forensic nursing Presentation

1. forensic nursing Presentation Prepared by: • Mr. Osama Emad. • Mr. Bassim Bakeer. Supervised by: • Dr. Abed Alkareem Radwan.

2. Presentation Objectives • Overview of forensic nursing. • Definition of forensic nursing. • Historical view. • Principles of forensic nursing. • Presentation of mental health need in forensic client. • Specific forensic nursing skills. • Client assessment. • Care planning and intervention

3. Definition of forensic nursing Forensic nursing is the term used when nursing is applied to those people who have come into contact with the criminal justice system due to their offending behaviors.

4. Definition of forensic nursing >>> Forensic nursing relates to the care, treatment and management of those persons who come into contact with the criminal justice system. This includes: high security, medium security, low security hospitals and community setting. It can also include police station, courts and prisons

5. Criminal in the prisons

6. Historical overview • The definition of forensic nursing is continually evolving. In 1997 it was defined as "the application of forensic science combined with the bio-psychological education of the registered nurse, in the scientific investigation, evidence collection and preservation, analysis, prevention and treatment of trauma and/or death related medical-legal issues." (IAFN/ANA, 1997) • The word "forensic" comes from the Latin word ‘forensis’ meaning public debate. The word forensic is used now to describe the debates that occur in courts of law and is even more broadly defined as any matter that is "pertaining to the law." (Evans, Wells, 1999)

7. Historical overview >>> • In 1998 that definition was expanded as follows. "Forensic Nursing is the application of nursing science to public or legal proceedings; the application of the forensic aspects of health care combined with the bio-psychosocial education of the registered nurse in the scientific investigation and treatment of trauma and/or death of victims and perpetrators of abuse, violence, criminal activity and traumatic accidents." (IAFN 1998)

8. Historical overview >>> • "Forensic Nursing is the health care response to (criminal and interpersonal) violence. Identification of crime victims, prevention of further injury or death due to cyclical violence, and early detection of potentially abusive situations are critical steps to stem the effects of human violence. Forensic Nursing provides a continuity of care from the emergency department and/or crime scene to courts of law… and a wider role in the investigation of crime and the legal process that contributes to a safer, healthier society." (IAFN, 1998)

9. Principles of forensic nursing In working with forensic client, five guiding principles are required: partnership, engagement, flexibility, pragmatism and team working.

10. Principles of forensic nursing >>> • Partnership The need for collaboration and negotiation are paramount The nurse should be working towards restoring • Engagement The need for honesty, genuineness and acknowledging the limitation of forensic mental health are crucial. • Flexibility Forensic nursing requires a great deal of the nurse. Dec- isions about care and risk need to be constantly evaluated and re-evaluated, sometimes on second by second basis.

11. Principles of forensic nursing >>> • Pragmatism The focused of nursing is based on the principles of Pragmatism as opposed to the application of theories or models. • Team working This includes working with other professionals and encouraging the whole team to work in partnership with the client. Team working can often involve including the family in assessing and meeting the client’s needs.

12. What do Forensic Nurses actually do? • "Forensic Nurses work with patients who are in some way involved in the criminal justice system. That is, patients who have allegedly committed or who have been convicted of a criminal offence, or alleged victims of crime.

13. What do Forensic Nurses actually do? >>> • "The forensic nurse provides direct services to individual clients, consultation services to nursing, medical and law-related agencies, as well as providing expert court testimony in areas dealing with trauma and/or questioned death investigative processes, adequacy of services delivery and specialized diagnoses of specific conditions as related to nursing." (IAFN 1998)

14. What do Forensic Nurses actually do? >>> • The services provided by forensic nurses can include examination of victims of abuse, sexual assault, violence, trauma or death, with documentation of injuries and findings, both in the written record and photographically. These services can include recognition, collection and preservation of physical evidence, either from the victim, the victim’s clothing or from the scene of the crime, accident or injury. These services can include examination of suspects for injuries, as well as collection of trace evidence and/or exemplars to be used for comparison to those found on the victim or at the scene.

15. What do Forensic Nurses actually do? >>> These services can include the collection of legal blood and urine specimens for alcohol and drug testing. These services can include providing physical and emotional comfort to victims and their family members, as well as help with decisions about organ and tissue donation. These services can include examining medical records for any clues as to cause and manner of death, or to possible liability in civil or criminal proceedings.

16. What do Forensic Nurses actually do? >>> • Services provided by forensic nurses can include assessments of infants, children, teenagers, adults and the elderly; of the mentally well and the mentally ill; of the victim or the offender; of the innocent as well as the convicted and the incarcerated; of the living as well as the dead.

17. Presentations of mental health need in forensic clients Forensic clients are defined by the nature of their offending or their propensity for potential offending and not by the nature of their mental health needs. There is violence. Individuals with psychotic disorders are more likely (than the general population) to behave violently towards other (bernnan et al 2000) and to have criminal convictions for violence (Wallace et al 1998). Consequently, a whole spectrum of mental health needs may be present.

18. Presentations of mental health need in forensic clients >>> Invariably, there are tow factors that the nurse is required to consider: • The mental health needs of the client • The actual or potential offending behavior. This leads to focus on forensic nursing as having one of three potentialities (Rogers & curran 2004) • Assessment, care, intervention and management for actual or potential offending only (e.g. sexual offending)

19. Presentations of mental health need in forensic clients >>> • Assessment, care, intervention and management for mental health needs only (e.g. delusional beliefs) • Assessment, care, intervention and management for both (e.g. violence to other which is driven by delusional beliefs) Ordinary, forensic nursing is focused on the third of these three potentialities, where it is considered that either the offending behavior harms the persons mental health or the person mental health leads to actual or potential offending.

20. Specific forensic nursing skills required Forensic nurse requires a wide range of knowledge and skills. A client may be depressed, suicidal and self-injurious after killing their children while in psychotic state. Another client may have post-traumatic stress disorder (PTSD) after crashing a stolen car they were driving in which their best friend died. Yet another client may be suffering from paranoia and command hallucinations causing behaviors that are difficult to manage in an acute mental health unit.

22. *1* Formulating risk Mental health needs will be the main reason for contact with forensic nurses, there will also be the potentail for, or the occurrence of actual offending behavior. The ability to skilfully formulate risk and the relationship between risk and mental health need develops over time through practice, discussion with client, seeking feedback about working formulation, and discussions with clinical team member and sometimes with family member. Experience in formal methods and procedures of risk assessment are necessary.

23. *2* Awareness and management of self Forensic nursing should also have an ability to remain objective, logical and evidence based. Occasionally a client may challenge our own beliefs and values through the nature of their offence. Asking question about the behavior is more useful : • What were the client’s experience at that time? • What function did the behavior serve? • What were the client’s circumstances at the time?

24. *3* Communication Effective communication is also essential as forensic services rely on the quality of information

25. *4* Collaboration By far the most important skill collaboration. Collaboration is a term that is often used in the wider mental health literature. Collaboration is paramount within forensic settings and requires the therapist to: (work with, as opposed to work against people)

26. Assessment Assessment should cover psychiatric, psychological and social functioning, risk to the individual and others, including previous violence and criminal record, any needs arising from co-morbidity, and personal circumstances including family or other carers, housing financial and occupational status.

27. Assessment goals A comprehensive assessment will result in: • A detailed and precise description of the problems the client is experiencing. • A clear description of the client’s current symptoms • A comprehensive risk assessment • A description of the client’s social, occupational and domestic circumstances • The support available to the client • Family/carer perspectives • An over management care plan • A treatment care plan • Methods for treatment to be evaluated

28. Timing of assessment Frequent assessment is potentially the ‘backbone’ of the forensic nursing. Frequent assessment reduce the likelihood that a client’s mental health needs or risk have increase without the nurse being aware. Usually it is uncommon for the clinical team member to want to assess the client through interview and psychometric measurement within the first week or tow of contact. Pre-admission assessment is cornerstone if many forensic services when admission is likely.

29. Sources of assessment information Assessment information come from a variety of people (client, carer/family, referrer, criminal justice system) and in several ways (letters, verbal reports, case note, court reports). The primary source of information in the assessment setting is patient himself or herself. Secondary source are the assessor, family and carers, case record, court reports, questionnaires and rating scales.

30. Assessing risk Assessing risk is not unilateral procedure, but should involve all the professions and involve a range of assessment that are captured on record. Risk assessment can be categorised as risk to self and risk to others. Known factors associated with a risk of self-injurious behavior include: • Past self –harm attempts ( nature, motivation, dangerousness) • Presence and severity of current depression • Presence of current suicidal ideation (method, ability to complete method, motivation) • Past and current drug or alcohol use • Past and current psychotic symptoms and their nature.

31. Assessing risk >>> Risk to others includes assessment of the following: • Known history of violence • Severity of previous violence • Who the victim of violence were • Thoughts of violence • Previous and current psychotic symptoms and their nature (e.g. paranoia, command hallucinations) • Past and current drug or alcohol use.

32. Observation Observation is a key intervention. Observation has been defined as (standing nursing and midwifery advisory committee 1999,p2) Regarding the patient attentively while minimizing the extent to which they feel under surveillance. Has classified observation into four levels: • General observation • Intermittent observation • Within eyesight • Within arms length

33. Observation forms three functions: First, it’s a process of ongoing assessment of the client. Second, is used as a management procedure. (when a patient is at risk of suicide) Third, observation is used as a potential means of engaging with and developing a relationship with clients.

34. Inter-observer agreement The first is inter-observer agreement. This relates to whether all those involved in observation identify all relevant instances of the behavior or sympotm and record these in the same way. Intra-observer agreement The second factor relates to whether the same observer will reliably produce similar accounts of the same behavior conducted at different times or in different settings.

35. Reactivity A final, and very important, factor to consider is the effect of the observer on patient and their behavior. In some cases the behavior or symptoms that are being assessed may vary according to the presence of the observer. This is known as reactivity. For example, some patients may appear more agitated, anxious and aggressive if they are aware that their behavior is being regularly monitored.

36. Care plans designed to ‘manage’ Care plans that are designed to manage are in effect plans where the nurse has determined situations where the mental health staff take control from the client. A comprehensive care plan to manage problem areas should include: • The specific problem behavior that the plan is designed to manage • Triggers for the problem behavior • Strategies to address such triggers in an attempt to avert their occurrence • Nursing strategies to be employed before the management plan is implemented

37. Care plans designed to ‘manage’ >>> • The specifics of the management plan and roles of each nurse • Strategies to be used with the client in order to assist them to regain control of the problem behavior as soon as is practical • The care that should be provided after the event including discussions with the client in order that all concerned can learn from the event and evaluate the usefulness of the care management plan • Reporting and recording processes

38. Care plans designed to ‘intervene’ A comprehensive care plan to intervene with mental health need should include: • A clear statement of the problem including relevant results from measurement procedures • The treatment goals (preferably specified in the client’s word and not the nurse’s) • The interventions that are to be used • Who is responsible for conducting the interventions • Methods for monitoring progress and the frequency of such monitoring • The family’s or carer’s involvement in such intervention

39. Examples of specific clinical areas A large degree of variation exists between peoples mental health and offending behavior. People commit offences for a variety of reasons, including financial gain, when influenced by peer or group pressure, when under the influence of drugs and or alcohol or as a result of behavioral responses to hearing voices or delusional beliefs.

40. Problem solving strategies A person’s offending behavior may relate to poor problem solving skills related to certain triggers. Problem solving including: • Identifying when problems arise • Generating alternative behaviors/strategies • Identifying steps to reach an alternative goal • Practicing implementing new skills through role-play.

42. Interventions for delusional beliefs Provide clients with a normalizing as opposed to alienating rationale for their experiences. The focus of intervention is to develop a safe and therapeutic relationship whereby the client can view their problems as worthy of examination and exploration.

43. Interventions for command hallucinations There is a known high prevalence of people with command hallucinations in forensic environments, found 38% of patients had command hallucinations. An examination of the research literature shows that: • There is evidence for relationship between violent content command hallucinations and violence. • There is relationship between self-harm command hallucinations and self-harm behavior in inpatient settings. Highly supportive and structured cognitive behavioral strategies are employed to assist the client to examine their perceptions about command hallucinations • Educating people about mental health symptoms can help them consider alternative explanations. • Coping strategy enhancement can be used

44. Thank you