In Japan, the Medical Treatment and Supervision Act (MTSA) determines the treatment plan for mentally ill persons who have committed crimes. Under the MTSA, a multidisciplinary team develops a postdischarge treatment plan during the patient's hospital stay. In the supportive interventions for the patient, the role of each professional and the treatment goals are determined. In addition, treatment plans are evaluated and amended during multidisciplinary team meetings and cannot be changed by nurses. The role of forensic community mental health nurses (FCMHNs) includes supervising patients, assessing risk and offense issues, assisting in transition to the community, providing support based on the treatment plan to enhance quality of life, and reducing recidivism. Other roles include collaboration with other professionals in the multidisciplinary team. These include clinicians, public health nurses, pharmacists, psychiatrists, occupational therapists, psychiatric social workers, and rehabilitation coordinators. Notably, the nurses have a dual role of supervising patients and assisting with community integration (Coffey, 2012).

However, forensic nurses face various difficulties because of these role requirements. These include difficulties in assisting patients with communication challenges (Riordan et al., 2005), helping patients reflect on their reasons for offending (Rask & Levander, 2001), difficulties in supporting patients who do not understand the forensic treatment system (Riordan et al., 2005), and difficulties in collaborating with other professionals, such as clinicians, psychiatrists, occupational therapists, and social workers. Furthermore, forensic nurses face difficulties in incorporating nurses' opinions in interprofessional collaboration (Haines et al., 2018). There has been some research investigating the experience of FCMHNs in Japan. Okuda (2019) interviewed Japanese FCMHNs and analyzed the interviews using qualitative research methods. The results showed that the difficulties these nurses encountered while supporting patients treated under the MTSA could be organized into five categories, namely, difficulties in (a) assessing and managing risk potential of forensic service patients, (b) addressing offending behavior, (c) managing the transition of patients, (d) supporting patients to understand the impact of justice processes and applying legislative knowledge to nursing, and (e) promoting the role of FCMHNs within the multidisciplinary team. These difficulties interfered with the fulfillment of the FCMHNs' roles.

Previous studies have examined the concept of support for FCMHNs in Japan, but these do not address all the issues faced by them. Regarding support for nurses working in inpatient settings, the reported studies examined the required skills to work with challenging behavior (Barr et al., 2019). They also examined the therapeutic nurse–patient relationships in forensic mental health patients (Doyle et al., 2017) and risk assessment regarding violence (Dickens, 2015; Gerace & Day, 2014).

In contrast, few studies have focused on assisting and supporting FCMHNs. The existing studies in this area have investigated the utilization of risk profiles, risk assessment plans, and management plans to prevent additional offenses (Kelly et al., 2002), and in addition, helping patients feel a sense of belonging to society, giving back to the community, and improving their self-awareness for rehabilitation (McKenzie & Tarpey, 2019). FCMHNs have had to face difficulties individually without support (Harris et al., 2015).

Strategies to establish professional skills need to be developed for FCMHNs dealing with difficulties (Harris et al., 2015). Thus, this study aimed to identify the strategies reported by Japanese FCMHNs.

Methods

Considering the paucity of research on strategies for the difficulties in forensic community mental health nursing, this study used a descriptive qualitative research design. We used content analysis (Mayring, 2000) to identify strategies for those difficulties.

Participants and Recruitment Method

The participants were required to have extensive experience as FCMHNs to identify the strategies previously mentioned. They were required to meet the following criteria:

1) Experienced in nursing practice at patients' homes. 2) Experienced in attending meetings related to the treatment order. 3) Recommended by the facility manager as having experience dealing with different issues within home nursing. However, the Japanese FCMHNs interviewed by Okuda (2019) were excluded from the participants in this study.

Participants were recruited using the network sampling method. The nurses and psychiatric social workers, working in a facility that provides home-visit nursing care for patients under MTSA, introduced us to the administrators of the nursing care facilities. Facilities that provide home-visit nursing care for patients were selected, including six designated hospital facilities under MTSA, four home nursing departments within psychiatric hospitals, and three home nursing stations operated by medical-related companies. We contacted the administrator of each of the selected facilities by telephone or email, sought the status of home nursing, and explained the purpose of the study. Subsequently, the administrators introduced us to potential participants.

Ethical Considerations

The Ethics Review Committee of Nara Medical University (No. 1977) approved this study. We provided oral and written explanations to prospective participants about the purpose and significance of the study, research methods, advantages and disadvantages of research participation, free will to participate in the research, freedom of withdrawal, protection of personal information, and handling of research results. We obtained written consent from the participants. All ethical requirements were met without problems. Confidentiality was maintained by de-identifying the data and assigning a unique subject number.

Data Collection

Data were collected using one-on-one semistructured interviews using the interview guide (refer to Table 1). During the interview, we provided examples of difficulties in each category and asked what strategies they used to address the suggested difficulties. The interviews were recorded on a digital voice recorder with the consent of the participants. One interview was conducted per participant and each interview lasted 46–99 minutes. The data were collected from October 2018 to May 2019.

TABLE 1 - Interview Guide* 1. What strategies do you use to overcome difficulties in assessing the risk potential of forensic service patients? 2. What strategies do you use to overcome difficulties in addressing offensive behavior? 3. What strategies do you use to overcome difficulties in managing the transition of patients? 4. What strategies do you use to overcome difficulties in supporting patients to understand the impact of justice processes and applying knowledge of legislation to nursing? 5. What strategies do you use to overcome difficulties in promoting the role of the FCMHNs within the multidisciplinary team? *First, we asked if they had any experience with difficult cases. If they answered yes, we then asked what strategies they used.
Analysis

Content analysis is a method of dividing data into analysis units and classifying them into created categories according to research questions (Mayring, 2000). Data were analyzed using the deductive approach of the content analysis of Mayring (2000). Participants were asked about the strategies concerning the five categories of difficulties identified by Okuda (2019). Therefore, a category of strategies was created, namely, strategies related to difficulties in (a) assessing risk potential of forensic service patients, (b) addressing offending behavior, (c) managing the transition of patients, (d) supporting patients to understand the impact of justice processes and applying legislative knowledge to nursing, and (e) promoting the role of the FCMHNs within the multidisciplinary team.

The division of the text into segments is a central element of content analytical procedures (Mayring, 2014). From the data obtained in the interviews, the narrative portion regarding a particular strategy, reported to have been used by the nurses, was extracted and assigned to one of the five categories according to its meaning.

After this, data were analyzed using an inductive approach to the content analysis of Mayring (2000). A code was created from the divided data, using verbatim expressions as much as possible. The codes were made of expressions that could be explained as a particular strategy reported by the FCMHNs, grouping content with the same meaning.

Throughout the data analysis process, the authors had several discussions with a co-investigator and members of a seminar of our graduate school, which included academic experts in qualitative research and nursing graduate students. We ensured that the code focused on the research questions. The coding and category classifications were repeatedly corrected to ensure the reliability of the analysis.

Results

Thirteen nurses consented to participate in the study. There were eight women and five men. Their ages ranged from 39 to 53 years. Their average experience as nurses was 21.6 years; and as psychiatric home nurses, 7.3 years. Their experiences of working as psychiatric home nurses ranged from 1.5 to 20 years. There were nine nursing managers, one certified nurse, and three other nurses. The participants were from three home nursing departments in designated hospital facilities under the MTSA, two home nursing departments in psychiatric hospitals, and three home nursing stations operated by medical companies.

Strategies Related to Difficulties

The categories relating to difficulties (Okuda, 2019) and the strategies for dealing with them can be seen in Supplemental Digital Contents 1–5 (available at https://links.lww.com/JFN/AA90, https://links.lww.com/JFN/A91, https://links.lww.com/JFN/A92, https://links.lww.com/JFN/A93, and https://links.lww.com/JFN/A94, respectively). In each category, some strategies have been explained using the FCMHNs' narratives, shown in quotation marks and italics.

Strategies Related to Difficulties in Assessing and Managing Risk Potential of Forensic Service Patients

To address the difficulty in assessing and managing risk because of patients hiding symptoms and not telling the truth, FCMHNs reported a strategy of “comparing what patients say and actually do, to evaluate the differences” (see Supplemental Digital Content 1, https://links.lww.com/JFN/A90).

“The patient says he takes a bath every day but has a body odor. I am told that the patient cleans every morning, but he sleeps every morning, and the room is not tidied up.” (ID No. 10)

Furthermore, FCMHNs reported that they used a strategy of “building relationships that help gain the trust of patients so that they could be honest.” FCMHNs believed that once a relationship was established with the patient, the patient would be honest with the FCMHNs.

“If they have a problem, I visit the patient’s house and immediately help them with their problems. Patients come to believe ‘nurses are reliable.’ And, the patient eventually tells the truth to the nurse.” (ID No. 8)

Strategies Related to Difficulties in Addressing Offensive Behavior

FCMHNs devised and utilized specific timing, listening styles, and reference documents for illness education to address difficulties in supporting patients to reflect on offenses (see Supplemental Digital Content 2, https://links.lww.com/JFN/A91). Besides, they reported the strategy of “when patients voluntarily talk about offenses, encourage them to reflect on harming others.”

“When a patient talks about harming others in a conversation, I judge that the patient can reflect on his crimes. Because the patient accepts the crime.” (ID No. 6)

FCMHNs reported the strategy of “working with patients in addressing their offending behavior by assessing the risk of offending and assisting in their understanding of their offending behavior.” FCMHNs built patient–supporter relationships by providing patients with assistance that was recognized as support.

“I will suggest: ‘The current state may be a pathological experience.’ On hearing this, patients recognize the nurses as supporters and accept assistance in preventing reoffending.” (ID No. 6)

In addition, FCMHNs considered the symptoms that cause crime to be serious in preventing reoffending and supported patients to better understand them. The strategy was “not focusing solely on offenses but reflecting on them so that patients understand that psychological symptoms were the cause.”

“In the case of an arsonist patient, I ask the patient if he was commanded to perform the arson by somebody in a hallucination. I encourage them to look back on the symptoms of the arson.” (ID No. 10)

Strategies Related to Difficulties in Managing the Transition of Patients

To address the transition period from the hospital to the community, FCMHNs developed provisional plans with graduated overnight leave into the community and gradually enabled the patient to make a plan (see Supplemental Digital Content 3, https://links.lww.com/JFN/A92). To address difficulties with intervening in family relationships when a family prevented a patient's independence, FCMHNs reported the strategy of “If a patient is not able to tell the family, practice with them telling the family to help improve communication skills.”

“I helped the patient with devising how to share what they couldn’t tell their mother. I tried to improve communication by thinking with the patient many times.” (ID No. 1)

To address the difficulty in promoting lonely patients' independence, FCMHNs reported that they used the strategy of “being positively involved with the patient and recognized as a supporter to motivate the patient.” This strategy meant that the nurses affirmed the patients, the patients accepted the nurses, and hence, the patient–nurse relationship was established.

“I think patients are less acknowledged for living by themselves. They like being trusted and receiving affirmation. Nurses encourage patients to be motivated by acknowledging them. By being recognized, patients trust the nurses and develop a good relationship with them.” (ID No. 4)

In addition, to address the difficulty in assisting patients with managing increased activity in their daily lives, FCMHNs reported that they used the strategy of “encouraging patients to look back on their excessive behavior and fatigue and help them become aware of it.”

“When the patients expand their range of action and the action time is longer, I ask them how they are feeling. Are you tired? I encourage them to be aware of their physical condition.” (ID No. 3)

Strategies Related to Difficulties in Supporting Patients to Understand the Impact of Justice Processes and Applying Knowledge of Legislation to Nursing

If the treatment plan created by MTSA's legal framework was insufficient to respond to a patient's condition, FCMHNs thought it was necessary to understand and utilize other available laws (see Supplemental Digital Content 4, https://links.lww.com/JFN/A93). They reported the use of a strategy of “understanding and utilizing other available laws.”

“When the patient's condition deteriorates, and an emergency response is required, I proceed with the hospitalization procedure based on the Mental Health and Welfare Law since MTSA doesn’t have an emergency response.” (ID No. 1)

In addition, FCMHNs reported that they used the strategy of “building relationships involving trust as people who support patients rather than simply monitor them.” FCMHNs believed that simply monitoring the patient would not make the patient accept the treatment plan. Hence, FCMHNs aimed to create relationships that would make patients recognize and trust them as their supporters.

“I think asking the patients only about their weekly living conditions makes them feel like they were merely being monitored. That is why we primarily work with patients to help them with their current life difficulties and help fulfill their wishes. We make it possible for patients to recognize that they are being assisted as well as monitored.” (ID No. 5)

Strategies Related to Difficulties in Promoting the Role of the FCMHNs Within a Multidisciplinary Team

When FCMHNs' opinion is not understood and accepted by other professionals, they reported paraphrasing them in other experts' words for their understanding (see Supplemental Digital Content 5, https://links.lww.com/JFN/A94). Furthermore, they reported the strategy of “articulating that the nurses' opinions were from a perspective different from other professionals as the viewpoint on support varies depending on specialties.” This strategy was to educate other professionals that FCMHNs expressed their views from a different perspective than other professionals.

“Nurses work in the medical field. The rehabilitation coordinator thinks according to the forensic treatment system. In that sense, the focus was different. I tell him about the differences in thinking and explain them to him so that he can understand the nurse’s perspective.” (ID No. 8)

Furthermore, to address the confusion about support because of differences in expertise when visiting other professionals, FCMHNs reported “sharing support objectives with professionals to unify the direction of the support.”

“When visiting with other professionals, we discuss and understand the purpose of each other's support before reaching the patient's home.” (ID No. 4)

Discussion

The central result of this study is that FCMHNs adopted strategies to build a trusting patient–nurse relationship. Trust between patients and nurses is essential in forensic psychiatry (Gildberg et al., 2012). The therapeutic approach to clinical offenses requires a relationship of trust (Askola et al., 2017). Therefore, the strategies in the current study for building trust were consistent with those of Askola et al. (2017) and Gildberg et al. (2012). However, it is difficult for patients and nurses to build positive therapeutic relationships (Askola et al., 2017). As nurses are both service providers and supervisors, they are likely to experience conflicts with patients (Meehan et al., 2006). Some of the strategies for building trust identified in this study could be put to practical use by FCMHNs.

In forensic mental health nursing, standards of practice have been developed in Australia, and they guide the practice (Martin et al., 2012). The senior nurses at the Victorian Institute of Forensic Mental Health wrote these based on their practice with adult forensic service patients and existing literature (Martin et al., 2012). By aligning the strategies identified in this study with the standards of practice (Martin et al., 2012), they prove to be appropriate. Some of these strategies matched the standards of practice, whereas others did not.

Standard 8 refers to patient risk assessment and management (Martin et al., 2012). This standard explains that nurses know the relevant risk assessment tools (Martin et al., 2012). The strategies related to “difficulties in assessing and managing risk potential of forensic service patients” did not include this reference. The described strategy did not use validated risk assessment instruments, which is fundamental for FCMHNs, and it is indeed an issue for Japanese FCMHNs. Meanwhile, patients may become distrustful of supporters and mask their symptoms if nurses monitor them closely (Riordan et al., 2005). FCMHNs reported using the strategy of “building relationships trusted by patients, so that they are honest” and do not hide their symptoms. This strategy was supported because patient–nurse relationships involving trust allow modification of patients' unwanted behavior (Gildberg et al., 2012).

Standard 6 discusses the issue of addressing offenses (Martin et al., 2012). It states that “the forensic mental health nurse demonstrates knowledge of the contribution of mental illness and other factors to the offending behavior” (Martin et al., 2012, p. 11). The strategies related to “difficulties in addressing offensive behavior” included “not focusing solely on offenses but reflecting so that patients can understand that psychological symptoms were the cause.” This strategy was based on the knowledge that mental illness contributes to offenses. However, in Standard 6, nurses need to know that mental illness, including substance use and antisocial traits (Mullen, 2009), can also contribute to offenses (Martin et al., 2012). Furthermore, Standard 11 explains, “There is an association between substance use and offending behavior, especially violence, for people with a mental illness” (Martin et al., 2012, p. 16). Such factors were not included in this strategy. We considered that substance use and antisocial traits had not been identified concerning the strategy because most patients for MTSA in Japan have schizophrenia rather than substance use issues or antisocial traits (Takeda et al., 2020).

Nurses generally prioritize patient surveillance for public safety (Coffey, 2012). Regarding the difficulty around “encouraging patients to reflect on their offenses,” FCMHNs reported that they used “working with patients in addressing their offending behavior by assessing the risk of offending and assisting in their understanding of their offending behavior” to build supportive relationships and prevent reoffending. Building supportive relationships can help patients reflect on their offenses (Askola et al., 2017) and increase their insight into them (Green et al., 2011). Therefore, building supportive relationships can be considered an evidence-based strategy.

The Good Lives Model effectively addresses offending issues for mentally disordered offenders (Barnao, 2013). However, strategies in this category were not relevant to the content of the Good Lives Model (Barnao, 2013). This remains a concern for these professionals.

Standard 9 refers to managing the patient's transition and explains that returning to the community is a stressful event, as well as the importance of a nurse's role in providing nursing care and reducing patient's stress (Martin et al., 2012). The strategies related to the “difficulties in managing the transition of patients” focused on supporting independence in the community, which differed from Standard 9. This stress may lead to unwanted behavior, such as harming others (Martin et al., 2012). Hence, FCMHNs in Japan also need to consider the stress caused by returning to the community.

Meanwhile, to address the difficulty in promoting lonely patients' independence, FCMHNs reported that they used the strategy of “being positively involved with the patient and recognized as a supporter to motivate the patient” for patient's confidence and to build a healthy patient–nurse relationship. This strategy was consistent with the findings of Vincze et al. (2015). When patients feel respected as individuals, they tend to regard nurses as valuable sources of support and, consequently, act more respectfully toward them (Vincze et al., 2015).

Standard 2 explains that nurses apply the knowledge of the legal framework to care and that nurses need to know relevant legislation (Martin et al., 2012). The strategies related to “difficulties in supporting patients to understand the impact of justice processes and applying knowledge of legislation to nursing” included “understanding and utilizing other available laws.” Therefore, this strategy applies to part of Standard 2 (Martin et al., 2012). In addition, FCMHNs reported that they used the strategy of “building relationships involving trust as people who support patients rather than simply monitor them” to overcome the difficulty of supporting patients who were not satisfied with their treatment plans based on MTSA. When nurses were trusted as supporters, they could balance the conflicting dual tasks of monitoring and reducing the risk of reoffending in forensic psychiatry (Pollak et al., 2018). Therefore, this strategy was consistent with the claims of Pollak et al. (2018).

As medicine and forensic law ideas intersect, an opinion from either field was likely to be established as superior depending on the patient's situation (Haines et al., 2018). Thus, during interprofessional collaboration, specific supporters' opinions would be reflected in the decision-making process, whereas others' views would be neglected (Chong et al., 2013). In Japan, FCMHNs' opinions are not understood by other supporters. Therefore, FCMHNs reported that they used “strategies related to difficulties in promoting the role of the FCMHNs within a multidisciplinary team.” The specific strategy among these approaches was to “articulate that the nurses' opinions were from a perspective different from other professionals, as the viewpoint on support varies depending on specialties.” This strategy meant that FCMHNs would give their opinions based on their expertise. Supporters must be familiar with each other's expertise to collaborate with other supporters (Andvig et al., 2014). Martin et al. (2012) explain in Standard 4 that nurses need to understand the roles of criminal justice staff to enable effective professional relationships. Therefore, this strategy was consistent with the opinions of Andvig et al. (2014) and Standard 4 of Martin et al (2012).

Implications for Clinical Forensic Nursing Practice

Participants in this study were FCMHNs who experienced the difficulties identified by Okuda (2019), who emphasized the practical features of this study. Thus, we believe that the findings can inform FCMHNs' practices; that is, the identified strategies can be utilized by FCMHNs experiencing difficulties or who provide home visits with patients. For example, these strategies can assist FCMHNs in developing effective therapeutic relationships and establishing good communication with other professionals. Because this research is based on the findings of Okuda (2019), it is necessary to verify the reliability and validity of the five categories of difficulty. However, these strategies help FCMHNs to reflect on, guide their practice, and research with findings providing reasonably conclusive evidence for, or against, particular nursing interventions.

FCMHNs must be provided with practical education about validated risk assessment tools and their application to practice in collaboration with patients as well as adequate education about evidence-based models.

Limitations

The strategies revealed in this study reflect the respondents' stated attitudes rather than their observed practical nursing interventions and behaviors. Therefore, these strategies have limitations and may not be generalizable to Japanese FCMHNs as a whole. For this reason, an observational study is necessary to investigate the actual behavior of FCMHNs. In addition, the findings are not intended for generalization because it is based on an exploratory qualitative study design. Future studies need to use a quantitative research design to verify whether the strategies based on these categories can resolve the difficulties faced by FCMHNs.

The Japanese FCMHNs still face problems. After the patient is discharged and the treatment in the community begins, suicide or readmission in less than a year often follows (Ando et al., 2014). It is necessary to investigate support strategies according to the patient's postdischarge course.

Conclusion

The findings of this study reported the strategies used to address the difficulties experienced by FCMHNs. Building relationships with patients has been central to the strategy. FCMHNs should not only monitor patients but also provide support. Furthermore, FCMHNs are required to understand the interdisciplinary differences in the competencies and skills of FCMHNs versus other professionals. These strategies will support the role of Japanese FCMHNs.

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