NURSING STRATEGIES FOR WORKING WITH PATIENTS PERCEIVED TO BE CHALLENGING AND DIFFICULT: A DISCOURSE ANALYSIS

Abstract

The forensic mental health nursing milieu presents unique challenges for nursing practice. Nurses contend with dual and conflicting roles of caring and custody. The provision of care is complicated by a mandate to ensure patients adhere to institutional rules and expectations, especially in high security settings. In these settings nurses work with patients they perceive to be challenging – a patient group identified as causing significant negative effects on nurses. Yet strategies for working with this group of patients remains relatively unstudied. The present study explored the strategies nurses employed when working with patients they perceived to be challenging in the high security forensic mental health setting. One-to-one, semi-structured interviews were conducted with seven nurses working in this setting. A discourse analysis methodology was utilized to explore challenging behaviours, nursing strategies, the construction of patient subjectivities by nurses, and power dynamics within the system. Participants identified two distinct groups of patients perceived to be challenging – patients with psychotic disorders and patients with antisocial personality disorder– both of which were deemed to be treatment resistant. Strategies for working with patients focused primarily on risk management and the prevention of disruptive or violent patient behaviours as opposed to therapeutic interventions and recovery. Participants identified the highly restrictive setting and limitations on patient freedoms as significant barriers to working with patients in a therapeutic manner. An analysis of nursing practice unit power dynamics, in particular Foucault’s disciplinary power apparatus, provided a framework for conceptualizing the role of nurses and patients in this setting. Implications for nursing practice and future research are explored.