Article

Understanding the Domestic Rupture in Forensic Psychiatric Nursing Practice

Journal of Correctional Health Care 2014, Vol 20(1) 45-58 ª The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1078345813505444 jcx.sagepub.com

Jean Daniel Jacob, PhD, RN1

Abstract The objective of this article is to examine the tensions that exist between care and custody in correctional environments by presenting the (im)possibilities of psychiatric nursing practice within this context. The analysis will be guided by empirical data obtained from a qualitative research conducted in a correctional setting. Semistructured interviews with nurses were conducted and used as the primary source of data for analysis. This article will explore the contextual characteristics of psychiatric nursing practice in correctional settings, describe the alienating effects of this context on nursing practice, theorize nurses’ experience using Festinger’s theory on cognitive dissonance, and, finally, explore how some nurses engage in the reconstruction of their care to counter the effects of working in correctional settings. Keywords alienation, cognitive dissonance, correctional nursing, psychiatric nursing, forensic nursing

Introduction Forensic psychiatric nursing has emerged from a complex association between two distinct disciplinary fields: nursing care and criminology. This association stems from a particular social need, one that seeks to provide society with two fundamental services: a social necessity (protection) and a social good (health care) (Peternelj-Taylor, 2008). Forensic psychiatric nursing is, therefore, the intricate combination of these two services in a hybrid work environment in which psychiatric hospitals and prisons merge (Holmes, 2005; Peternelj-Taylor, 2008). Here ‘‘the mentally ill person as patient intersects with the mentally ill person as criminal’’ (Sekula, Holmes, Zoucha, Desantis, & Olshanky, 2001, p. 55). Nursing practice at this intersection is what makes forensic psychiatry a domain of nursing specialty, its practice in secure environments entailing the creation of unique responsibilities for nurses working in this field (Lynch, 2006). Under the working conditions of the secure environment, nurses are vested with a dual mandate of care and social control (Holmes, 2005). Indeed, ‘‘the forensic nurse is forced to consider illness, crime, morality, treatment, containment and possibly punishment’’ (Burnard, 1992, p. 139). 1

School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada

Corresponding Author: Jean Daniel Jacob, PhD, RN, School of Nursing, Faculty of Health Sciences, University of Ottawa, 451 Smyth Road, Ottawa, Ontario K1H 8M5 Canada. Email: [email protected]

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Understanding the medicolegal management of inmates living with a mental illness, as well as the physical structures that are involved in the management of their recovery, has been and continues to be an empirical and theoretical endeavor for researchers and clinicians. Apart from a small number of critical studies, very little research provides information on forensic settings and their effects on nursing practice. However, a few studies drawn from correctional and psychiatric literature (Cormier, 1975; Goffman, 1990; Lemire, 1990; Lhuilier & Aymard, 1997; Rhodes, 2004) highlight how both patients and those involved in their surveillance (including health care professional and security personnel working within these structures) are two groups whose ‘‘realities’’ are characterized by a traditional separation, one that is often desired and imposed by the institution (Goffman, 1990; Rhodes, 2004). In effect, what Goffman (1990) refers to as ‘‘total institutions’’ (including correctional institutions) tend to establish ‘‘a basic split between a large managed group, conveniently called inmates, and a small supervisory staff. [ . . . ] Social mobility between these two strata is grossly restricted; social distance is typically great and often formally prescribed [by the institution]’’ (Goffman, 1990, p. 7). As a result, ‘‘two different social and cultural worlds develop, jogging alongside each other with points of official contact but little mutual penetration’’ (Goffman, 1990, p. 9). In this case, Goffman’s (1990) description of a divisive institutional culture is important for understanding the implications associated with the human management of patients and its effects on nursing practice. Ensuring mass social control within a closed environment entails inevitable relations of subjugation between staff and patients (Goffman, 1990) and also dictates social interactions as those involved in surveillance are expected to keep a distance from the ‘‘dangerous’’ inpatient population (Holmes, 2005; Jacob & Holmes, 2011). Such a reality reinforces Horwitz’s (1990) position, reiterated by Rhodes (2004), that the effectiveness of social control in corrections is directly proportional to the interpersonal distance that is produced between patients and those who must ensure their surveillance. As a result, forensic psychiatric environments are fertile grounds for the development of new cognitive processes where both patients and staff reinterpret the meaning of social interactions and develop reciprocal polarized representations of each other (Chauvenet, Rostaing, & Orlic, 2008; Lemire, 1990); that is, each grouping comes to understand each other’s worlds in terms of hostile stereotypes (Goffman, 1990) which, in turn, limit therapeutic opportunities. The question then becomes, how can nurses balance the institutional need to ensure social control while maintaining a therapeutic environment congruent with nursing ideals of care? Guided by findings from a qualitative research, this article seeks to examine the tensions that exist between care and custody in correctional environments by presenting the (im)possibilities of psychiatric nursing practice within this context. According to Senior (1998), the exploration and understanding of this issue is of vital importance for nursing because of the unique types of interactions that are shaped by the correctional setting. This author adds: This current situation raises the question of how it may be possible, within a penal establishment, to provide mental health care which is appropriate in both quality and quantity; respectful of an individual’s rights to make informed and free choices about their receipt of care; and aimed specifically at the well-being of the prisoner-patient, not the demands of the institution. (Senior, 1998, p. 235)

The following sections of the article will present a short methodological section, explore the contextual characteristics of psychiatric nursing practice in correctional settings, describe the alienating effects of this context on nursing practice, theorize nurses’ experience using Festinger’s (1957) theory on cognitive dissonance, and, finally, explore how some nurses engage in the reconstruction of their care to counter the effects of working in the correctional setting.

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Methodological Considerations The objective of the research was to explore the dual role associated with being both agents of care and agents of social control in correctional environments. A qualitative design, which incorporates explorative and descriptive attributes, was thought to be an appropriate choice for this research project. Qualitative designs are most useful when researchers seek to explore social phenomena through naturalistic and interpretive inquiry, and they are also useful in their contribution to knowledge development in research domains where few investigations have been undertaken (Guba & Lincoln, 1994; Lincoln & Guba, 2000). Grounded theory was considered to be the research method of choice for this study mainly for its inductive methodological approach with explicative, descriptive, and exploratory properties (Strauss & Corbin, 1998). Institutional review board approvals were obtained prior to the beginning of the research. Following the presentation of the study to members of the correctional staff, convenience sampling was used to recruit participants based on their interest in the study. Voluntary participation in the study included one 60-minute interview with the researcher. Given the highly sensitive nature of research being conducted in correctional environments (Renzetti & Lee, 1993), the protection of participants and the confidentiality of their statements were priorities. Interviews were conducted in private offices and participants were given an alphanumerical code that prevented any form of identification in the dissemination of results. In total, 25 semistructured interviews with nurses were conducted and used as the primary source of data for analysis. In keeping with grounded theory’s inductive principles, data collection and data analysis were conducted simultaneously (constant comparison) in order to remain empirically grounded in the participants’ narratives. Data analysis followed the basic principles of grounded theory (Strauss & Corbin, 1998) as adapted and displayed in a sequential fashion by Paille´ (1994): codification, categorization, integration, conceptualization, and theorization. As such, the codification/categorization of data initially included repeated readings of interview transcripts to explore the possible meaning or significance of the data and to later nuance initial interpretations. Line-by-line readings of the data enabled the production of preliminary codes. These codes were based on the content of each individual statement and its position within the larger contextual structure. Once three transcripts had been analyzed, codes were aggregated into themes; similar codes were identified and placed together. As the research progressed and new information became available through the interview process, themes were explored in subsequent interviews and reevaluated to ensure that they were internally homogenous (combined codes belong together and are coherent) and externally heterogeneous (themes are mutually exclusive). In the attempts to articulate the content of each theme, both independently and in relation to one another, the researcher sought to identify instances in the data that did not necessarily fit the proposed thematic construction. The recognition and accommodation of these variations in the data served as a foundational element in determining the thematic structure and saturation of the data, thus producing an explanation that remains empirically grounded in the participants’ experiences without excluding the fact that it remains a human construction. That is, any conceptualization is value-laden. Although the resulting conceptualization is the result of a rigorous analytic process, it remains influenced by the researcher’s theoretical sensitivity and paradigmatic position (Annels, 1996; Strauss & Corbin, 1998). For this study, the researcher was aware of the threat of imposing preconceived frameworks into the research process (Backman & Kynga¨s, 1999) and, therefore, made considerable efforts to draw the themes from the data and introduce theoretical explanations (like the one presented in this study) once the categories had been produced. A short discussion of the limits of this study is presented at the end of the article. The analytical process, which included the codification of interviews and gradual categorization and integration of emergent concepts, produced four mutually exclusive categories: (1) the penal

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apparatus, (2) deviance and representations, (3) the rhetoric of therapy, and (4) the domestic rupture. This article will focus on the research’s emergent category—the domestic rupture—as it constitutes the main object of analysis and represents the primary conceptual category of the research (point of contact where all other categories converged).

Correctional Environments and Professional Alienation Although forensic settings may be conceptualized as ‘‘healing machines’’ in contemporary society (Foucault, 1995), nurses who work in these environments face several difficulties inherent to the secure environment. The imposition of a distance (both physical and psychological) between nursing staff and inmates for security purposes is one of the major difficulties encountered in correctional settings since ‘‘pastoral’’ and dialogic aspects of psychiatric care require just the opposite; that is, the need to get closer rather than maintain a distance from the patients (Frisch & Frisch, 1998). The data support the fact that it is extremely difficult to establish a therapeutic relationship between nurses and psychiatric inmates as the terms of the organization reinforce the establishment of such a separation (Foucault, 1995; Goffman, 1990). In this analysis, the distance that is created between the nurses’ previously consolidated professional identity and a newly formed correctional persona is of utmost importance in the theorization of nurses’ work experience in the correctional institution. In a tentative fashion, the term alienation will be revived from a discursive vantage point to describe the empirical experience conveyed to us by nurses who participated in this research to emphasize the rupture that takes place at a socioprofessional level. Alienation, or estrangement, may be defined here as a general process ‘‘through which something or somebody becomes (or has become) alien (or strange) to something or somebody else’’ (Ludz, 1973, p. 10). Such a broad definition will enable us to draw parallels between individual experiences and a general process of professional estrangement (rupture) from nursing ideals of care in forensic psychiatric settings. The feeling of estrangement described by nurses participating in this research was, first of all, rooted in the physical and ideological separation between the forensic psychiatric setting and the civic hospital. In effect, the participants expressed a strong feeling of isolation from the ‘‘outside’’ nursing community. Personal experiences depicted the correctional environment as a rigid and impermeable structure that limited nursing activities and resources. The working conditions of forensic psychiatric settings made it difficult to achieve the quality of psychiatric care modeled after the civic hospital. I think a lot of it, we, as nurses over there, made all the decisions regarding patients and our patient care. Now here, we have to work within the guidelines of corrections, you know, so we’re more limited to what we can do as a nurse. (Informant 3) We have to work within the confines of what the [correctional facility] offers. (Informant 5) It’s just like who are we? Second-class citizens. And like I said, the inaccessibility to any of the inservices even though we try, it’s frustrating. (Informant 15)

It was clear to participants that the environment under study did not follow a traditional culture of therapy. The environment was, above all, a correctional environment where therapy is mandated, but where security is emphasized. It is precisely this emphasis on security that made it difficult to maintain the therapeutic culture known to nurses. As these next participants explain, the rigidity of the correctional order made it difficult for nurses to practice within a nursing framework, which, in turn, made it difficult to create a therapeutic environment.

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I guess, there’s more of an emphasis on security here than where I worked before. Even though I worked in a locked unit before. (Informant 4) In our orientation, of course everything was very black and white. ‘‘This is how we do things. We don’t veer. This is how it has to be.’’ But in time that didn’t work. It wasn’t therapeutic at all. Not whatsoever, it was totally out of our realm and foreign and if we had continued on that route it would not be because as nurses we can’t function in that environment. We just simply can’t and we can’t do what we’ve been trained to do. (Informant 1)

According to Goffman (1990), the difficulty forensic psychiatric nurses face in practice results from the underlying institutional mechanisms of the correctional setting. Even with the best intentions (therapeutic rationalization), nurses must realize that the correctional institution will not substitute its own unique culture for each individual’s (staff and patient) presenting culture. The correctional institution, therefore, tends to suppress any previously consolidated identity and imposes its own internal frame of reference, making it difficult for outsiders (such as nurses) to actualize certain behaviors (such as imposing therapeutic/caring imperatives). Following the nurses’ accounts, the feeling of estrangement that is produced demonstrates the negative effects of working in an environment where the contradictory mandates of care and custody exist. The therapeutic perspective put forward by nurses is, in the current context, presented as an unrecognized radical conceptualization of the patient. The primacy of deviance and collective representations of the inmate remain at the forefront of interactions within the correctional system. From a nursing perspective, the individualized approach to treatment plans is juxtaposed with the correctional mentality geared toward the control of masses through the application of strict regulations. Correctional staff had their opinion about how these individuals should be treated, and then we had nurses who had their ideas of how these people should be treated. [ . . . ] Correctional staff had the opinion that these people are serving a sentence for a crime that they’ve committed. Nursing are focused on these people being individuals who have needs, who have difficulties with life, who suffer from mental illness, who have stressors in their life, and who need treatment and assistance in rehabilitating themselves. (Informant 7)

Nurses’ difficulty in imposing the recognition of their patients as patients rather than inmates implies a disjuncture for nurses who work in the correctional setting. Having to practice within the existing organizational structure, and abide by correctional ways of operating, positions nurses in an unfamiliar territory, one that can be extremely destabilizing from a professional standpoint. For example, one participant explains how institutional rules imposed inaction in the face of perceived distress. If this is what you want us to enforce and we enforce it, we need support and back-up. [ . . . ] For example, a patient is saying to you in the middle of the night, ‘‘I’m hungry, I’m starving. Can you give me some crackers? Can you give me some food?’’ and I have to say ‘‘no.’’ That’s tough, that’s hard. So is that ethical to say to somebody when they’re hungry, ‘‘You’re not going to . . . ’’? I don’t know. (Informant 11)

As the research results show, previously defined social representations of the self (being a nurse) are modified by forensic settings. The imported (or domestic) culture inculcated by professional socialization is, to say the least, threatened by an overriding correctional/secure mind-set that impose a distant approach to care (Holmes, 2005; Holmes & Murray, 2011; Jacob, 2012). Caught in a matrix of power relations, nurses are in a position where they must carry out specific tasks imposed by the correctional institution that are symbolically incongruent with the previously embodied sense of self (Holmes, 2005). For nurses working in forensic settings, this process contributes to the deconstruction of their professional frame of reference and substitutes it with institutional roles

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that are highly influenced by correctional/secure imperative (Holmes, 2005; Holmes & Murray, 2011; Jacob & Holmes, 2011; Perron, Holmes, & Hamonet, 2004). According to Bowden (1997), nursing care revolves around person-to-person relationships. These relationships imply a reciprocal emotional commitment in order to give a sense of purpose to the care being provided. In this research, the inability to act on the suffering of the other (referring to the inmate) may further enhance the feeling of professional estrangement. As the nurses described it, this feeling of estrangement reached its epitome when their socioprofessional status incorporated the role of a correctional officer. I’m not nursing. Right now, I’m not. Sometimes I feel like I’m a correctional officer. (Informant 2) People in the community ask me what is my job. I say, ‘‘One third like a nurse, one third like a social worker, one third like a corrections officer.’’ We are the enforcer of the rules on the unit. (Informant 11)

Effects of Cognitive Dissonance According to Maeve (1997), trying to care at a distance while having to ignore the suffering of the other ‘‘leads to an alienation that is not easily overcome’’ (p. 502). In effect, the research participants perceived a gap between the values of the correctional institutions and their own professional standards, which produced a form of estrangement with their original conceptions of their roles as nurses. In light of Festinger’s (1957) theory, the feeling of estrangement expressed by some nursing staff can be explained (theoretically) through the concept of cognitive dissonance. Nurses who work in forensic psychiatry may experience cognitive dissonance as a result of their antagonistic mandates of care and custody. Generally speaking, individuals seek to create coherence between their knowledge, their beliefs, and their actions (Festinger, 1957). Cognitive dissonance occurs when people are given conflicting information or when they are asked to perform certain tasks that conflict with their beliefs or value system. In this case, cognitive dissonance may occur because there is a disjunction between what nurses know, what nurses believe in, and how nurses act (Festinger, 1957). Their professional socialization implies the need to create an alliance with patients during treatment, while the correctional mind-set implies the creation of a distance on account of dangerousness and effective punishment. From a psychological standpoint, cognitive dissonance is unpleasant. Individuals experiencing cognitive dissonance are, therefore, intrinsically motivated to decrease the dissonance and reorganize their thoughts or behaviors to reduce this dissonance (Festinger, 1957). In this research, it is clear that for some nurses, reconceptualizing patients as dangerous individuals somewhat reorganized their thoughts to justify distancing behaviors on their part. Well, they’re manipulators and if they know that they can get staff, you know, to sit on a one-to-one and feel comfortable with them, well, they’re going to do it. (Informant 18) You have to know that they’re going to trick you 5 times out of 10. You have to be prepared for that and know that whether they’re trying to test you or whether they’re trying to get away with something. (Informant 19)

As a result, nurses are constantly in a position of mistrust, their practice being reoriented toward trying to find the ulterior deviant motives that prompt behavior. As these next participants explain, this way of practicing is somewhat foreign to nurses. The fact that patients are conceptualized as being con artists and manipulators inevitably affects the way care is delivered. Nurses are constantly on the lookout for deviant behavior and, in the process, change nursing practices and routines.

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I always have to think to myself in this type of environment, ‘‘Why are they asking me this? What is this leading to? Why are they questioning?’’ I mean this is what they want but what is this down the road going to get to? What is this ultimately going to lead to? (Informant 11)

Dynamic Effects of Mistrust When exploring the concept of therapeutic relationship, descriptors such as congruency, genuineness, and authenticity on the part of the nurses all seem to underline the importance of a seamless and unambiguous interaction (Welch, 2005). However, the genuineness of a relationship is relative since nurse–patient interactions are influenced by personal and professional boundaries (Andra & Street, 1999). Revealing or concealing information about oneself is not a neutral action, and it is not uncommon for patients and nurses in forensic settings to build a relationship edged by mistrust and concealment. Nurses may conceptualize their patients as being dangerous, manipulative, and lying (Holmes & Federman, 2003; Peternelj-Taylor, 2004) and, as a result, fear being outmaneuvered, used, and abused by patients (Mason, Lovell, & Coyle, 2008). Such a situation makes it difficult to engage in a trusting, genuine relationship when nurses feel they have to adapt their responses and interactions to avoid becoming victims of violence or the manipulative behaviors of the patient population. Similarly, forensic patients may not fully trust the nurses because of the dual role they occupy as agents of both care and social control; that is, nurses working in forensic settings may be invited to participate in the application of disciplinary actions and clarify objectives in terms of both sentencing and therapy (Bessin & Lechien, 2004). Thus, from the patient’s perspective, divulging information may be considered more of a risk than a positive action. As the results of this research indicate, the conceptualization of patients as being dangerous justifies the need to keep a safe distance (physically, emotionally, and professionally), thus creating a barrier to the development of a therapeutic/trusting relationship.

Creating a Physical Distance Conceptualizing the patient population as social deviants has repercussions on the way nurses describe their professional experience in this environment. How nurses view their patients shapes the way forensic psychiatric care is conceptualized. Working with the dangerous patient creates a discourse of omnipresent danger that comes to define nurses as vulnerable subjects and, in the process, influences the way nursing practice may be exercised (Jacob, 2012). These next participants explain how their vulnerable position as subjects of the patients’ gaze justifies the need to intensify a physical separation between the two groups. They’re not dumb by any means. They have 24 hours a day to sit and watch and see who does what, when, and where. (Informant 16) You’re never away from the patients. They can see and lip-read. They can tell you what you told them in the report if you’re not careful. They’re pretty good at picking up on who we’re talking about and our body language and so they know already before we even come out what’s been discussed on report. (Informant 15)

Creating an Emotional Distance The deviant representation that nurses make of patients is further incorporated in the way nurses emotionally engage in interactions with patients. The next participant describes the development of a facade or personality that is tailored to work in the correctional environment.

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The biggest change for me is I guess, I mean I’m not the same person as I am at home as I am here. So I come to work and I put on a personality, I put on a [ . . . ] a role that has to work in this environment. (Informant 11)

Seeing the patients as deviants and constantly having to reinforce rules on the units forces the creation of an emotional distance between nurses and patients that, in practice, can result in a loss of empathy and trust. I have changed in the last year and a half. It is not like working with the elderly in the nursing home that I worked in for 20 years. I’ve lost some empathy as a nurse. I really have because I’m so busy, again, enforcing rules and making sure, you know. It’s hard to be a nurse and a correctional officer at the same time and that’s what we’re doing here. (Informant 2) Here, we don’t touch them unless we’re defending ourselves. In the hospital, in psychiatric nursing [ . . . ] If you wanted to show your empathy, you would touch someone on the shoulder or something if it were appropriate. In this facility, you don’t touch anybody for any reason because they’re a different population [ . . . ] If you were showing care and empathy and so forth, you would not do that here. (Informant 5)

Creating a Professional Distance The conceptualizations mentioned above mainly revolved around deviant representations, where patients are seen as dangerous and manipulative. The most common examples given by nurses included difficulties associated with providing care to patients diagnosed with a personality disorder. Clinical directives on how to actually engage in a therapeutic encounter with these patients remain vague and, in some cases, will further encourage the development of a distant professional approach. They’re personality disorders. The worst thing you can do is sit down and talk to them. You’re just feeding into their illness and there’s this stigma that if you spend time with the client, you care too much, you know. And really I still don’t know to this day what I’m supposed to do. Like if they have a problem, I would like to help them through it but I’ve been there and helped them through it and then turned around and got manipulated too. So what do you do? You get to a point where you just sort of . . . I personally hide out in the nursing station. I do meds . . . so that I don’t have to deal with that. (Informant 12)

This participant goes on to explain how socialization by other group members becomes an important variable in the way nurses practice. In this case, a certain type of learning takes place where nurses are encouraged to minimize interactions. ‘‘Just don’t even give them the time of day.’’ I don’t find that very therapeutic. But at the same time, I feel peer pressure to comply with the way they’re doing things because I don’t know another way other than getting manipulated and I see myself doing it to myself all the time. Like I want to spend the time with them and help them out. (Informant 12)

Spending time with patients who are considered difficult or manipulative (often including inmate-patients diagnosed with a personality disorder) may, therefore, be unwelcomed on the units and create mixed messages regarding the way therapy is conceptualized. Very few people will take them in a room and talk one-on-one with them because of this little stigma about spending too much time or being too caring or being too friendly. (Informant 12)

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If nurses chose to ignore these social constructs, then these individuals may be subjected to criticism from other nurses who do not agree with the approach—mainly making reference to a negative representation of a maternal attitude toward the patients. Question: And this is pretty much nurses looking at another nurse and saying ‘‘you’re doing this and’’ . . . Is it ever being said to each other like ‘‘you’re doing this wrong’’? Answer: Oh yes. Everyday. [ . . . ] ‘‘What are you doing? Are you in there breastfeeding or what? [ . . . ]’’ Joking but not joking. (Informant 12)

In other words, nurses who attempt to fill the gap that exists between patients and staff risk being marginalized by their peers.

Resistance in Corrections Some of the nurses referred to the conflicting values of the institutions and their own professional values. For some, this conflict accentuated the discomfort related to their socioprofessional identity. In effect, there is a feeling of estrangement from the professional self (being unable to be genuine). I won’t say I don’t like it here. I like it here because it’s a full-time job and I have my benefits but as far as the works goes, I don’t . . . I’d rather . . . .It’s clear-cut when you work with geriatrics. You just treat them all with respect and you’re allowed to be nice to them and you know they’re not going to screw you over. You know what I mean? It’s more genuine. Here you’re always wondering what the mind games are . . . (Informant 12)

If many nurses reconciled their cognitive dissonance by incorporating the correctional discourse of deviance, other nurses attempted to ‘‘reconstruct’’ their practice to give new meaning to the care they provided. This individual endeavor is congruent with what Foucault calls ‘‘a work on oneself by oneself’’—a type of work that not only inscribes itself in a personal and/or professional ethic but also in an existential aesthetic where technologies of the self are utilized. When utilized as tool for resistance, these technologies of the self may be used in a way to escape ‘‘institutional tyranny’’ (Starkey & McKinlay, 1998). As this next participant explains, nurses must engage in a process of reflection where they can objectively examine their practice—a reflection that is necessary to differentiate the role of nurses in this environment. Like I said, sometimes I work with people that forget that. They make comments or talk about the patients in a negative way and you know that that’s affecting the way they’re dealing with the person or not dealing with the person. It’s unfortunate and I think they have to take a step back sometimes and remember what job they’re doing. They’re not a guard, you know, they’re a nurse. (Informant 6)

To reduce cognitive dissonance (Festinger, 1957; Paicheler, 1997) and slow the progression of the feeling of estrangement, some nurses attempted to reconstruct their care. This careful reconstruction of nursing care and the potential alliance it created with inmate-patients served as a drastic change in the correctional structure by trying to narrow the ‘‘gap’’ ideology. Reconstruction of care took on various forms depending on the nurse, such as bending of rules to diminish their authoritative figure, joking with patients, playing cards with patients, or simply allocating time to patients. In other words, the reconstruction of care refers to the way nurses find other (nontraditional) ways to create an alliance with patients, one that showed their role as nurses rather than correctional officers. This form of alliance was believed to be essential to the establishment of a trusting relationship within the correctional rigidness. This perception of nurses is shared by Porter (1996), who argues

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that the quality of care provided is proportional to the knowledge nurses have of their patients. Indeed, the encounter between the nurse and the patient allows the nurse to talk about the reality and suffering, to alleviate the psychological suffering, and to specify or change interventions (Frisch & Frisch, 1998). From a therapeutic standpoint, this meeting also allows nurses to accumulate information about the patient, to estimate the degree of adherence to the treatment offered, and to increase it as needed by various tactics. However, as seen previously, these practices exist in the margins as they do not necessarily fit well with discourses of dangerousness and deviance presented by correctional settings.

Limitations to the Study As with all research, this study had limitations that imposed restrictions on the results. In this case, limitations could be grouped under two themes: methodological and theoretical.

Methodological The interview process may have created limitations because it excluded from the data collection nurses who did not feel confident regarding issues of confidentiality. Thus, only nurses who felt they would not be jeopardized by the research may have participated. Prospective participants may have seen the interview process and its lack of anonymity as a professional threat, seeing the interviews as being more like an individual investigation (performance evaluation). Also, the interview process itself may have limitations. During face-to-face interactions, participants may have reported what they felt the researcher wanted to hear rather than expressing what they actually felt (social desirability bias) despite attempts by the researcher to limit such a response (e.g., using broad questions that do not suggest a preconceived thematic construction).

Theoretical Although the choice of method (grounded theory) allowed theoretical works to be added as dictated by the data collection, the analysis remains limited to the researcher’s theoretical position. In other words, the results were mediated by the researcher’s values, clinical experiences, and theoretical influences. These elements constitute limitations to the extent that they influenced the interpretation of the data as well as the selection of specific interview excerpts to create the descriptive categories. It is therefore important to note that the results from this research may not reflect the beliefs and experiences of all nursing staff working at the forensic hospital and that the findings represent the researcher’s interpretation.

Implication for Practice and Research As with May (1990), we hope that the theoretical conclusions drawn from inductive research will ultimately benefit other nurses (both researchers and clinicians) in that the results have a direct relation to their respective realities (transferability). For practice, the results from this research highlight the tension that exists when caring practices are governed (in part) by an institution where the objectives differ greatly from those endorsed by the nursing profession. We hope the presentation of these results will enable nurses working in correctional settings to recognize the implications of the environment on their practice since professional standards of care are continuously threatened by the resurgence of a security discourse. The imposition of external frameworks to govern practice may, in this case, prove to be fruitless. Resistance to institutional ways of operating and the development of new practices needs to originate at the clinical level. The results of this research may serve as a tool to problematize current practices rather than offer a prescriptive recipe on clinical ways of operating.

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From a research perspective, there continues to be a need to highlight the core meaning of everyday interactions in correctional environments to help define the professional boundaries of nurses who practice in this field. More importantly, there needs to be ongoing ethical discussions in areas of practice where nurses may be responding to a social need (care to mentally ill offenders) while concurrently being required to fulfill roles congruent with institutional objectives that may not always fit within professional ideals espoused by the profession. In comparing different models of care in forensic nursing (including correctional and/or psychiatric settings), it is clear that the introduction of health care professionals within secure structures causes multiple ethical tensions (Burrow, 1991a, 1991b; Fisher, 1995; Holmes, 2005; Holmes & Murray, 2011; Martin, 2003; Martin & Street, 2003; Mason, 2002; Mason & Mercer, 1998, Mason, Richman, & Mercer, 2006). In the models often found in North America, nurses must assume the dual role of care and custody due to their roles in the management of inmate-patients. This, as explored in this article, highlights the clinical issues associated with the incorporation of a punitive framework into their practice (being a correctional officer). That is, despite the altruistic imperatives of providing much-needed mental health services to inmate-patients within the correctional structure, the reality of the work creates ethical dilemmas. In Europe, however, the need for health care professionals to function as an autonomous body within the correctional structure has influenced the provision of care (Holmes, Perron, Michaud, Montuclard, & Herve´, 2005). In effect, in their conscious attempts to separate care and custody, the health office is physically removed from the inmate wards. Health care providers are considered to be consultants within the correctional structure and, in the process, avoid being implicated in the day-to-day management of inmate-patients. The ethical issue becomes access to care, as health care providers are no longer in constant contact with the population being treated. Researchers need to encourage the sociological understanding of the correctional environment using both traditional and new methodological approaches such as ethnography, autoethnography, comparative case studies, and critical phenomenology to break the status quo and develop a space for practices to be discussed and, possibly, changed.

Final Remarks According to Mason and Mercer (1998), the emergence of forensic psychiatry in the broad field of psychiatry is relatively recent. But the continuing expansion of forensic psychiatry, along with the medicalization of crime (Foucault, 1994), requires professionals to increasingly perform functions related to both social control and care. Goffman (1990) argues that staff who work in ‘‘total institutions,’’ such as correctional environments, are positioned on either side of an ideological divide that appears insurmountable, but this research finds that nurses who do not agree with a strict correctional order attempt to reduce the distance imposed by a careful ‘‘reconstruction’’ of their care. As with other nursing studies conducted in forensic psychiatry (Holmes, 2001; Perron, 2008), it would seem that local practices of resistance exist in clinical practice. In this research, despite an imposed correctional/divisive mind-set, some forensic psychiatric nurses are able (albeit with difficulty) to reconstruct their care in order to somewhat avoid correctional ways of operating and implement nursing processes. Acknowledgment The author thanks Professor Dave Holmes, University Research Chair in Forensic Nursing at the University of Ottawa, for his invaluable assistance in the revision of the manuscript.

Declaration of Conflicting Interests The author disclosed no conflicts of interest with respect to the authorship and/or publication of this article. For information about JCHC’s disclosure policy, please see the Self-Study Exam.

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Funding The author disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Social Science and Humanities Research Council of Canada.

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