Patient Participation in Inpatient Forensic Psychiatric Care

Factors Influencing Patient Participation in Inpatient Forensic Psychiatric Care – A Mixed-Method Systematic Review 

Valentina Vidaurrazaga Aras; Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Forensic Psychiatry, Sahlgrenska University Hospital, Region V€astra G€otaland, Gothenburg, Sweden; Center for Ethics, Law, and Mental Health (CELAM), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

Eirini Alexiou; Department of Forensic Psychiatry, Sahlgrenska University Hospital, Region V€astra G€otaland, Gothenburg, Sweden; Center for Ethics, Law, and Mental Health (CELAM), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

Thomas Nilsson; Department of Forensic Psychiatry, Sahlgrenska University Hospital, Region V€astra G€otaland, Gothenburg, Sweden; Center for Ethics, Law, and Mental Health (CELAM), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

Axel Wolf; Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Sahlgrenska University Hospital, Department of Anesthesiology and Intensive Care, Gothenburg, Sweden; Institute of Nursing and Health Promotion, Oslo Metropolitan University, Oslo, Norway

Sepideh Olausson; Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Sahlgrenska University Hospital, Department of Anesthesiology and Intensive Care, Gothenburg, Sweden

In this systematic review, we aimed to identify facilitating or hindering factors for patient participation in inpatient forensic psychiatric care. Ten studies, qualitative (n=8), quantitative (n=1), and mixed method (n=1), were included. Findings were categorized using the European standard for minimum requirements for patient involvement in health care. We identified a supportive care relationship as an essential prerequisite for participation. This includes ensuring that patients feel trust, included in discussions, and seen as a person, beyond the index crime but with an understanding for their psychiatric illness. Patients’ transition phases through their illness and the forensic psychiatric care system initially appeared to negatively influence patient participation. However, as they approached their release from forensic psychiatric care, a positive shift in their willingness to participate in their care became evident. Factors such as stigmatization, safeguarding one’s own security, and the coercive forensic psychiatric care environment, were identified as factors significantly hindering patient participation. Moreover, patients perceived participation in care planning as confusing, as they felt excluded from influencing any care-related decisions. Staff, in contrast, were restrictive with information regarding patient care, which had additional negative effects on patients’ understanding of their situation. We conclude that future research is needed to examine clinical routines and strategies that may improve patient participation. Furthermore, more quantitative research is needed to examine the challenges for this specific patient population and environment. Future interventions should focus on improving the quality of relationships, information-sharing, and patient involvement in key elements of forensic psychiatric care. 

Patient participation; person-centered care; forensic nursing; forensic psychiatry; systematic review 

“Forensic psychiatric care (FPC) is specialized psychiatric healthcare provided in secure psychiatric units, often in forensic psychiatric hospitals or specialized wards. Patients within this context present a complex combination of psychiatric disorders, often alongside antisocial and offending behaviors. Their forensic psychiatric care treatment is shaped both by their mental health needs and their involvement with the criminal justice system… A significant increase in the average treatment duration for patients in forensic psychiatric care over the past two decades has been noted in several studies, including the total duration of treatment and the proportion of patients receiving longer treatment periods… Research reports that forensic psychiatric care is characterized by high levels of control, low patient participation, and long inpatient care periods” (p. 440-441). 

“Despite the growing adoption of participatory approaches, such as person-centered care, by organizations like WHO, nursing guidelines and European standards, factors affecting patient participation in forensic psychiatric care have not yet been systematically presented in the literature (European Committee for Standardization, 2020; WHO, 2015). This study aimed to summarize the key factors that influence patient participation in forensic psychiatric care. Ultimately, we hope that this review may support future implementations of patient participation in forensic psychiatric care settings” (p. 441).

“A systematic mixed-method review was conducted, according to the PRISMA methodology…The literature search was conducted by VVA, with assistance from librarians at the University of Gothenburg, Sweden, utilizing three electronic databases: Scopus (which includes PubMed), CINAHL, and PsycINFO… Ten articles in total were selected for the literature review” (p. 441-442). 

“We found that patients’ perceptions of their participation varied, ranging from mistrust and resistance to a desire for collaboration and assuming responsibility. These differing perceptions often aligned with the stage in their forensic psychiatric care journey. Trust has previously been described as a prerequisite for eliciting or sharing narratives” (p. 450).

“Research consistently indicates that patients in forensic psychiatric care who have experienced complex trauma often exhibit disrupted relationships with caregivers and engage in antisocial behavior. Given the pervasive impact of trauma on mental health symptoms, social skills, and aggression patient participation is seemingly affected negatively, and collaborative working methods are hampered. This underscores the importance of trauma-informed care in supporting patients’ ability to actively engage in their care. Trauma-informed care that emphasizes trust, partnership, and phases of recovery, is essential to reinforce patient participation in forensic psychiatric care settings” (p. 450).

“Stigma, described as the feeling of not being treated as fully human, as well as focusing on patients’ negative characteristics, was identified as a factor hindering partnership. Negative and neglective staff actions were reported to reinforce stigma and contribute to patients feeling dehumanized. We found that negative emotions concerning patients affected staff interactions and led to avoidance and misuse of power” (p. 451).

"Low participation seemed to result from an overall absence of organizational routines that supported patient participation in planning, reviewing, and evaluating the care plan and of patient access to documentation. A previous review in general psychiatry found that staff do not involve patients if they consider them incapable. This finding was echoed in this review. Furthermore, the perception of the patient as incapable, together with perceived security reasons, influenced the staff’s motivation to engage in shared decision-making. Information gatekeeping was identified as an important barrier to documentation and shared decision-making” (p. 451).

“Examining patient participation in forensic psychiatric care reveals both challenges and promising practices. A common theme in the reviewed articles is the significance of trust and partnership in fostering patient participation, aligning with person-centered care principles. This highlights the potential benefit of training programs tailored for forensic psychiatric care, equipping staff with skills for therapeutic alliances and safe environments. Prioritizing supportive care relationships and incorporating patient narratives into policies and organizational structures is essential in order to optimize possibilities for participation (Britten et al., 2020). However, it is essential to recognize that narrative elicitation, a key aspect of person-centered care, requires specific skills and strategies. Incorporating tailored forensic psychiatric care staff training programs that equip professionals with these narrative elicitation skills, might promote therapeutic alliances and create safe environments (Naldemirci et al., 2020). This aligns with the European standard for patient involvement in healthcare for continuous quality improvement in healthcare settings; the document emphasizes patient participation in quality indicator design, implementation and evaluation (European Committee for Standardization, 2020). Additionally, embracing trauma-informed care principles (Butler et al., 2011) and actively involving patients in care planning, risk assessments and decision-making can further integrate patients’ perspectives into their treatment (S€oderberg et al., 2023). S€oderberg et al. (2023) study on power imbalance in court hearings suggests a need for more transparency and collaboration in decision-making, mirroring the importance of patient involvement in critical elements of forensic psychiatric care. Implementing these practices at the policy, organizational and staff levels may significantly enhance patient participation, improve care outcomes, and support rehabilitation in the forensic psychiatric care system” (p. 452).

“We followed the guide for systematic literature reviews in nursing authored by Bettany-Saltikov and McSherry (2016). Many studies were excluded due to not being empirical or conducted in an exclusively forensic psychiatric care inpatient setting. We acknowledge that there may be interventions and practices in forensic psychiatric care settings that promote patient participation without explicitly stating this as their primary aim. This review may thus not reflect all aspects of patient participation in inpatient forensic psychiatric care. It is essential to continue examining various practices and interventions to gain a more comprehensive understanding of how patient participation is facilitated and enhanced in these complex healthcare environments. Many studies had methodological limitations, such as small sample sizes or potential selection bias, which should be considered when interpreting our results. The articles generally had high quality-assessment scores, although most lacked ethical considerations, which is particularly noteworthy given that they all concerned coercive care.

Despite these weaknesses, we believe that the knowledge presented here is highly relevant when planning and evaluating models aiming to enhance patient participation in clinical forensic psychiatric care. This review summarizes factors affecting participation, adds knowledge about contextual challenges to improving participation in forensic psychiatric care environments and includes both staff and patient perspectives on participation” (p. 452).