial for the patient’s recovery process and to achieve successful care. If the carer fails to adopt patient perspective when caring for the patient, there is a risk that they do not understand each other, thereby preventing the establishment of a caring relationship. The Need for a Caring Attitude A basic prerequisite is that the carers incorporate a caring attitude when caring for patients to provide good and safe care of high quality (Dahlberg & Segesten, 2010). This means that the carers incorporate an increased awareness and a reflective attitude implying a holding back of their natural attitude, that is, the everyday attitude. This caring attitude has its roots in Husserl’s (1977/1929) description of a phenomenological attitude. Dahlberg (2006) clarifies that this entails challenging and problematizing the whole process of understanding and not taking any meanings for granted. In this more reflective attitude, the process of reflection (understanding) is slowed down in order to become more aware of one’s own actions that can increase the quality of care.An example of a caring attitude is when patients are asking for something then they should never need to be approached in a bad way by a carer who for example has “a bad day” or is tired and thus reacts in an unreflective way. Carers always need to reflect on the care provided in each encounter with patients and also need to reflect on the care provided by their colleagues. It is thus the healthcare environment as a whole that is of significance for the patient’s opportunity to achieve better health and well-being. This caring approach requires an openness to the patients’ lifeworld and to meet them as unprejudiced as possible. This entails understanding as much as possible about how the patients understand their life situation, which can contribute to identifying both what brings health and what causes illness in their lives. It can thus contribute to a discovery of something new and important that can be used when caring for the patient. Dahlberg and Segesten (2010) point out that the carer must develop his or her own “caring style” from an ethical point of view. This means that the carers in forensic psychiat280
ric settings need to develop an ethical sensitivity and reflect on how the care given affects the patients as well as themselves as carers. Austin, Goble, and Kelecevic (2009) emphasize a relational ethic that focuses on “being with,” as well as “being for” patients. This could provide a perspective that deepens the understanding of how to interact with patients in forensic psychiatric care. The ethical approach should include a “sensitive wakefulness” that is characterized by integrity and dignity where the carer reflects on how his or her caring is experienced by the patient (Sivonen & Kasén, 2003), for example, in a situation where the carer denies the patient the opportunity of going outside the ward due to the lack of staff on the ward. A carer with a sensitive wakefulness can try to understand how the patient experiences the situation and ask himself or herself questions such as: In what way does the patient experience my approach in the situation? What does it mean for the patient not to be able to go outside the ward this day? How can I support the patient in this situation? Ranheim and Dahlberg (2012) emphasize that carers need to develop an expanded awareness in order to meet patients in a way that provides space for existence and that supports the patients’ health processes. This means that carers need to cultivate and widen their experiential horizon. Carers thus need acuity of the senses, self-awareness, and self-confidence in order to be able to recognize the patients’ unspoken needs (Ranheim & Dahlberg, 2012). For example, a carer is caring for a patient who is a mother to a 5-year-old daughter she is not able to take care of and she is only allowed to meet her daughter once a month while being supervised by a carer in a visiting room on the ward. In this caring relationship, the carer has to try to really understand what it means to be cared for on a forensic psychiatric ward and at the same time to be a mother. The carer also needs to give the patient the opportunity to articulate her feelings, thoughts, and existential vulnerability in order to be able to support the patient’s health processes. It is thus with the help of a caring attitude the carer has the opportunity to gain insight into the patient’s lifeworld and to create a true caring relationship. This perspective could support carers in forensic psychiatric settings to really understand how the patients perceive themselves, their life situation, and enable them to meet the patient’s existential thoughts. The caring relationship is an interpersonal encounter and must be characterized by a carer’s professional commitment, focusing on the patient’s needs for care and that the carer consistently reflects on what is happening in the relationship (Dahlberg & Segesten, 2010). Dimensions of Health: Vitality, Rhythm of Life, and Coherence Health could be described as finding one’s own place in existence and a way to live both with oneself and with the surrounding world (Dahlberg & Segesten, 2010). This could be Perspectives in Psychiatric Care 51 (2015) 277–284 © 2014 Wiley Periodicals, Inc.
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an overall goal when caring for patients in forensic psychiatric care. According to Heidegger (1978/1927), we can understand what it means to live in an authentic way, to handle our lives, and take responsibility in order to make the best of our lives. The opposite is to live in a non-authentic way, which means losing oneself and failing to take responsibility for one’s life (Dahlberg & Segesten, 2010), which could be the case for the patients in forensic psychiatric settings. Health could be further described in relation to vitality and life rhythm. Vitality is put forward as a human being’s driving force or engine in order to cope with life that could bring both opportunities and obstacles or difficulties. The challenge when caring for patients in forensic psychiatric settings is to identify their vitality and support them to use it in a healthy way, for example, to choose a life without drugs and criminality. Health in terms of life rhythm means finding harmony and balance in life where both experiences of stillness and movement are important from an existential (thoughts and feelings) point of view and from a biological (physical) point of view (Dahlberg & Segesten, 2010; Dahlberg et al., 2009). There is a risk that the patient’s life rhythm becomes imbalanced due to feeling that their life situation lacks meaning and the restrictions to activities on and outside the ward. Patients in forensic psychiatric settings are more or less limited in their freedom of movement both literally and metaphorically.There is thus a challenge for the carer to support the patients to use time in a proper and meaningful way. It also entails the carers using all available time in the everyday life on the ward to support and encounter patients in a “true caring” way, for example, by performing meaningful activities together. The need for meaning and for coherence is a deep human desire that is related to how health can be strengthened or weakened.Both disease and suffering affect a human being’s experience of meaning and coherence. Even the care environment can affect a patient’s sense of meaning and coherence. Based on Heidegger’s thinking (1978/1927), Svenaeus (2013) outlines the difference between a homelike (healthy) versus an unhomelike (unhealthy) “being-in-the-world” for human beings. In forensic psychiatric care, this could entail both patients’ illnesses and the fact that they are incarcerated in a ward that contributes to feelings similar to homelessness in an unhomelike existence. Meaning and coherence are both interdependent and intertwined and it is of utmost significance for human beings to lead a healthy life,even for patients in forensic psychiatric settings. It can, however, be difficult to achieve this in the forensic psychiatric environment,and whether it is difficult or not,the patients need support to live and to express their vitality in a healthy and balanced way. Learning Instead of Being Corrected There is a great need for patients “to learn” in forensic psychiatric settings. Patients’ learning to live with illness can be Perspectives in Psychiatric Care 51 (2015) 277–284 © 2014 Wiley Periodicals, Inc.
viewed as a movement toward a change of understanding of one’s access to the world (Berglund, 2014). Learning can thus not be based on pure correction and discipline if it is at the same time to be a true caring, that is, a caring that is founded on correction and discipline is not caring. Hörberg (2008) showed that learning based on discipline and the use of the dual system of “punishment—rewarding” cannot alleviate the patients’ experiences of suffering. Within such a framework the patients have to conform and adapt to the rules and requirements of the carers, which cannot be considered as a health-promoting learning from a caring science perspective. How can the caring be designed in forensic psychiatric care to be a health-promoting learning for the patients? In the studies by Hörberg and Hörberg et al. (2012), it is maintained that a basis for caring other than that of correction and discipline is needed and that carers need primarily to adopt a reflective attitude when caring for forensic patients. The promotion of patients’ learning should be based on a patient perspective, and this kind of learning is described by Ekebergh (2007, 2009) and Hörberg, Ozolins, and Ekebergh (2011) as a lifeworld-led learning. There is a clear distinction between learning based on a lifeworld perspective and learning based on correction and discipline. The former focuses on the patients “learning themselves,” that is, the carers support the patients in their learning. On the other hand, a learning based on correction and discipline concerns “teaching you,” which entails the carer dictating the rules for the patient and how the patient has to behave (cf. Berglund & Källerwald, 2012; Hörberg, 2008; Hörberg et al., 2012). The problem within this latter framework is that the patient could learn to adapt to prescribed rules and behavior without really understanding why this is important to them and their relation to the world around them. Correction and discipline appear to be related to the exercise of power and destructive relationships based on inequality and can be devastating in a caring context as they can divert from what could be a breeding ground for true caring. Without any effective caring, the correctional and disciplinary activities lead to care that is experienced as meaningless (Hörberg, 2008; Hörberg et al., 2012). Based on Heidegger’s (1978/1927) philosophy, open, responsible, and responsive carers will join with the patients and assist them with their knowledge and show the way by not running too far ahead and taking over (Dahlberg & Segesten, 2010). The caregiver must therefore be where the patient is and highlight their possibilities. Berglund and Källerwald (2012) state that teaching and information for patients on an “admonishing level” entails telling the patients what they are expected to do. This kind of learning is not the same as genuine learning for the patients, and these authors maintained that genuine learning takes place on a deeper level and can be transformed into knowledge. Genuine learning means that the learning is incorpo281
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rated into life as a whole. This requires carers adopting a patient perspective when providing support for the patients’ learning. For example, when you are caring with a lifeworld perspective you are not only saying “no” to patients who are asking for something they are not allowed to do. You are also asking,“Why do you think that you are not allowed to do this? What could happen if we allowed you to do this?” You also explain in a caring way why the patient is not allowed to do this. A caring that contributes to genuine learning for the patients in forensic psychiatric settings could be a “new” and authentic caring way of encountering patients who have both problems and possibilities. The patients should be cared for without using methods that include correction and discipline and embrace the concept of lifeworld-led learning. Implications for Nursing Practice In this article the need for greater knowledge, understanding, and willingness to care for patients in forensic psychiatric settings in a “true caring” way is highlighted. In order to achieve this, a caring culture and environment is required; however, this also requires that the managers in forensic psychiatry seriously grasp and understand this need in order to support and provide opportunities for carers to further develop a caring attitude. Such support could include: • A customized educational program founded on caring science that focuses on how to provide “true caring” within a forensic psychiatric context, one that includes the aspects of risk and security. This “true caring” should contain a focus on a genuine learning for the patients. • Supervision from a caring science perspective that focuses on existential and ethical issues and starts from patients’ perspectives in relation to illness and their whole life situation. • A daily forum for the staffs’ reflections on the care given and the opportunities and barriers for achieving a common caring culture and environment. • Highlighting the advantages of having time to spend on, for example, caring conversations in order to use the time well in the everyday life on the ward as a complement to therapy. This may both enhance the possibility of getting through to the patients and of establishing or furthering the development of a caring relationship. Conclusion Forensic psychiatric care must be questioned and challenged by scientifically based theories and concepts of what true caring is. This article demonstrates the possibilities for using caring science theory in forensic psychiatric care when caring for patients in supporting the patients’ health processes. The preconditions for creating a caring environment where “true caring” can be provided are that the prevalent care culture 282
needs to be made visible, questioned, and discussed. Hard work is necessary at all levels in such institutions, but the most important is that the basic values, the understanding about human beings, the concepts of caring, and its aim, means, and methods should be brought forward and discussed by those who have a responsibility and a caring assignment within forensic psychiatric care. There appears to be possibilities to implement a caring science perspective based on a lifeworld approach in forensic psychiatric units. Staff/nurses need caring science tools to use when caring for patients. They also need support to transform the caring science theory into practice. In order to know if and how caring science can support staff/nurses in the care for patients, it is necessary that such an implementation is investigated and evaluated from the perspective of both staff/nurses and patients. An important area for future research is the relationship between the content of received care and patients’ ability to be rehabilitated and to live in society.
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