Forensic Mental Health and Professional Boundaries

This article discusses the issue of professional boundaries in forensic mental health nursing practice. It highlights the challenges faced by forensic nurses in maintaining professional boundaries and provides recommendations to improve practice and enhance patient recovery.

Running head: FORENSIC MENTAL HEALTH AND PROFESSIONAL BOUNDARIES 1
Forensic Mental Health and professional Boundaries
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FORENSIC MENTAL HEALTH AND PROFESSIONAL BOUNDARIES 2
Forensic Mental Health and Professional Boundaries
Forensic health nursing practice revolves around working with criminal offenders and
victims of crime. The nursing professionals under this specialty have in-depth knowledge in both
nursing and law. Under the operating environments of the forensic mental nurses, the issue of
professional boundaries and its implications often arise. It should be noted that the offender
populations in most correctional facilities have violated professional boundaries in several cases.
Moreover, most of the patients under forensic nursing care scope have previous personal and
bodily boundary integrities breached significantly (Bressington et al., 2011). As such, patients
under forensic settings have implied issues with adhering to professional boundary practice
expectations. One of the standards of FMHN in practice is the maintenance of ethical standards.
The ethical standards require that all clients should be respected and accorded their human
dignity irrespective of their history or mental health status. The respect to clients also
encompasses keeping all their data and information confidential. The consent of the clients
should always be sought and any aspect of dilemma solved through the professional code of
conduct.
Notably, most of the clients in forensic mental healthcare settings have disturbing
backgrounds and get locked in secure institutions. The entrapment of the individuals within the
criminal justice system deprives them of their freedom and restricting their movements much.
These changes in the level of freedom pose difficulties to the forensic nurses in maintaining
effective professional boundaries (Adshead, 2012). Research notes that there are serious issues
related to gender that emerge during forensic practice. Complex gender issue comes to play

FORENSIC MENTAL HEALTH AND PROFESSIONAL BOUNDARIES 3
concerning boundary violations. Most of the male clients would easily collaborate with female
forensic mental nurses in practice. On the other contrary, female patients would want to associate
and work with male forensic nurse professionals. Survey through the media publications reveal
many cases of female forensic staffs engaging in sexual affairs with their clients placed in secure
services.
Vulnerability and risk are strictly related concepts in forensic nursing practice that may
be difficult to distinguish. The concepts interplay due to the circumstances associated with the
clients of forensic nurses, especially in secure settings. Given the powerlessness and desperation
of the patients', they are more susceptible to abuse. It can be very easy for forensic mental nurses
to take advantage of their situations and violate professional boundaries (Askola et al., 2017). On
the other hand, the clients in correctional facilities have histories of violent behavior. As such,
they may easily abuse other people and violate professional boundaries. The major challenge is
to prove whether a professional violation was due to vulnerability or due to risk. Operating
effectively under such combinations can be a challenge to the forensic mental health nurses.
The diversity of clients presenting to forensic mental health nurses poses difficulties in
the maintenance of professional boundary. The clients at the secure facilities have been confined
for committing small to highly sophisticated offenses. Most of the offenses are a result of
complex mental disorientations that affect the personalities and behavior of the clients (Gildberg,
Elverdam & Hounsgaard, 2010). The forensic mental health nurse in the consolidation of their
skills carefully assesses all the diverse and varied circumstances of the clients to arrive at
conclusions. In the process of gaining the trust and relationships to collect the right information,
they may get carried away by the situations of the clients to breach professional boundaries

FORENSIC MENTAL HEALTH AND PROFESSIONAL BOUNDARIES 4
(Drennan & Wooldridge, 2014). These practice dynamics when handling forensic clients poses
serious challenges in relation to professional boundaries.
Consequently, striking a balance between meeting the goals of the law enforcement
demands and respecting the confidentiality of the patients may affect the nurse’s perspective of
the professional boundary. Despite the complex nature of establishing therapeutic and
professional boundaries for the forensic mental health nurses, there is no adequate evidence in
the literature to support the forensic nurses in their daily practice. There is no defined guidance
necessary to direct the forensic nurses on their salient roles and duties in relation to practice. The
realities of daily practice in the secure environments include balancing of situations, experiences
of confronting diverse behavioral manifestations, and working within the brinks of professional
boundaries (Gildberg et al., 2012).
The relevance of Professional Boundaries to Forensic Mental Health Nursing
Knowledge of professional boundaries is critical to forensic mental health nurses while
practicing. The patients undergoing forensic treatment programs experience stigmatization from
two fronts, being mentally ill and for engaging in criminal activities. Their detachment from
families and friends associated with spending time at the secure facilities makes their treatment
process complex. This is because they engage with a multi-professional team with different
objectives (Drennan & Alred, 2013). Under such situations, the role of the staff towards the
recovery of the patients is key. Central to the recovery of the patients is a long time defining the
engagement between the staff and the nurse. The long exposure poses a major challenge to the
establishment of professional boundaries (Mann, Matias & Allen, 2014). Hence, acquiring

FORENSIC MENTAL HEALTH AND PROFESSIONAL BOUNDARIES 5
knowledge about the professional boundaries in relation to forensic mental health nursing
prepares the nurses for the complex operating environment in forensic settings.
Furthermore, within the treatment environment for forensic nurses, it is noted that the
development of therapeutic relationships with the patients is critical towards the prediction of the
treatment process, patient satisfaction, and retention. However, most of the forensic nurses are
not experienced in the development and sustenance of therapeutic relationships. Literature
reveals that there are two perspectives of the staffs and nurses within the forensic treatment
programs. These two perceptions relate to pertanalistic and behavior transformation care as well
as relational and personal quality care (Gildberg, Elverdam & Hounsgaard, 2010). Under the
paternalistic approach, the forensic nurses would be engaged in a process whereby they set the
rules for the patients, distinguish limits, observe, and provide support to clients during the
treatment program. On the other hand, the relational aspect emphasizes on the use of chatting,
social activity engagements, and personal quality in seeking treatment and behavioral change of
patients. All the perceptions require a certain amount of interaction with patients that would
progress on a daily basis (Barnao, Ward & Casey, 2015). The gradual progression of interactions
between the staff and the patients require in-depth knowledge and understanding of professional
boundaries to realize positive outcomes of treatment.
In addition, developments of relationships are essential for the recovery of the patients in
forensic settings. The staff members with forensic environments have dual roles to play that
include custodial and relational care responsibilities. As such, understanding the establishment of
professional boundaries would be crucial towards understanding how the forensic staffs navigate
through their relationships with patients to support and enhance the recovery motives. The staffs

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undergo behavioral transformation to match that of their patients at times (Clarke et al., 2016).
The changes are essential to allow the patients to identify with the forensic nurse professional as
part of the therapeutic process. The practice process of the forensic nurses also involves
deconstruction of the perceptions and stigma associated with working with offenders. It is
important to view the patients in forensic care as people rather than as offenders during the
treatment programs (Mezey et al., 2010). The complex situations necessitate the development of
emotional attachments as a factor of the frequency of interactions between the patient and the
staffs. These situations require that nurses possess good skills in relation to professional
boundaries for safe and quality working relationship and hence successful recovery process.
Recommendations to Forensic Mental Nursing Practice
Given the complexity of the relationships developed in the forensic mental health system,
some recommendations are required to improve practice and enhance the recovery of the patients
while maintaining professional boundaries. One way to sustain professional boundaries towards
successful recovery is through the use of activities. The activities influence the engagements
between the forensic nurses and the patients beyond the medication administration level and
official interactions. It changes the perceptions of the patients to forensic nurses providing a
favorable environment to influence social interactions. Moreover, the activities reduce any
inhibitions that may be inherent in forensic practice like the power differentials that could affect
the establishment of professional boundaries effectively.
Secondly, environmental changes would enhance the establishment and sustenance of
professional boundaries during therapy. The tough and strict environment associated with
correctional facilities set a very serious mood and influence the attitude of the patients during

FORENSIC MENTAL HEALTH AND PROFESSIONAL BOUNDARIES 7
care. It also acts to bold the inherent power differentials that exist between the forensic patients
and the nursing staff. When the environment is made to mimic the home setting, it relaxes both
the staff member and the patient to facilitate the development of a healthy therapeutic
relationship that enhances the recovery process.
As noted above, forensic mental health practice is a complex setting for nurses. The
complexity of professional service delivery is due to the nature of the clients. The clients are
either victims of criminal activities or are criminals themselves. Establishment and sustenance of
professional boundaries is a challenge and affected by aspects of ethical practice standards. It is
noted that there is no adequate literature on the aspect of forensic mental health practice
dynamics and professional boundaries. It is recommended that more activities and transformation
of the forensic setting can influence the establishment and sustenance of professional boundaries.

FORENSIC MENTAL HEALTH AND PROFESSIONAL BOUNDARIES 8
References
Adshead, G. (2012). What the eye doesn’t see: Relationships, boundaries and forensic mental
health. Professional and therapeutic boundaries in forensic mental health practice, 13-
35.
Askola, R., Nikkonen, M., Putkonen, H., Kylmä, J., & Louheranta, O. (2017). The Therapeutic
Approach to a Patient's Criminal Offense in a Forensic Mental Health Nurse–Patient
Relationship—The Nurses’ Perspectives. Perspectives in psychiatric care, 53(3), 164-
174.
Barnao, M., Ward, T., & Casey, S. (2015). Looking beyond the illness: Forensic service users’
perceptions of rehabilitation. Journal of interpersonal violence, 30(6), 1025-1045.
Bressington, D., Stewart, B., Beer, D., & MacInnes, D. (2011). Levels of service user satisfaction
in secure settings–A survey of the association between perceived social climate,
perceived therapeutic relationship and satisfaction with forensic services. International
journal of nursing studies, 48(11), 1349-1356.
Clarke, C., Lumbard, D., Sambrook, S., & Kerr, K. (2016). What does recovery mean to a
forensic mental health patient? A systematic review and narrative synthesis of the
qualitative literature. The Journal of Forensic Psychiatry & Psychology, 27(1), 38-54.
Drennan, G., & Alred, D. (2013). Recovery in forensic mental health settings: From alienation to
integration. In Secure recovery (pp. 21-42). Willan.

FORENSIC MENTAL HEALTH AND PROFESSIONAL BOUNDARIES 9
Drennan, G., & Wooldridge, J. (2014). 10. Making Recovery a Reality in Forensic Settings.
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(2), 103-113.
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(4), 359-368.
Mann, B., Matias, E., & Allen, J. (2014). Recovery in forensic services: facing the
challenge. Advances in psychiatric treatment, 20(2), 125-131.
Mezey, G. C., Kavuma, M., Turton, P., Demetriou, A., & Wright, C. (2010). Perceptions,
experiences and meanings of recovery in forensic psychiatric patients. The Journal of
Forensic Psychiatry & Psychology, 21(5), 683-696.