Mid Sweden University

Background: Forensic psychiatry is characterised by compulsory care and long hospital stays, where nurses care for patients with severe mental illness, who often have committed crimes. The main objective is to rehabilitate the patient to once again become a part of society by improving mental health and decreasing the risk of criminal relapse. This is mainly achieved through encounters with the patients. Encountering patients in forensic psychiatry means coming face to face with suffering and the duality of caring, doing what is best for the patient and protecting society.

Aim: The purpose of the study was to obtain a deeper understanding of encounters with patients with mental illness in forensic inpatient care as experienced by nurses.

Method: This licentiate thesis consists of two studies (I, II), both conducted with a qualitative design. A total of 13 nurses working at a forensic psychiatric hospital in Sweden were recruited through a purposive sample to participate in the studies through narrative interviews. Study I was analysed with phenomenological hermeneutics in line with Lindseth and Norbergh (2004) in order to illuminate the lived experience of nurses’ encounters. Study II was a secondary supplementary analysis, which applied hermeneutics in line with Fleming, Gaidys, and Robb (2003) to gain a deeper understanding of nurses’ compassion in forensic psychiatry. The two studies were merged to provide a comprehensive understanding in this licentiate thesis.

Findings: Study I illuminated the meaning of nurses’ lived experiences of encounters with patients with mental illnesses in forensic inpatient care, that is the nurses’ desire to do good despite being confronted with their own emotions as fear, humiliation, and disappointment. Encounters were also occasionally perceived as positive, awakening emotions of compassion, competence, pride, trust, satisfaction, and gratification regarding the patient’s recovery. However, a source of conflict was the struggle between doing what was best for the patient and protecting society. The study comprised of four themes: being frustrated, protecting oneself, being open-minded, and striving for control. Study II aimed to gain a deeper understanding of nurses’ compassion in providing forensic psychiatric inpatient care with three themes: recognising suffering and need for support, responding to patient suffering, and reacting to one’s own vulnerability. Abstracting to a main theme of being compassionate in forensic psychiatry which is described as an emotional journey, an ongoing inner negotiation between own vulnerability and expressions of suffering. This inner negotiation of making sense of patients’ plea and how they were perceived was crucial for determining the development of compassion rather than turning to control and rules as a means to protect oneself.

Discussion: A interpretation of the studies (I, II) revealed two topics, being sensitive and responsive and keeping distance, which were reflected upon against the theoretical framework of Kari Martinsen. The studies showed that nurses faced a variety of encounters that forced them to face their own vulnerability and that trust could reduce power imbalances as well as help deal with societal, man-made constructs. The nurses’ encounters with incomprehensible expressions of suffering also show that nurses need to find a way to make room for “expressions of life”– taking a step back and turning their gaze inwards – in order to regulate their own emotions. This may better equip nurses to encounter patients with compassion and kindness rather than turning to norms and rules to protect themselves and guard their own vulnerability. Rather than distancing themselves from the patients, nurses can instead take a step back to come closer to their patients.

Background: Forensic psychiatric care (FPC) encompasses involuntary care and treatment of those who have committed a crime. On the one hand, FPC is constructed regarding the respect for the individual’s freedom and autonomy, and on the other hand, it is constructed on societal protection. Being a carer in FPC is intertwined with being faced with a distinct ethical dimension of care, as it involves caring for patients who are deprived of their freedom, meaning dealing with the tension of care and custody. Caring means often finding oneself in encounters with individuals with inevitable elements of rules, coercion, threats, and violence. In this complex environment, a caring relationship is to be established, which is intended to be built on trust, as a forensic nurse’s main purpose is creating wellbeing and care, based on the patient’s perspective. It is in the everyday encounters that occur often spontaneously that the carer–patient relationship should be established. It is in these encounters that the carer is given the opportunity to relive suffering. The encounter becomes the focal point where the lifeworlds of the carer and patient meet. Dealing with the duality of FPC and contradictory emotions requires a deeper understanding, which encourages to self reflect the meaning of these encounters and oneself as a carer. Aim: The overarching purpose of the thesis was to obtain a deeper understanding of carers’ lived experience of encounters with patients with mental illness in forensic inpatient care. Method: The thesis consists of four studies (I, II, III, IV) with qualitative design, based on ontological and epistemological reasonings of phenomenology and hermeneutics. The studies illuminated the lived experience and are conducted with phenomenological hermeneutics (I, III), hermeneutics (II), and reflective lifeworld research (IV). Findings: Encounters with patients are characterised with the duality of acting upon the patients’ needs and managing rules and norms stipulated in laws and regulations that govern FPC and societal protection. Encounters in FPC and being a carer is intertwined with being put in a position of power, where the carer also must be allowedviito be fragile and deal with vulnerabilities and not play a role. The encounter means being in a duality and having the insight of the tension of impressions of expressions of suffering, being in the “space in-between”. In this space, there is room and a possibility for carer’s personal growth, and achieving a phenomenological attitude and to truly embrace the patients’ lifeworld. Discussion: A comprehension of the studies (I, II, III, IV) revealed four topics, having trust or feeling distrust, being compassionate or being indifferent, having courage or being afraid, and being genuine or pretending. These were reflected upon against the theoretical framework of K. E. Lögstrup. The duality of FPC and the space in-between that arises in the encounter suggests that the carer is forced to be confronted with existential phenomena that constitutes one’s world. By being active in the space in-between and reflecting upon openness, the carer moves between this duality that exists in the continuum that the opposite phenomenon contains. The space in-between may become a place and a possibility for personal growth by being active and obtaining a phenomenological approach. This is obtained by an openness and consciousness to the impression by self-reflection to convey its meaning. If carers can do this by openness and compliance, there is a possibility for the encounter to become a place for personal growth, that encourages the sovereign utterances of life, and carers may to a greater extent understand themselves as well as patients’ expressions of suffering.

Bakgrund: Rättspsykiatri (FPC) omfattar tvångsvård, behandling och omvårdnad av individer som begått brott. FPC är konstruerat ur avseende för respekten för individens frihet och autonomi, å andra sidan om samhällsskydd. Att vara vårdare i FPC är sammanflätad med att ställas inför en distinkt etisk dimension av vården, eftersom det handlar om att ta hand om patienter som är berövade sin frihet, det vill säga att hantera spänningen mellan omsorg och samhällsskydd. Omsorg innebär ofta att befinna sig i möten med individer med oundvikliga inslag av regler, tvång, hot och våld. I denna komplexa miljö ska en omtänksam relation etableras, som är tänkt att bygga på förtroende, då rättspsykiatrins huvudsakliga syfte är att skapa välbefinnande och utgå från patientens perspektiv. Det är i de vardagliga möten som ofta uppstår spontant, vård- och patientrelationen ska etableras. Det är i dessa möten vårdaren ges möjlighet att lindra lidande. Mötet blir samlingspunkten där vårdarens och patientens livsvärldar kan mötas. Att hantera dualiteten av FPC och motsägelsefulla känslor kräver en djupare förståelse som uppmuntrar till självreflektion angående innebörden av dessa möten och därmed sig själv som vårdare. Syfte: Det övergripande syftet med avhandlingen var att få en djupare förståelse av vårdares levda erfarenhet av mötet med patienter med psykisk ohälsa inom rättspsykiatrisk slutenvård ur vårdarnas perspektiv. Metod: Avhandlingen består av fyra studier (I, II, III, IV) med kvalitativ design, baserad på ontologiska och epistemologiska resonemang inom fenomenologi och hermeneutik. Studierna belyser den levda erfarenheten och är bedriven enligt fenomenologisk hermeneutik (I, III), hermeneutik (II) och reflekterande livsvärldsforskning (IV). Resultat: Mötet med patienter kännetecknas av dualiteten att agera utifrån patienternas behov och hantera regler och normer som fastställs i lagar och förordningar som styr FPC och samhällsskydd. Möten i FPC och att vara vårdare är sammanflätade med att försättas i en maktposition, där vårdgivaren också måste tillåtas vara skör och hantera sin sårbarhet och inte behöva spela enixroll. Mötet innebär att vara i en dualitet och ha insikten om spänningsfältet som uppstår i intrycken av uttryck för lidande, att vara i “mellanrummet”. Det är i mellanrummet, det finns utrymme och möjlighet för vårdarens personliga mognad att växa, genom att vara aktiv och anamma en fenomenologisk attityd som tillåter vårdaren att se patientens livsvärld. Diskussion: En förståelse av studierna (I, II, III, IV) avslöjade fyra områden, att ha tillit eller känna misstro, vara medkännande eller vara likgiltig, ha mod eller vara rädd och vara äkta eller låtsas, som sedermera reflekterades mot den teoretiska ramen av K. E Lögstrup. Dualiteten av FPC och utrymmet däremellan som uppstår i mötet, gör att vårdgivaren tvingas konfronteras med existentiella fenomen som utgör ens livsvärld. Genom att vara aktiv i mellanrummet och reflektera över öppenhet rör sig vårdaren mellan denna dualitet som finns i det kontinuum som de motsatta fenomenen innehåller. Mellanrummet kan möjligen bli en plats för personlig växt genom att vara aktiv och anamma ett fenomenologiskt förhållningssätt. Detta erhålls genom en öppenhet och medvetenhet för intrycket genom självreflektion för att förmedla dess mening. Om vårdare kan göra detta genom öppenhet och följsamhet finns det en möjlighet för mötet att bli en plats för personlig växt, som uppmuntrar de suveräna livsyttringarna och vårdare kan i större utsträckning förstå sig både själva samt patienters uttryck av lidande.