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Forensic Nursing and Multidisciplinary Care of the Mentally Disordered OffenderReview - Forensic Nursing and Multidisciplinary Care of the Mentally Disordered Offender
by David Robinson and Alyson Kettles (editors)
Jessica Kingsley, 1999
Review by Frances Gillespie
Jun 30th 2001 (Volume 5, Issue 26)

A reading of the first chapter of this book, Educational Aspects of Forensic Nursing, stringently written by Lawrence A. Whyte almost persuades that the discipline of forensic nursing is non-existent. He queries its definition, its empirical base, and fundamentally whether it is nursing at all! (p13) These are bold editors that place a paper that so clearly delineates the range of problems the term "forensic nursing" has, at the start of an exposition of the nursing care of the mentally disordered offender. Included is 'empirical evidence … with international and cross cultural-contributions (and) a first account of forensic nursing.' (p11)

Thus the stage is set for a fascinating and meticulous multifaceted journey through the practice of the fledgling profession of forensic nursing. Because the term is problematical, the various definitions that arise are of interest.

Kettles and Robinson arrive at the conclusion based on an empirical study that the forensic nurse in the UK performs similarly to the mental health nurse but 'more so....in backup; in awareness of the patient's potential; in dealing with violence and greater complexity and therefore had to cope with more; in being more team based.' (p32).

By contrast Lynch and Bear in the United States list seven separate specialist areas in forensic nursing, each 'specialist (serving) a vital role in the investigation, evaluation and care of forensic patients involving both the health and justice systems.(258-259) They also conclude that 'Forensic nurses represent health care's response to anti-violence strategies and protection of individual human rights' (p260).

The US 'Scope and Standards of Forensic Nursing Practice (ANA and the IAFN 1997) places forensic nursing in the medical-legal investigation of injury and/or deaths of victims of violence, criminal activity and traumatic accidents and as being a significant resource in forensic psychiatric practice.' (Hufft, p213)

In Canada 'forensic nursing is emerging as a fairly new and unique specialty (with) ... little understanding of what it means.' (Perternelj-Taylor, p192) although the writer's definition is 'the integration of mental health nursing philosophy and practice, within a socio-cultural context that includes the criminal justice system, to provide comprehensive care to individual clients, their families and their communities.' (p195)

Both Norway and Germany have no official term for the forensic nurse. The fragmented and ad hoc development of Australia's forensic services also precludes a formal definition of its forensic nursing.

Given the confusion surrounding the term forensic nursing, the degree of agreement concerning services performed, the population to whom they are addressed, its complexity and the need for a multidisciplinary team approach to care is surprisingly unanimous. 'A cohesive multidisciplinary team is critical to safe and professional practice and can guard against manipulation, splitting and therapeutic boundary violations' (Peternelj-Taylor, p200). 'It is obvious that no employee, no matter in which area they were working, could be endowed with the necessary knowledge and experience to meet the complex and complicated demands of modern forensic care...' (Kuppen and Donisch-Seidel, p243).

It seems that the speed with which the mental disordered forensic population has been increasing world-wide - in the USA alone there are 210,000 severely mentally ill individuals in jails and prisons compared to approximately 70,000 in public psychiatric institutions - has forced a serious appraisal of the care they presently receive, and of the training options open to those who professionally care for them. Serious examination has also raised questions about the care of those working in these areas and the crucial effects of the environments in which they work, be they high, medium or low security or an 'outside walls nurse (translated into) perhaps, a forensic community nurse' (Norway, Almik, Hatling and Woods p234), or team work without walls (Canada, Peternelj-Taylor, p209)

Also revealed are the stresses peculiar to the work of the forensic nurse. For example, it is estimated that there is one serious life threatening assault per week in a special hospital (in the UK). (Quoted by Gournay and Carson p154-5). The necessity for excellent clinical supervision in a secure environment that contains the risk of hostage taking, attempted escape, of accusation of malpractice and, conversely, the problems of counter-transference' is explored. (Addo, p144; Cordess, pps 77-85) Indeed as I continued to read, the differences between this kind of nursing and any other became so apparent that its right to grow into a discrete discipline standing alone under the umbrella of Nursing became unarguable.

Throughout this book is a concern for the paucity of formal education for the forensic nurse. It was noted that the role of the psychiatrist, the psychologist and the social worker were acknowledged and usually clear cut but the role of the nurse, charged with the twenty-four hour care of a number of difficult people was often undervalued or ignored - 'forensic nurses with there constant and committed daily care … form the bedrock of the multidisciplinary team' (Swinton and Boyd, p141.) A nurse speaks of this thus:

'I can write a report that is far superior to any psychologist's, but when 'nurse' is behind someone's name, it is discounted. There is still that interpretation: nurse - hospital what do they know about forensics? So I tend not to play it up. I am a therapist or a team member and I downplay the nurse part.' (Peternelj, p197-8)
It is that lack of a formal career path, of recognition of nearly impossible tasks well done that is the biggest stumbling block to the acknowledgment of the existence of the profession. On top of that is the public belief that the job is a waste of money and such people, especially those whose crimes are horrendous should be locked up with the key thrown away or worse. And the forensic nurse struggles to leave such judgment behind and find the person behind both crime and illness and balance between custody and caring. How else can a therapeutic relationship be achieved? The nurse is also faced every day with staff shortages, funding cuts and a 'system which assumes that the professional interactions that make up the majority of the patients' day (and evening), i.e. those with nurses are somehow not those of major significance. (Cordess, p78)

There is a staggering amount of information in this book . I have not even touched on John Swinton's chapter, Reclaiming the soul (113-127) nor on the body of work about other members of the multidisciplinary team. Each contribution lives up to the editors' promise of 'raising more questions than it solves'(p12) and should be ingested like very rich food: slowly and with much relish. A word of warning: there are some acronyms that are unfathomable even with recourse to the index.

Anyone whose daily life - professionally, educationally, in policy making, in law, personally or through an interest in social justice - is touched by the 'mentally disordered offender' please read this book. It is the only one of its kind.

© Frances Gillespie 2001

Frances Gillespie describes herself as follows:

I am a mental health consumer of forty years standing. My family is steeped in this experience as we have traced it through four generations I therefore have also a personal understanding of caring in this difficult area. In the last five years I have moved from hiding under the blankets to giving evidence to an enquiry into the human rights of the mentally ill in Australia to spearheading an understanding of the mental health consumer as a resource in our community in Hobart, Tasmania. With the support of likeminded people a system of paid consumer consultants arose from this activism. I am at present on leave from studying for a research Masters in Medicine that centres on an analysis of the development of mental health consumerism in Tasmania. I believe that it is necessary to set aside anger generated from personal experience in this area in order to achieve lasting solutions. Thus I also work as a consumer advocate.


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