Fear and power in forensic psychiatry: Nurse-patient interactions in a secure environment.

This research project was situated at the crossroads of two distinct disciplinary fields: nursing and criminology. It sought not only to situate nursing practice in an extreme environment, but also to explore a professional practice in a context where the probability of nurses becoming victims of interpersonal violence is considered to be high, and where fear becomes a perceptible variable that shapes nurse-patient interactions. The goal was to describe and comprehend how fear as a dynamic process influences nursing interactions with patients. This understanding of the relationship between nurses and patients required that fear, the central concept in this project, be examined within the context of the total institution where nurses are both objects and subjects of power. To accomplish this, a qualitative design, which incorporates explorative and descriptive attributes, was thought to be an appropriate choice for this research project. Given the embryonic state of research regarding fear in forensic psychiatric nursing, and given the nature of the research question, grounded theory was considered to be the research method of choice for this project. Once the methodological groundwork was completed, introduction into the research setting permitted the direct observation of nursing routines as well as the completion of eighteen (18) semi-structured interviews. In keeping with an inductive methodological framework, the analysis of the data produced four mutually exclusive categories: 1.) Context, 2.) Nursing Care, 3.) Fear, and 4.) Othering. The fourth category (Othering) that emerged from the data analysis is the core category, because it is the site of a basic social process, and represents the site where all other categories converge. In brief, the results from this research indicate that the environment in which nurses practice is extremely constraining. Within this highly regimented context, nurses are socialized to incorporate representations of the patient population as being potentially dangerous, and, as a result, distance themselves from idealistic conceptions of care. In effect, the heightened awareness and suspicion that a few patients may evoke creates an environment in which trust is difficult to develop. Moreover, the research results emphasize the implication of fear in nurse-patient interactions and particularly how fear reinforces nurses' need to create a safe environment in order to practice. A constant negotiation between space, bodies and security takes place where nurses are forced to scrutinize their actions (self-discipline) in order to avoid becoming a victim of violence. As a result, security is a factor that needs to be present in order for care to be provided. If the environment is considered to be unsafe, then interventions to secure the space are inevitable. In parallel, participants also described how being able to identify with patients enabled positive (read ''therapeutic'') interventions to take place. Casting the patient in the role of the other (sick and/or vulnerable) enabled the nurse to create a rapport with the patient and to use the relationship in a transformative way (self-governance). However, exposure to the patient's criminal history, as well as the inability to rationalize the patient's behaviours within a sickness model, fostered a negative differentiation process wherein nurse-patient interactions became difficult. Along these lines, demonstrating "potential" was also described as an essential motivator for nurses to invest themselves in therapeutic relationships. The tension generated by (a)potential individuals disrupts the normal nursing process, because nurses experience difficulty in finding meaning in nursing care. Finally, participants also highlighted the presence of gender dynamics and social norms that implicitly and explicitly governed work divisions and the presentation of the self in the forensic psychiatric units. Incorporating the masculine standards (being fearless) was seen as a socially desirable attribute. Overall, this research project suggests that the need for safety (both at the individual and collective levels) will always cast a dark shadow over the ideals of care. When nurses feel threatened, security will take precedent over care