Enhancing Compassion in these Unprecedented Times of a Pandemic through a Resilient and Social Support Training Program: Mental Health Forensic Nursing Perspectives

The COVID-19 pandemic has exhausted healthcare providers such that compassion towards patients and families has become harder and harder to evoke. Nursing is at the forefront of patient care and is in a unique position to impact the patient’s experience and outcomes. While nurses tend to have an intrinsic desire to help others, compassion fatigue has the potential to impair that innate propensity. Particularly in mental health forensic settings, compassion fatigue increases the risk for adverse health outcomes in this population. Losing compassionate and empathetic nursing care when providing for patients with mental health problems in forensic settings can hinder the nurse-patient relationship by depersonalizing it [1]. Psychiatric forensic nursing involves complex relations between mental health care and the criminal justice system [2]. Often, forensics nurses care for those who have committed violent crimes. Therefore, the psychiatric forensics nurse must be well-equipped for the emotional challenges that may arise while providing care to psychiatric forensics patients.

The purpose of this paper is two-fold: to gain a comprehensive understanding of how compassion fatigue in the psychiatric mental health forensic nursing (PMHFN) workforce impacts patients’ experience and outcomes and to suggest a resilience and social support training program to enhance compassionate care. Compassion fatigue (CF) results from the emotional strain and stress of exposure to working with those suffering from the consequences of a traumatic and harrowing event. CF may occur due to exposure to one case or cumulative traumatic events, or a perception of a traumatic event [3]. When considering compassion fatigue, we use the analogy of driving on an empty gasoline tank (Figure 1) In order to provide appropriate care for others, we must first care for ourselves by ensuring our “emotional tank” is not empty.

Recent research specific to compassion fatigue as it relates to the forensic nurse is scarce. CF is no respecter of geography or country. CF can occupy any unsuspecting healthcare provider, even the most empathetic and compassionate ones. Understanding CF is appropriate for any nurse who may be placed in traumatic environments and emergent situations. A noteworthy aspect of Berg and colleagues [4] study that data revealed the trauma team members were not as adept at managing work stressors as well as they perceived themselves to be. In addition, the lack of institutional resources for coping was a concern. Although treatment teams are required to attend debriefings after direct exposure to trauma, this may not be the case for those who experience it indirectly and repeatedly, which results in familiarity and indifference to such distressing events. Thus, internal mechanisms to advocate for team coping may be necessary, as well as better staff support systems in general. The lesson that can be applied from this qualitative study is that the nurse is likely to be affected by the traumas they witnessed and vicariously absorbed. Research with and of forensic nurses on the occurrence of posttraumatic stress symptoms and their relationship to professional quality of life in nursing staff at a forensic psychiatric security unit is a valuable one [5]. Moving forward in research, it is important to support healthcare providers in these settings and target research on CF in these underserved areas to provide real, timely, and appropriate effective interventions to combat this costly and intrusive yet preventable phenomenon.

The admission process, inpatient treatment, and aftercare planning all influence the patient’s experience. Positive patient experiences will yield ideal patient outcomes, such as decreased relapse into severe mental illness and decreased risk of reoffending. Throughout their inpatient stay, patient experience leading to positive patient outcomes can be optimized when treatment focuses on working through the factors that led to the offense while emphasizing the protective factors of the patient [6]. Patients are more likely to engage in their treatment and participate in treatment planning when nursing personnel approach them with compassionate care and take measures to provide as much autonomy as possible in the secure psychiatric forensic institution [7]. Furthermore, comprehensive aftercare and treatment guidelines for discharge from the psychiatric forensic setting help to inform the best patient outcomes by decreasing the risk of reoffending [6]. The recommendations inferred from a review of the literature provide psychiatric forensic nurses with tactics to enhance patient experience while in a particularly vulnerable setting for the patient and the nurse.

Narrative content analysis of interviews with psychiatric forensic patients describing their experiences and perspectives of their treatment in a psychiatric forensic setting yielded various themes depicting the importance of their perception of the quality of their care and health outcomes [8]. Patients described the process of being institutionalized into a psychiatric forensic setting as a very chaotic, confusing, and distressing experience [8]. Furthermore, patients described that stigma they perceived from medical personnel regarding crimes they committed had negative effects on their recovery process. One patient felt that some staff lacked an understanding of the influence their mental illness had on their mental status at the time of the committed crime, impeding their ability to recover promptly [8]. The results of this study shed light on how psychiatric forensic patients’ perception of their care, especially when stigmatized, can hinder the recovery process, and lengthen the time spent institutionalized.

Stereotypes are detrimental to healthcare delivery. Specifically, gender as a social construct influences the perception of psychiatric forensic patients [2]. To best understand how psychiatric forensic nurses use gender as a construct when caring for their patients, an ethnographic approach was applied in a recent study [2]. An important result that emerged from this study includes the influence of various preconceived stereotypes by nurses of their patients related to their gender and committing a crime. The emerged theme of “patients as untrustworthy” revealed that psychiatric forensic nurses believe their patients to be dangerous as a result of their mental illness [2]. Furthermore, differences were found between the health-promoting activities put forth by nursing staff between men and women following patterns of gender norms, which affect the nurse-patient relationship [2].

Interviews with forensic psychiatric patients and forensic psychiatric nurses shed light on the significance the offending crime by the psychiatric forensic patient has on the rehabilitation process in a psychiatric forensic hospital [6]. Thematic analysis of interviews demonstrates that the committed offense has an important bearing on the treatment and rehabilitation process of the psychiatric forensic patient [6]. Three main themes emerged to include the factors with a bearing on the offense, working through the offense and the factors leading up to it, and the planning and administration of intervention intended to reduce the likelihood of reoffending [6]. The main factors leading up to the offense occurring are mental illness, maladaptive coping, life stressors, and inadequate treatment [6]. All of these factors can be addressed through integrated mental health treatment for patients at risk for committing crimes. Following admission to psychiatric forensic settings, positive recovery can occur when mental health treatment includes processing the reasons leading up to the offense, emotional processing of the offense, and strengthening the patient’s survival mechanisms. Moreover, discharge from a secure psychiatric forensic setting will yield the best outcomes with a reduced likelihood of reoffending when treatment planning includes collaborative care, life management skills, and further development of the service system.

Treatment plans, including the aftercare to best support patients in the community to live fulfilling lives with a low likelihood of reoffending, must be tailored to the specific needs and supports that pertain to the patient’s case. Committing crime and the factors leading up to the crime play an active role in guiding what the psychosocial needs of the patient will be once reintegrated into society. In conclusion, research supports the necessity of developing standardized treatment models based on the clinical forensic picture for psychiatric forensic settings [6].

Understanding the impact compassionate care has on the patient’s recovery process is essential to the development of evidence-based treatment guidelines for psychiatric forensic patients. Depending on the nature and circumstances of the offending crime, psychosocial support and treatment vary for the psychiatric forensic patient. Psychiatric forensic nurses are in a leadership position to employ their knowledge of primary, secondary, and tertiary prevention [9] and the intersection of the legal and health systems to best support patients along their recovery.

Mental health forensics care aims to reduce criminality while providing mental health care in a secure institution, rather than within the carceral system. Psychiatric forensic nursing care is a complex form of nursing, where nurses provide care to one of the most marginalized populations. Humanity leaves nurses vulnerable to experiencing compassion fatigue and stereotyping patients through social constructs, particularly considering additional pandemic-related demands. Research proves that optimal patient experience and patient outcomes are achieved when psychiatric forensic patients are treated with respect, dignity, and humanized. Therefore, psychiatric forensic nurses will benefit from specialized training that equips them with the necessary tools to care for a highrisk and vulnerable population of patients. Psychiatric forensic nurses must remain resilient while providing compassionate quality care to psychiatric forensic patients in a secure setting that inherently limits autonomy.

Analysis of interviews with nurses working in a forensic psychiatric setting helps in understanding the impact of their experiences working with psychiatric forensic patients [7]. The lack of freedom psychiatric forensic patients perceives to have while institutionalized hinders their willingness to participate in treatment [7]. Nurses further provide insight on ways to increase patient engagement in their psychiatric forensic treatment. A crucial foundation to involving patients in their care is a caring relationship, approaching treatment as a mutual goal between the nurse and patient that they will work towards together, in which compassion fatigue may hinder this process [7]. Increased patient participation occurred when a caring relationship was established where the psychiatric forensic nurse could provide continuous support and encouragement to the patient [7]. Compassionate nursing care allowed patients to believe they have control over their situations, fostering as much autonomy as possible while in a secure setting.

Violence toward nurses, especially forensic nurses, is frequent in forensic mental health hospitals, but the implications of this highrisk environment have not been systematically assessed. One study explored the occurrence of post-traumatic stress symptoms (PTSS) and its relationship to professional quality of life for 100 forensic psychiatric nurses through self-report questionnaires, including the PCL-C and ProQOL, assessing symptoms of post-traumatic stress and professional quality of life distributed among psychiatric nurses in a high security forensic psychiatric unit with a high frequency of violent behavior. During the year of the study, staff experienced 221 incidents of threat and violence [5]. Furthermore, relationships between posttraumatic stress symptoms (PTSS), forensic nursing experience, type of ward and compassion satisfaction, burnout, and CF were assessed [5].

The following literature review helps the reader to gain a thorough understanding of how compassion in the psychiatric forensics nurse affects patient care, the patient experience, and patient outcomes. Specifically, how the patients in a psychiatric forensic setting perceive their treatment, how the specific offenses of psychiatric forensic patients may impact their treatment, how nurses work with patients in their psychiatric forensic treatment, how stereotypes impact nursing care on the psychiatric forensic patient, and the role of compassion in psychiatric forensics nursing.

Compassion is a critical component in nursing care. Nurses working in the psychiatric forensic setting experience unique challenges in the emotional journey of providing compassionate nursing care [1]. Hammerstrom and others [1] conducted thirteen interviews with psychiatric forensic nurses to deepen the understanding of the concept of compassion in caring for patients with mental illness in forensic psychiatric inpatient care settings. A hermeneutic analysis was applied to the transcribed interviews, resulting in one main theme, “being compassionate in forensic psychiatry is an emotional journey,” with three subthemes and subsequent subthemes [1]. The emotional journey of providing compassion to psychiatric forensic patients entails recognizing their suffering and the need for support, responding to the patients suffering, and reacting to one’s vulnerability [1]. To recognize suffering, and the need for support, psychiatric forensic nurses must first understand that suffering is obvious, hidden, and frightening. These realizations help to equip nurses to see through the opaqueness of patient presentations. Moreover, nurses respond to patients suffering by complying with the patient, persuading the patient, and adapting themselves to the patient [1]. The multifaceted care required when caring for forensic psychiatric patients is a delicate balance between meeting the needs of the patient and the provider. One cannot care for their patient’s vulnerability without the acceptance of their own. Therefore, reacting to one’s vulnerability entails becoming persistent, becoming resigned, and feeling shame [1]. Being attuned to one’s vulnerability while simultaneously recognizing and responding to patients’ suffering are not easy feats. Psychiatric forensic nurses meet those who have committed serious crimes while suffering from severe mental illness in their daily work [1]. Psychiatric forensic nurses must do personal work of self-reflection and self-awareness to allow for this degree of compassion to prevail in their nursing work.

While resilience remains, an ambiguous term lacking a clear definition and conceptualization, there is no reservation about the benefits that resilience serves for individuals enduring difficult, stressful, and traumatic situations [10-12]. Implementing creative ways to foster resilience through social support among healthcare workers helps to protect and promote the mental health of those working in the forefront of our healthcare system. Specifically, resilience can be fostered and sustained when active, purposeful interventions are employed. It has been well established through prior research that psychological well-being in healthcare workers, especially amidst a global pandemic, can be preserved through sustaining resilience and social support [12]. Therefore, there stands a defined need for interventions aimed at resilience and social support for our healthcare workers.

Resilience is an attribute that supports health outcomes for those who have been exposed to trauma, environmental hazards, or post-acute experience in abuse [13]. Resilience throughout the life course enhances the ability to recover from adversity, thrive with a sustained purpose, and grow in a world of change, trauma, and chronic illness [14]. Resilience allows individuals to adapt to the wear and tear of living while coping with problems and crises in ways that leave them feeling stronger, and wiser than they would have been if they had not encountered those problems [15,16]. Furthermore, resilience is seen as both an intervention process and an outcome, while others consider resilience a trait or inborn capability, or as a more fluid attribute that comes into play as one equilibrates thinking, feeling, and behaving in an uncompassionate world [17,18].

At the core of resilience is stress responses that are sufficient as well as efficient psychobiological for recovery following stress, however, continuous exposure and severity of stress or an illness diminishes resilience (Sakar & Fletcher, 2014). Social support, such as the modular immersive experience of resilience and social support intervention that activates emotional regulation, reappraisal, and help-seeking behaviors, breaks the cycle of depletion (Karatoreos & McEwen, 2013). Studies have shown resilience and social support go hand and glove because positive emotions arise from belongingness, self-esteem, and helpseeking behaviors. Ingredients of social support prompt broader associative thinking, cognitive reappraisal, and adaptive coping, properties of resilience, thus replenishing resilience, and social support and magnifying the practical effect of the intervention. The potential impact of the intervention in terms of an empirical basis is significant. Adequate resilience to master challenges, coping with stressors through positive emotions and help-seeking behaviors, acceptance of things they have no control over, capacity for cognitive reappraisal, and emotional regulation (Southwick, Bonana, Masten, Panter-Brick, Yehuda, 2014) [19].

Psychiatric forensic nursing is a subspeciality of the specialized nursing practice of forensic nursing. While a shortage of nurses is entering the mental health field, there are few nurses specializing in forensics treatment. Therefore, there remains a need to promote and support nurses to provide care as psychiatric forensic nurses. Psychiatric forensic nursing is a particularly rewarding, yet challenging, subspecialty of nursing where nurses provide psychiatric and emotional care for patients struggling with severe mental illness who have also committed a crime. The inherent vulnerability of nursing care creates a need for the people providing care in these settings to be emotionally resilient in their compassionate approaches. Evidence-based research proves that nurses can positively influence patient experience and patient outcomes when they recognize their vulnerability, as well as the patient’s vulnerability [1]. Additionally, stigma-free nursing care requires the insight to challenge preconceptions or stereotypes of patient populations. Gender constructs can be particularly harmful when influencing the care of the psychiatric forensic nurse [2]. In conclusion, compassion fatigue can directly compromise a nurse’s job performance, causing undesired and negative patient experiences [20]. Further education and training to deepen and strengthen the emotional intelligence and resilience of psychiatric forensic nurses can help to inform best practices in a psychiatric forensic setting.

We suggest developing training on how to mitigate compassion fatigue through resilience and social support training. Resilience is the human regenerative capacity to resist, adapt, recover, or grow from a challenge [14]. It maintains health and function in the face of loss, trauma, disease, or bending without breaking. In resilience, the system’s response to a challenge will fluctuate and show various degrees of responses depending on the severity and length of time of exposure to the challenge with innate psychobiological factors. If successful, it will transform failure into growth and challenges into opportunities but are fungible and expendable. Studies show that the human attribute of resilience comes with positive adaptation as a marker. The construct of resilience is found in theories of motivation, self-advocacy, and self-efficacy.

Further research is warranted to understand the dynamics of compassionate care and efforts in psychiatric forensic care in the United States. Specifically, the research should explore patient perceptions, experiences, and outcomes with their psychiatric forensic care, as well as nurses’ perceptions, experiences, and compassion in providing psychiatric forensic care.

None.

No conflict of interest.

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