The Development Of Forensic Mental Health Care Social Work Essay

This assignment discusses the conflicting functions of the forensic mental wellness nurse as both health professional and keeper. It will look at whether forensic mental wellness should be considered as a forte service by analyzing how these seemingly conflicting functions can ( with the right degrees of accomplishments, cognition and attitude ) provide quality services that are informed by a sound empirical cognition base.

To accomplish this we will look at how mental wellness attention evolved from the Poor Law Act of 1601 through to the present twenty-four hours. We will see the FMHN ‘s function in the protection of the populace and expression at how forensic mental wellness services are placed within a assortment of scenes to help in accomplishing this purpose. We will besides analyze the impact the function of the keeper can hold on the curative relationship between nurse and patient.

First nevertheless we need to understand what is meant by the term ‘forensic ‘ . Forensic means “ of the jurisprudence ” ( Kettles et al 2007:1 ) or “ related to tribunals of jurisprudence ” ( Baker et al 2011:400 ) . Possibly, due to the misinterpretation of the word ‘forensic ‘ , the term forensic mental wellness forensic mental wellness induces high degrees of anxiousness amongst the populace ( Baker et al 2011 ) . Due to the forensic mental wellness services ‘ function in covering with the more serious wrongdoers and the stigma produced by the imperativeness this anxiousness is non entirely surprising. Although the term forensic can be affiliated to any condemnable activity it is of import to recognize that non all forensic patients should be considered to be a danger to society.

The development of forensic mental wellness attention.

Mental wellness attention can be traced back to the Poor Laws of 1601. This introduced a duty for every Parish to back up those incapable of looking after themselves ( Sadiq et al 2011 ) and was perchance an early effort in tie ining poorness and disablement. Specific jurisprudence pertaining to the mentally sick emerged in the eighteenth century when the power to imprison the ‘furiously mad and unsafe ‘ was enshrined in The Vagrancy Act 1714 ( Moncrieff 2003 ) and the Regulation of Private Madhouses Act 1774 which required refuges to be licensed by the Royal College of Physicians ( Miller et al 2011 ) .

In 1843 Daniel M’Naughton was tried for slaying. After a successful defense mechanism of mental incompetency, treatments within the House of Lords resulted in criterions by which a individual could be acquitted by ground of insanity ( Vij 2008 ) . McNaughton regulations are still the standard trial for condemnable liability in relation to mentally broken wrongdoers today and let tribunals to see whether:

The party accused was laboring under such a defect of ground, from disease of the head, as non to cognize the nature and quality of the act he was making ; or, if he did cognize it, that he did non cognize he was making what was incorrect.

Cowen et Al ( 2012:723 ) .

The Lunacy Act ( Great Britain 1890 ) , legalised the detainment procedure by the usage of monthly studies forestalling patients remaining longer than necessary and regulated intervention attacks which applied legal rules to imprison patients ( Glover-Thomas 2002 ) . The 1959 Mental Health Act ( MHA ) ( Department of Health and Social Security ( DHSS ) 1959 ) repealed the Lunacy Act and marked a displacement from accent from legal facets of intervention to care going a medical duty ( Warne et al 2010 ) .

1863 saw the gap of Broadmoor Hospital ( Forshaw 2008 ) followed by Rampton Hospital ( 1912 ) and Moss Side Hospital ( 1917 ) . Ashworth Hospital opened in the early 1970 ‘s after the meeting of Moss Side and Park Lane Hospitals ( Forshaw 2008 ) .

The basicss of forensic mental wellness nursing began with the gap of these province infirmaries ( Woods 2004 ) . An question into gross security oversights at Ashworth Hospital led to the Fallon Report ( Fallon et al 1999 ) which recommended greater security such as the recording of phone calls, random searching of ego and environment, and farther betterments to the external and internal security ( Tilt 2000 ) across all three particular infirmaries. This marked a displacement back towards the burden being placed more on security than on attention.

Servicess were further developed after the publication of the Glancy Report ( DHSS 1974 ) and Butler Report ( DHSS 1975 ) which focused on forensic demand at a local degree to supply attention and security for the intervention of MDOs ( Bartlett & A ; Kesteven 2010 ) . Both identified a deficiency of security in inpatient scenes and the demand for an interim service between high security infirmaries and the community ( Davies & A ; Leech 2012 ) . These influential studies paved the manner for the development and building of regional medium secure units ( McMurran et al 2009 ) .

As with the Glancy and Butler studies, the Reed Report ( Department of Health & A ; Home Office ( DH & A ; HO ) 1992 ) besides discussed the demand for more secure beds ( Dix 2005 ) and set out rules of secure attention, saying that attention should be provided harmonizing to single demand, near to the patient ‘s place or household, every bit far as possible in the community and in conditions of no greater security than is justified ( DH & A ; HO 1992 ) .

Under The MHA 1983 ( GB 1983 ) the mentally broken wrongdoer ‘s ( MDO ) ‘health or safety ‘ every bit good as the ‘protection of others ‘ are considered. As an illustration the subdivision 41 limitation order purposes to protect the populace from serious injury, and allows for mandatory supervising of a conditionally discharged patient ( DH 1983 ) which shows a good balance between liberty of the patient and the protection of the public.. The MHA 2007 ( GB 2007 ) amalgamated the MHA 1983 and Mental Capacity Act 2005. It reinforced that MDOs should hold the same right to assessment and intervention as people who have non offended ( Ministry of Justice 2008 ) . However, the act has been criticised for “ puting public protection above the demands and rights of the patient ” ( Wrench & A ; Dolan 2010:240 ) by presenting the construct of intervention handiness as opposed to the treatability ( Thomson 2008 ) .

The publication of the NHS Plan 2000 highlighted the importance of supplying intervention for captives with mental wellness jobs ( DH 2000 ) saying that no captive with mental unwellness will go forth without a program of attention and care co-ordinator ( DH 2000 ) . This was reinforced by Changing the Outlook ( DH 2001 ) which reminded us that the criterions for mental wellness services apply every bit within prisons as they do to the wider community ( DH 2001 ) and captives that should hold entree to the “ same scope and quality of services appropriate to their demands as are available to the general population ” ( DH 2001:5 ) . This was farther echoed in the Bradley study which stated “ prison may non ever be the right environment for those with terrible mental unwellness ” ( Bradley 2009:1 ) and MDOs “ could, in appropriate instances, be diverted aˆ¦ to other services. ” ( Bradley 2009:8 ) . Despite this the rates of MDOs still being held unsuitably in the prison system remains high ( Berman 2012 ) .

We now see FMHN ‘s working in many different countries such as high secure infirmaries, medium and low secure units, prisons, immature wrongdoer establishments, constabulary Stationss acute wards, psychiatric intensive attention units, tribunal affair strategies, outpatient sections, community attention and rehabilitation services.

The function of the forensic mental wellness nurse in protecting the populace.

Many facets of the FMHN ‘s function in the direction of MDOs are based around public safety such as escorting a patient in the community to measure their psychosocial operation, informing the constabulary should a patient fail to return from unescorted leave and authorship studies for Mental Health Review Tribunals. Other countries connected to public protection are the completion of the Care Programme Approach ( CPA ) ( DH 1990 ) and affair with the multi-agency public protection agreements ( MAPPA ) ( Home Office 2001 ) .

The CPA is a multi-disciplinary procedure, intended to supply a systematic appraisal of a patient ‘s biopsychosocial demands, a program of attention ( including the preparation of a hazard appraisal ) , the allotment of a cardinal worker upon discharge and regular reappraisals of a individual ‘s attention ( Earp & A ; Byrt 2010 ) . Its chief purpose is to be after for the patient ‘s future demands and maintain the multi-disciplinary squad aware of any concerns environing hazard ( Bartlett & A ; Kesteven 2010 ) . The consequences of an efficient CPA are the constitution of an effectual attention pathway, where all relevant bureaus are made cognizant of their function with the MDO ( Bartlett & A ; Kesteven 2010 ) , that “ combines an apprehension of both the patient ‘s mental wellness and their possible hazard ” ( Gournay et al 2008:531 ) . This is continued after discharge, within the community, to let for a forensic community mental wellness nurse to be appointed to co-ordinate attention by guaranting that the services identified within the patients attention program are put in topographic point and go on to run into their demands. The CPA besides applies within the prison system where it is used to “ back up improved throughcare and discharge planning ” ( Senior & A ; Shaw 2008: 181 ) therefore guaranting appropriate discharge with aftercare is provided.

The completion of a hazard appraisal, undertaken by the key-nurse, is a needed constituent of the CPA procedure ( Gournay et al 2008 ) . It incorporates both inactive and dynamic hazard state of affairss that may take to heightened hereafter hazard ( such as refusal of medicine, detachment from services and other psychosocial issues ) . The ability to measure and pull off hazard is a skill forensic nurses must possess and polish to advance patients ‘ safe reintegration into the community ( Encinares et al 2005 ) .

It would look from the above treatment that the CPA within forensic services is the basis on which effectual appraisal and direction of hazards are based and effectual aftercare is identified and provided.

Another facet of the nurse ‘s function in public protection is involvement with MAPPA. Troubles in accomplishing interagency attention were recognised as far back as the Reed Report ( DH & A ; HO 1992 ) . The debut of MAPPA enabled bureaus to work collaboratively in interchanging information and managing MDOs, therefore guaranting potentially unsafe wrongdoers are decently hazard assessed and managed in the community. MAPPA placed a statutory responsibility to set up agreements for the appraisal and direction of hazard presented by wrongdoers one time leave or discharge have been considered ( GB 2000, Home Office 2004, OBMH 2009 ) . Health governments have a statutory responsibility to collaborate with MAPPA ( GB 2003, Thomson 2008 ) which may include the exchanging of patient information.

It is the professional responsibility of the nurse to portion with MAPPA any information that they think is of import to help in the protection of the populace. Therefore should a patient unwrap any information that may refer to put on the line to the populace, the nurse has a responsibility to unwrap this information ( OBMH 2009 ) . This information may be presented in the patients clinical team meetings ( CTM ) where treatment environing the hazard can take topographic point with the multi-disciplinary environment. If it is felt necessary this information can so be relayed to MAPPA via the cardinal nurse or care co-ordinator ( OBMH 2009 ) . This sharing of information enables the relevant bureaus to measure hazard more efficaciously and do determinations on how to pull off it ( Ministry of Justice 2012 ) and is critical to inform hazard appraisal and any needed aftercare ( Snowden & A ; Ashim 2008 ) .

The pattern of information-sharing between bureaus can nevertheless hold deductions on patient confidentiality. Nurses owe a responsibility of confidentiality to their patients ( DH 2003, Snowden & A ; Ashim 2008 ) every bit good as a responsibility under the European Convention on Human Rights ( ECHR 2004 ) and the Data Protection Act ( GB 1998 ) which both convey support for the breaching of confidentiality merely in the involvements of forestalling serious injury and public protection. The nurse must seek the consent of the patient before unwraping information ( Snowden & A ; Ashim 2008 ) albeit it the really nature of the information being disclosed may deter the patient from accepting ( Eastman et al 2010 ) . However a breach of confidentiality would still be allowed where the jurisprudence requires revelation or where there is an issue of public safety ( NMC 2008, RCP 2010, Bartlett & A ; McGauley 2010 ) .

Care versus Custody, the impact of the function of ‘custodian ‘ on the curative relationship.

Since the Fallon Enquiry ( Fallon 1999 ) and subsequent Tilt Report ( 2000 ) recommendations, the chief accent of forensic mental wellness attention has been on security.

Within unafraid mental wellness scenes there are three distinguishable countries of security. Physical security in the signifier of locked doors, keys, fencings and dismaies ; procedural security, such as policy and process, to keep safety and security ; and relational security which is the cognition and apprehension of the patient and the reading of this cognition into appropriate responses and attention ( DH 2010 ) . These security intercessions are reflected in the National Institute for Clinical Excellence ( NICE 2005 ) guidelines that set out counsel to bettering security within secure scenes.

Some of the largest quandary within forensic mental wellness nursing surround the challenges of keeping ‘boundaried ‘ relationships, the tensenesss between revelation of information versus patient confidentiality ( Adlam et al 2012 ) and the demand to supply holistic attention against the demand to incorporate the patient in order to supply public protection ( care versus detention ) ( Chaloner 2000, Mason et al 2008, Rogers & A ; Soothill 2008, Adlam et al 2012 ) . These issues of attention versus detention have been highlighted in a figure of studies ( Butler 1975, Reed 1992, Tilt 2000 ) .

In the old subdivision we looked at how the sharing of information and breaching of confidentiality may be allowed in the involvements of public safety, even if the nature of the information being disclosed may deter the patient from accepting ( Eastman et al 2010 ) . As MAPPA is finally concerned with public protection, non health care, it may make up one’s mind in fortunes of possible heightened hazard to do a determination which impacts on a patient ‘s freedom ( Snowden & A ; Ashim 2008 ) which patients can comprehend as penalty or forced containment ( McCourt 1999, Aiyegbusi 2009 ) . The revelation of such information may be seen as a negative act by the patient, which in bend may bring forth barriers to the curative relationship such as troubles in swearing the nurse and seeing them more as a custodian as opposed to a carer, detachment from curative communicating and rejection of intervention, resistance and ill will ( Kettles et al 2006, Byrt 2010 ) .

Knowledge, Skills, Attitudes and behaviors.

Forensic mental wellness nursing is multifaceted. Chaloner ( 2000 ) explains that the function of the forensic nurse has expanded the scope of accomplishments that are usually required the general mental wellness practician. The most obvious differences such as security, offence- specific hazard appraisal and direction accomplishments have already been discussed.

Less obvious characteristics of the forensic nurse ‘s function are the differing diagnosing and classs of the patients ( sociopath, sex wrongdoers, pedophile and socio-political diagnosing ‘s such as unsafe and terrible personality upset ) makes the function different from the general mental wellness nurse due to public perceptual experience and governmental intercessions ( Byrt & A ; Dooher 2006, Kettles et al 2007 ) . The forensic mental wellness nurse contributes to the curative attention and intervention of the patient every bit good as assisting them to understand their ain piquing behavior and recidivism ( Kettles et al 2007, McMurran et al 2009, Coffey & A ; Byrt 2010 ) .

Whyte ( 1997, 2000 ) argued against the function as a forte saying that FMHNs do no more than general mental wellness nurses and have the same responsibilities. However Kettles et Al ( 2007:7 ) counter this saying that FMHNs “ surely do hold the same rolesaˆ¦in footings of the proviso of attention… but with the added caution that these individuals do no injury to themselves or others ” . This function of pull offing the patients ‘ multiple pathologies requires specific curative competences such as interpersonal accomplishments, boundary direction, the turning away of negative tutelary attention, changing safety and security steps and duty towards public protection ( Kettles et al 2007 ) .

The ability to make and keep a curative relationship has been noted as “ one of the most of import competences required by nurses working in secure environments ” ( Peternelj-Taylor & A ; Schafer 2008:195 ) . Scanlon & A ; Adlam ( 2009 ) point out that FMHNs face continual challenges to abandon the curative relationship in favor of tutelary related undertakings such as administrative responsibilities and security related issues.

However it is of import to retrieve:

In a forensic mental wellness scene… the care of a safe and unafraid environment is the indispensable footing for all other psychotherapeutic work, instead than being in resistance to it

( Dale & A ; Gardner, 2001: 256 ) .

Therefore the FMHN needs to happen solutions to the care of the curative relationships in instances of patient transference, detachment and intervention refusal. As such they require a battalion of accomplishments, capablenesss and cognition that start with the 10 indispensable shared capablenesss ( DH 2004 ) ( Appendix 1 ) , which provide the starting point for instruction, preparation and go oning development of all mental wellness nurses, to accomplish this, which could be argued, travel beyond that needed by the mental wellness nurse in general ( DH 2004, Kettles et al 2008 ) .

One of the accomplishments needed is the ability to keep boundaries within the curative relationship. The issue of boundary care is cardinal to the curative procedure in order to non merely protect the patient but besides to supply protection of the staff ( Dale 2001 ) through the creative activity of curative infinites, therefore maintaining issues of attention and detention apart. Within forensic scenes boundary care is of import in supplying safety for unregulated feelings, leting the patient to show straitening ideas and feelings in an appropriate mode ( Adshead 2007 ) that do non overspill into the wider ward environment.

Nurses working with MDOs have a dynamic relationship that can keep both good remedy advantages every bit good as possible booby traps ( Blumenthall 2010 ) . The fact that some MDOs have offended in terrible ways brings about the demand for staff to stay cognizant of their ain positions and feelings refering patient offenses ( Byrt 2010 ) and to non allow them overspill into the curative relationship where they can impact the quality of attention provided.

The FMHN needs a formidable cognition base in order to present curative intercessions. They must able to advance the rights of patients whilst sing both the wellness attention and legal systems. This includes extended cognition of the Mental Health Act 2007 ( GB 2007 ) court-imposed subdivisions, public protection issues, tribunal proceedings and safeguarding. Along with this FMHNs need to obtain a higher degree of hazard appraisal accomplishments that are related to “ put on the line to self or others in footings of serious force ” ( Woods 2007 ) which allows for the completion and apprehension of assessment tools such as the Historical, Clinical, Risk -20 Assessment. ( HCR-20 ) ( Webster et al 1997 ) .


MDOs come into contact with both the health care and condemnable justness system whose involvements in public safety and single attention vary greatly. This means that the FMHN needs to see both attention and tutelary facets in their interactions with MDOs. However as a caring profession we need to be cognizant that the effort to acquire the balance right between secure and caring environments presents the danger of losing the issue of caring for people in an effectual, safe and holistic mode which should be the primary aim for all forensic mental wellness professionals.

The inclusion of restricted patients under MAPPA has led to better multi-agency direction of the hazard posed by such patients. Both the CPA and MAPPA have a common intent of maximizing public safety and the decrease of serious injury with the underlying rule of assemblage and sharing of information between bureaus in relation to hazard. However they differ in that the CPA focuses on attention and intervention to understate the hazard presented, whilst MAPPA focuses on the multi-agency direction of hazard.

Security within forensic mental wellness units should non entirely trust on physical and procedural facets. Relational security, built upon a sound curative relationship, allows for both supportive and effectual interventional work to happen and is the most of import component in the care of curative advancement. An consciousness of the curative importance of environmental, relational and procedural security is valuable in outlining safe and effectual intervention programs for patients and working within these three protections allows for the recovery procedure to go on.

FMHNs need a big accomplishment and cognition base in which to efficaciously work. The hazard of recidivism within MDOs requires the FMHN to be able to efficaciously assess hazard of force to others as portion of their nursing function. This appears to travel beyond the DH ‘s 10 indispensable shared capablenesss and shows that FMHNs have to cover with a battalion of issues and intercessions in their work with MDOs. Forensic mental wellness nursing differs in that it attempts to both de-stigmatise and de-criminalise the MDO as portion of the recovery procedure which, in this writer ‘s sentiment, should come under the auspice of a forte within mental wellness nursing.

Word Count 3287.

Appendix 1.

Ten Essential Shared Capabilities.

The Ten Essential Shared Capabilities ( ESCs ) model provides the basic edifice blocks for the instruction, preparation and go oning development of all mental wellness workers.



Working in Partnership.

Developing and keeping constructive working relationships with service users, carers, households, co-workers, lay people and wider community webs. Working positively with any tensenesss created by struggles of involvement or aspiration that may originate between the spouses in attention.

Respecting Diversity.

Working in partnership with service users, carers, households and co-workers to supply attention and intercessions that non merely do a positive difference but besides do so in ways that respect and value diverseness including age, race, civilization, disablement, gender, spiritualty and gender.

Rehearsing Ethically

Recognizing the rights and aspirations of service users and their households, admiting power derived functions and understating them whenever possible. Supplying intervention and attention that is accountable to service users and carers within the boundaries prescribed by national ( professional ) , legal and local codifications of ethical pattern.

Challenging Inequality

Addressing the causes and effects of stigma, favoritism, societal inequality and exclusion on service users, carers and mental wellness services. Creating, developing or keeping valued societal functions for people in the communities they come from.

Promoting Recovery.

Working in partnership to supply attention and intervention that enables service users and carers to undertake mental wellness jobs with hope and optimism and to work towards a valued life style within and beyond the bounds of any mental wellness job.

Identifying People ‘s

Needs and Strengths.

Working in partnership to garner information to hold wellness and societal attention demands in the context of the preferable life style and aspirations of service users their households, carers and friends.

Supplying Service User Centred Care.

Negociating accomplishable and meaningful ends ; chiefly from the position of service users and their households. Influencing and seeking the agencies to accomplish these ends and clear uping the duties of the people who will supply any aid that is needed, including consistently measuring results and accomplishments.

Making a Difference

Facilitating entree to and presenting the best quality, evidence-based, values-based wellness and societal attention intercessions to run into the demands and aspirations of service users and their households and carers.

Promoting Safety and Positive Risk Taking.

Empowering the individual to make up one’s mind the degree of hazard they are prepared to take with their wellness and safety. This includes working with the tenseness between advancing safety and positive hazard pickings, including measuring and covering with possible hazards for service users, carers, household members, and the wider public.

Personal Development

and Learning.

Keeping up-to-date with alterations in pattern and take parting in life-long acquisition, personal and professional development for one ‘s ego and co-workers through supervising, assessment and brooding pattern.

Department of Health ( DH ) ( 2004 ) The Ten Essential Shared Capabilities: A Model for the Whole of the Mental Health Workforce. London. Department of Health.

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