Facilitating a safe and caring atmosphere in everyday life in forensic mental health wards - a qualitative study

ABSTRACT

Purpose

To explore healthcare professionals’ experiences with facilitating a safe and caring atmosphere in patients’ everyday lives in forensic mental health wards.

Methods

This qualitative study employed interviews with 16 healthcare professionals working shifts in two forensic mental healthcare wards in Norway. Data were analysed using phenomenological hermeneutic analysis.

Results

The findings are presented in terms of two themes. The first theme is “Creating a calming atmosphere” and includes the subthemes “Creating caring surroundings with safety, comfort and trust” and “Balancing everyday life activities”. The second theme is “Facilitating risk assessments and care” and includes the subthemes “Acting as a team”, “Becoming aware of the meaning in signs” and “Becoming aware of vulnerability and the window of tolerance”.

Conclusions

Involvement in patients’ history and lived lives is important both for understanding general social behaviour as well as for assessing signs, symptoms, and changes in patients’ conditions; furthermore, it provides valuable information that allows healthcare professionals to become aware of the underlying meanings in signs, which can facilitate examinations and treatment. Acting as a team is essential to solve issues in a calm and safe way when signs of violence occur. In addition, our participants highlighted the need to be aware of individual patients’ vulnerability and windows of tolerance to obtain a deeper understanding of patients’ lived lives as a whole in the context of providing therapy and care to patients.

KEYWORDS:

• Encounters
• Forensic psychiatry
• Healthcare professionals
• Mental disorders
• Qualitative research

Introduction

Forensic psychiatry is a speciality within the mental healthcare system and emphasizes providing care to patients with severe mental disorders with a focus on creating a safe and secure environment (Seppänen et al., 2018; Söderberg et al., 2022; Tomlin et al., 2018). Patients in forensic psychiatry wards are vulnerable and exposed because they suffer from severe mental disorders, have committed serious crimes and are being cared for against their will in a secure hospital environments with a high level of security (Cartwright et al., 2022; Hörberg, 2018).

Healthcare professionals in forensic psychiatric settings are expected to balance patients’ desires, needs for care and safety routines and constraints in everyday life activities (Söderberg et al., 2022). Marklund et al. (2020) suggest that more patient participation may give meaning and empowerment to patients in the context of a meagre existence and restricted life in forensic care wards. The high levels of security and restrictiveness within forensic care challenge healthcare professionals to find place for normality and the provision of individual care for patients in everyday life in the ward (Lawrence et al., 2022; Söderberg et al., 2022; Tomlin et al., 2018). Individualized care that empowers patients is recommended and aims to rehabilitate patients after severe mental illnesses caused by severe childhood victimization and losses; to give patients space for future hope, a meaningful life, and connectedness to others; and to allow patients to develop skills that can decrease the risk of inpatient violence (Senneseth et al., 2021). Patients’ mental health conditions and the corresponding risk of violence require restrictions and security routines in forensic care units (Fosse et al., 2021; Roaldset et al., 2017). Patients’ desires and need for care as well as staff members’ attempts to constrain patients based on safety and considerations of policies in the criminal justice system represent a duality that challenges healthcare professionals’ attitudes towards and relation to patients in forensic care units (Marklund et al., 2020; Selvin et al., 2016; Söderberg et al., 2022).

Forensic care as a speciality is responsible for balancing control and risk assessments with individual therapy and care (Söderberg et al., 2022). Violence is a notable concern for healthcare professionals who work in forensic psychiatry (Anderson & Jenson, 2019), and a variety of violence risk assessment screening tools have been developed (Anderson & Jenson, 2019; Fazel & Wolf, 2018; Rytterström et al., 2021; Whiting et al., 2021). Risk assessment tools may offer opportunities to acknowledge the patient as a person and establish a trusting relationship that can be used to strengthen hope and empower caring perspectives in interprofessional teamwork (Nyman et al., 2020). Due to the increasing number of assessment tools, there is a continuous and ongoing need to evaluate the quality and underlying evidential base of particular risk assessment tools to support the choice of a tool for practical use (Douglas et al., 2017; Fazel & Wolf, 2018).

Rytterström et al. (2021) highlight the influence that healthcare professionals have on patients’ care needs and future recovery, and these authors argue that everyday life activities are not trivial but rather represent important parts of psychiatric therapy. Furthermore, healthcare professionals and patient interactions play a central role both as antecedents of aggressive episodes and as measures to prevent their escalation (Myklebust & Bjørkly, 2019; Nyman et al., 2020).

To the best of our knowledge, few previous studies have examined in depth how healthcare professionals secure a safe environment and meet patients’ need for care in forensic psychiatric wards. Consequently, the aim of this study is to explore healthcare professionals’ experiences with facilitating a safe and caring atmosphere in patients’ everyday lives in forensic mental health wards.

Materials and methods

Design

A phenomenological hermeneutic design inspired by Ricoeur (1976) was adopted and further adjusted by Lindseth and Norberg (2022). This design is suitable for exploring healthcare professionals’ lived experiences and the essential meanings associated with facilitating a safe and caring atmosphere in patients’ everyday lives in forensic mental health through textual interpretation. This study conforms to the Standards for Reporting Qualitative Research (SRQR) checklist (O’Brien et al., 2014).

Procedure and setting

Approval for conducting the interviews was obtained by the head of the clinic. Participants were informed and recruited via email and phone calls, and all interviews were conducted with participants’ consent.

The clinic is a regional security ward with national admission and is classified as having a high security level under the Mental Health Act and The Penal Code. The clinic is staffed by a minimum of one healthcare professional per patient at all times. The patients were all men aged 28–63 years, and most patients were diagnosed with schizophrenia and personality disorders; the patients were undergoing involuntary inpatient forensic psychiatric care due to having committed criminal acts. The entrance halls to the wards had permanently closed doors and metal detectors, and all staff carried keys and alarms. Patients’ single rooms had the special alarm systems and equipment that characterize units with the highest level of security. The wards were staffed by psychiatrists and psychologists as heads of the department as well as multidisciplinary teams with different healthcare professionals working 24-hour shifts.

Participants and data collection

The sixteen healthcare professionals were recruited via purposeful sampling from two different high security forensic care wards in a university hospital in Norway from January 2013 to July 2013. Purposeful sampling was chosen to gain varied and rich data regarding the healthcare professionals’ experiences (Polit & Beck, 2021). The inclusion criteria in the study were healthcare professionals with a minimum of two years of experience in forensic mental wards who were working shifts caring for forensic care patients. The participants consisted of 10 males and 6 females; eight participants had a bachelor’s degree in nursing, two in occupational therapy, three in social education and three in social work and welfare. The participants all had more than four years of experience working in the wards; in addition, five who agreed to participate had experience working in other high-security forensic care hospitals.

In-depth interviews were conducted, recorded, and transcribed verbatim by the first author (SAS). The interviews were conducted in meeting rooms located outside the ward to ensure the participants’ anonymity and lasted between 60–120 minutes each.

To facilitate the healthcare professionals’ recollection of emotions and thoughts, the interview took a narrative form, and the following opening question was used: “Could you tell me what you do in everyday activities on the ward to create a calming and caring atmosphere?” (Lindseth & Norberg, 2022). Follow-up questions, including “Can you please explain … ?” and “Can you please describe…?”, were asked for purposes of clarification and avoiding misunderstandings; these questions enabled participants to put into words what, in their opinion, was the plot of their stories concerning their lived experience and to participate in a process of telling and being asked to retell their experiences using concrete, intelligible, meaningful, loaded words (Lindseth & Norberg, 2022)

Data analysis

The transcribed interviews were interpreted using the phenomenological-hermeneutic method of analysis developed by Lindseth and Norberg (2022), which consisted of three methodological steps: a naïve reading, a structural analysis and a comprehensive understanding.

The first step involved a naïve reading; each interview was read several times, which enabled the first author (SAS) and the last author (MEK) to obtain an impression of the whole text and formulate an immediate understanding of the text. In the subsequent step, the text was separated into meaning units, which were later condensed and reflected upon to form subthemes and themes (Table I). Structural analysis is a more precise component of the analysis, and multiple structural analyses may be conducted to disclose various meanings. The researchers (SAS and MEK) returned to the original text several times to ensure that every subtheme in the text could be identified and, conversely, that all relevant text was reflected in the themes. The comprehensive understanding was formed as part of the final step, which involved arriving at an understanding of the text as a whole and elucidating the expressed meaning of the participants’ lifeworlds. This step is based on an interpretation of the naïve understanding and the findings of the structural analysis and focuses on the research question, the context of the study and the relevant literature (Lindseth & Norberg, 2022).

Table I. Overview of the themes and subthemes.

Theme	Subtheme
Creating a calming atmosphere	Creating caring surroundings with safety, comfort and trust Balancing everyday life activities
Facilitating risk assessments and care	Acting as a team Becoming aware of the meaning in signs Becoming aware of vulnerability and the window of tolerance

Ethics

The study was conducted in accordance with the principles outlined in the World Medical Association Declaration of Helsinki (World Medical Association, 2013). The Norwegian Center for Research Data (reference number 27,841) and the research ethics committee at the hospital approved the study. All participants received written as well as oral information regarding the study aims in advance and were informed that participation in the study was voluntary. Written informed consent to participate was collected from all participants before the interviews.

Results

Naïve understanding

Healthcare professionals’ need to ensure a balance between creating a safe and calming atmosphere for staff and patients and caring for the patients’ serious mental illnesses and reaction repertoire in a manner that expresses confidence, dignity, integrity and the ability to meet individual needs in therapy trigger a dualism in healthcare professionals and cause them to feel vulnerable and exposed in everyday life at the ward. A strong need for support and protection entail that predictability and security are necessary with respect to the ability to put knowledge into practice and to take charge of and be responsible for the entire patient group and the situations of individual patients in a caring manner. Proximity to the patients’ lives and experiences is present in interaction with the patients and in the healthcare professionals’ responsibility for caring for the patients and remaining conscious of risk assessments regarding the possibility of danger and recurrence becomes a difficult balancing act. Acute and unforeseen situations stress and affect everyone involved. Risks related to one’s own life and exposure were described by the healthcare professionals who work with problems of violence as related to a need for reassurance through regularly training safety procedures and support from others who are present, competent and ready to re-establish safety by securing and calming patients and staff.

Structural analyses

The structural analysis resulted in two themes. The first theme is “Creating a calming atmosphere” and includes the subthemes “Creating caring surroundings with safety, comfort and trust” and “Balancing everyday life activities”. The second theme is “Facilitating risk assessments and care” and includes the subthemes “Acting as a team”, “Becoming aware of the meaning in signs” and “Becoming aware of vulnerability and the window of tolerance”.

These themes and subthemes are illuminated in the following text by quotations from healthcare professionals involved in this study; the healthcare professionals are identified using numbers (e.g., Participants 1–16)

Creating a calming atmosphere

The theme of creating a calming atmosphere describes how healthcare professionals, by providing a friendly and caring presence, seek to instil faith, comfort and predictability in vulnerable patients to help them relax and become amenable to therapy.

Creating caring surroundings with safety, comfort and trust

In this subtheme, healthcare professionals described the ways in which they managed to create a calming and caring atmosphere, which led to a lower risk of stress and anxiety and enabled patients to engage in everyday activities more easily. This subtheme involves the ability to exhibit a calming presence via comforting behaviour and avoid provoking conversations and activities that trigger trauma with the aim of helping patients experience peace and relaxation and become receptive to therapy. Healthcare professionals rarely need to cope with aggressive episodes because the healthcare professionals as a team are so responsive to individual patients’ flashback experiences, and they address and respond kindly to every sign of illness immediately in specific situations.

Being attentively present in everyday activities was described in terms of being extraordinarily predictive and trustworthy, behaving politely and kindly towards patients and colleagues in all situations and making patients feel that the healthcare professionals worked as a team and kept an eye on everything:

Our patients have severe relationship injuries and trauma experiences that make them extraordinarily vulnerable and emotionally fragile. They isolate, have negative expectations and focus on their control of their feelings. You can say they are trapped and prejudiced, but we experience that we can influence this in daily interaction through good role modeling and human kindness, which can help them let go of self-destructive thoughts and threats (Participant 5).

The participants noted that they used a calming presence to create an atmosphere similar to a kind and healthy family atmosphere in a caring environment. They were concerned about their duty to think and act as healthcare professionals, but they tried to also act as nice, trustworthy and ordinary fellow human beings. To ensure a calming atmosphere, it was necessary for healthcare professionals to be aware of their own presence by playing the role of a professional worker who is responsible, attentive and fair while simultaneously holding themselves back. They described this approach as being concerned about the patients’ situations by being particularly aware of the need to practice and convey respect and kindness in all conversations by adopting caring and transparent attitudes. They wanted to convey to the patients a feeling of relaxation within the atmosphere at hand to reflect a society that treats fellow human beings with respect, attention, peace of mind and support.

Balancing everyday life activities

The participants noted that stability and predictability in everyday life were important in the ward. In everyday life in the ward, healthcare professionals facilitate individual patients’ therapeutic processes by ensuring a calming atmosphere. They listen to the ways in which patients talk, sense how they feel and observe in detail how they behave towards others. Within this calming atmosphere, healthcare professionals collaborate in the task of making patients feel completely taken care of, seen and understood to ensure that friendly and care are the essence of the therapeutic process. They continuously translate social codes and facilitate group processes to ensure that an atmosphere of care and respect within the group of patients is in alignment with what most of us consider to be normal social life.

Healthcare professionals use everyday life situations to demonstrate how a society is actively created and maintained by the interactions of human beings and how people, by reflecting on their own responsibility for influencing other peoples’ social lives, can experience the power of kindness. Most patients were so fragile that establishing such a calming atmosphere was a priority because many of the patients had lived lives in which they felt exposed and unprotected and reacted quickly to the mood conveyed by the environment.

Knowledge of the patients, continuity in observations and awareness of the calming atmosphere seemed to enable the healthcare professionals to anticipate situations and quietly re-establish a safe atmosphere by giving individual patients extra attention to sort out issues and solve situations.

Because a calming atmosphere represented ordinary everyday life at the ward, the creation of a sense of presence through attention helped to prevent dangerous situations that could occur unexpectedly. The healthcare professionals explained that if one of the patients has a bad day or experiences stress or agitation, the healthcare professionals take the initiative by quickly and quietly identifying what is at stake and trying to de-escalate the situation. They limit sensory impressions, reduce physical space and perform systematic observations in a kind manner by paying attention to and closely following the patient until the situation is stabilized. Simultaneously, some colleagues remain with the other patients to ensure that they have not left anything out and to signal that the team is in control and is prepared to take good care of everyone.

The healthcare professionals explained that the patients as a group are extraordinarily vulnerable and fragile, which entails that even small changes in everyday life patterns could activate uncertainty and a desire for protection. Their experience was that patients must be continuously assured that they can rely on the healthcare professionals within a secure and calming atmosphere:

We behave in a kind and relaxed manner, but we are prepared and trained for the intense awareness that characterizes high-security wards. All our patients are potentially dangerous due to their diagnoses and their criminal acts before hospitalization. If an acute situation with turmoil occurs, we quickly but silently divide responsibility for each patient and work as a team. Because we know that stress transfers quickly, we support patients’ individual windows of tolerance by being extra and attentively caring toward the patients while sorting out the problems. The main task is to stabilize the situation immediately and make the atmosphere calm again (Participant 8).

Teams including psychologists and psychiatrists are debriefed regarding acute and dangerous situations as part of the patients’ treatment programmes as well as to evaluate and support the healthcare professionals’ emotional reactions, thus allowing them to reflect on further risk assessment strategies and individual needs for team support. Most participants noted that they can become stressed but also that they seldom become self-centred or rigid in acute situations. Responding to observations and acting immediately, taking control by following security routines and leaning on colleagues within a team is an important aspect of managing everyday life activities. When acute situations are resolved, reactions such as feeling shaky, needing a debriefing session and being cared for by colleagues seem to be common. All participants noted that they are reminded of their own vulnerability and exposure when they are involved in situations that trigger the fear of being seriously injured. In periods during which patients’ therapeutic process is demanding and challenging for the staff over time, caring conversations and support in the college and the possibility of spending time with friends and family who represent normal life outside the institution are invaluable resources that support healthcare professionals’ ability to behave professionally towards patients. The debriefing sessions were described as very important with regard to avoiding individual stress and sharing details regarding their situational understanding with the aim of reorganizing their mental issues. Being supported as vulnerable fellow human beings by others strengthens their ability to care for patients. In this context, training teamwork collaboration involving the provision of attentive feedback to each other is a form of support that balances professional views with tolerance and presence regarding the patients’ life challenges in the context of everyday activities in the wards.

Facilitating risk assessments and care

The theme of facilitating risk assessments and care describes the ways in which the healthcare professionals, through trust in a prepared and supportive team, decrease their concern regarding their own exposure and their vulnerability to the risk of violence and direct their attention to security, the maintenance of a calming atmosphere and the need to address patients´ individual needs for therapy and care.

Acting as a team

The healthcare professionals highlighted the fact that collaboration within the team is essential to solve issues quietly and safely when the risk of violence emerges. The healthcare professionals noted that within an atmosphere of fellowship, they agree upon routines and practice de-escalation techniques quickly and quietly to avoid dangerous situations. They use close communication and teamwork strategies to remain professional towards the patient who engages in negative behaviour and collaborate with their teams to secure the environment and exhibit a caring and calming attitude towards the other patients.

Because of the risks that patients’ illness histories and situations represent in a forensic care ward, the healthcare professionals noted that backup and a professional team’s stability in the context of continuously ongoing collaboration and shared decision-making can help them remain calm and focus on patient care. Trust in the team enables healthcare professionals to act less rigidly and more caring towards patients while dealing with the situation at hand. Turmoil affects everyone involved, but if the team manages to de-escalate and avoid injuries before anxiety and stress can be transferred to the whole group. In their experience, debriefing to ensure a good team spirit and a positive attitude towards the patient’s situation, which represents the essence of treatment and care, becomes the main focus.

Regular training in team collaboration and de-escalation enables the healthcare professionals to become more aware of signs indicating changes that require investigation and preparation as a team to re-establish safety in acute situations:

Initially, in every acute situation involving strong emotions, de-escalation is primary. We use soft methods, a calming voice, and few words. We act friendly and behave in a calming and professional manner. We help each other stay calm. We observe closely and limit sensory impressions to get an overview and find ways to help the patient calm down and put their faith and trust in us. The rest of the team assures the other patients that everything will be taken care of (Participant 10).

In summary, the intertwined connection between regulating one’s own situation and that of patients is closely linked to good teamwork in terms of best practices. The better the support provided by the team is, the greater the capacity of team members to support therapy in a professional and caring manner with the aim of creating an atmosphere that can calm patients by preventing acts of aggression and promoting the security and confidence that enable both patients and staff to relax and feel safe.

Becoming aware of the meaning in signs

In this subtheme, healthcare professionals noted that they became aware of changes in the patients’ conditions by providing an attentive presence and spending time becoming familiar with the patients as persons. Being aware of the individual patients’ daily conditions and the atmosphere in the ward is essential:

I become aware of the atmosphere in a room before I even reflect upon it; it is like a spinal response and an instrument that we unconsciously use for risk assessments. I get a feeling first, and afterward I understand what it was that I perceived in the first place. Since I know the patients well, small things like how they behave or move tune me in (Participants 12).

Finding ways to give patients friendly attention, such as inviting them for a coffee in their room, going for a walk or having a friendly talk, enables healthcare providers to determine whether there is something in the atmosphere that might indicate a change in patients’ conditions. Knowing the patients makes it possible for healthcare professionals to draw on the information that patients provide in confidence in conversations in everyday life to inform their behaviour. By behaving in a friendly and informal manner towards the patients and focusing on a calming attitude, close observation and team collaboration, healthcare professionals manage to re-establish a calming sense of stability quickly:

Being systematic and observant, we get ahead by sensing signs that help us quickly capture underlying changes in a situation. If we notice a change in facial expressions, the way of responding – the use of words, mood and details of signs that indicate the activation of the illness, we are prepared to intervene kindly in the upcoming situation. The better you know how a patient behaves in normal situations and under pressure, the easier you can foresee what comes next and find a good way to stabilize and debrief to avoid violence (Participant 2).

When sensing the atmosphere and becoming aware of changes in individual patients’ conditions, healthcare professionals immediately collaborate to ensure that their observations are by within the team and that the situations at hand are addressed:

We notice how he walks and moves his hands, his eye movements, his mouth movements – you observe closely and explore whether there is latency or symptoms of psychoses with hallucinations or voices. Most patients deny the presence of voices, but when we know them well, we can easily discover the presence of voices through changes in the body and social appearance and thus offer them situated help. We also know that these changes will be noticed by the fellow patients, who need to be assured by us (Participant 8).

Patients’ lived lives affect not only their inner feelings but also what they observe and how they respond in social settings. If fellow patients’ conditions change or worsen, this change in atmosphere is noted by the other patients, who are highly concerned and aware of the kind of ward in which they are hospitalized.

The health care professionals noted that hearing voices represents a challenge and indicates that the patient perceives the outside world differently. Through continuous observation, healthcare professionals are quickly able to become aware of changes and collaborate to overview situations with the aim of developing adequate and situated therapeutic plans; however, they watch the patients closely and subsequently rethink the situation as a whole in the context of debriefing. In the professional team, they evaluate the patients’ presence in the environment and the ways in which the other patients react to the situation by spending time with them and observing whether and how the situation affects the social atmosphere and patients’ wellbeing.

The healthcare professionals noted that they used scoring tools, documentation and checklists but highlighted the fact that the interpretation of situated observations requires knowledge about the patient’s lived lives:

To many of our patients, hearing voices is a sign that indicates psychosis or other changes in the patient condition, meaning that he is getting worse and perceiving reality differently from us. Risk assessment scores are not sufficient. We become aware of symptoms that we might have negotiated and forgot to document, but evaluation must include who the unique patient is as a person. (Participant 6).

Becoming aware of vulnerability and the window of tolerance

The healthcare professionals exhibited an awareness of signs indicating that a patient’s condition was deteriorating or improving. The metaphor “window of tolerance” was used by the participants to explain individual patients’ limits in care or therapy situations. They illustrated this point by noting that experiencing trust towards a professional can be an overwhelming feeling, so if a patient pushes you away, it can mean that the patient is unable to tolerate the feeling of receive care. In this context, the professional team was said to be essential for distinguishing between what the patient is actually expressing and the staff’s preconceptions. If a close relationship or situation triggers the patient’s “window of tolerance”, the recovery process might have made an important advance that can promote recovery.

The healthcare professionals noted that team collaboration in response to sudden aggressive and impulsive reactions in ordinary situations must also be investigated by asking the patient. The professional understanding is that deeply traumatized persons require patience, trust, respect and openness to feel assured that healthcare professionals truly care about them whatever they do, say or feel, even if the pain is expressed in a form that people outside the ward would normally consider to represent risky and dangerous behaviour.

The evaluation of risk assessment findings must be interpreted, contextualized and linked to the patients’ lived lives, and one participant explained this situation as follows:

A new door is opened when the patient invites us to share images of frozen pain because we are nice people whom he trusts. We call these “golden moments” in therapy. Flashbacks from rape, violence or abuse trigger movements in the body that may appear to indicate aggression, but as professionals, and we must know what the patient has experienced to help him translate the overwhelming feeling of humiliation and shame into what can be a normal human reaction. (Participant 6).

Healthcare professionals noted that patients’ behaviour must be understood in light of their situation; signs were difficult to interpret when taken out of context and were viewed as linked to the patient’s previous experiences, such as anxiety being concealed by the image of aggression. Continuing to exhibit a calm and comforting demeanour may help the patient discover his or her unknown and frozen feelings, and releasing embodied pain is an important step towards recovery. When embodied pain triggers the need to flee or defend oneself, is it a common task for the trained forensic staff to help each other remain calm, offer protection and maintain a kind appearance, a purpose for which a high security ward is staffed. Professional help to enable the patient to let go of the pressure and understand why this situation happens must be provided by a professional team who can coach the patient in the task of forgiving himself and understanding his situation contextually throughout the therapeutic process.

Discussion and comprehensive understanding

This study provides insight into healthcare professionals’ experiences with the task of facilitating a safe and caring atmosphere in patients’ everyday lives in forensic care wards. The healthcare professionals included in the study highlighted the value of balancing everyday life activities to meet individual patients’ needs and facilitate comfort and trust. Acting as a team is essential to solve issues in a calm and safe way when signs of violence occur. In addition, the healthcare professionals highlighted the need to be aware of the individual patient’s vulnerability and window of tolerance in therapy and care for patients.

Patients in forensic psychiatric care have severe relationship injuries and trauma experiences caused by severe childhood victimization and losses, and our participants emphasized the importance of engaging with patients’ life stories to understand their behaviour and health processes. Recent studies have shown that a therapeutic atmosphere within a strictly routinized and controlling context requires healthcare professionals’ engagement in patients’ lifeworld (Fosse et al., 2021; Marklund et al., 2020; Rytterström et al., 2021). Furthermore, patients in forensic psychiatric care are unique individuals with their own needs, abilities, and interests despite their difficult life circumstances (Hörberg, 2018).

Studies have highlighted the importance of a therapeutic staff-patient relationship (Myklebust & Bjørkly, 2019; Norcross & Lambert, 2018). However, certain ethical considerations are relevant in this context due to the risk of violence and challenges concerning patients’ participation as a central concept (Ljungberg et al., 2017; Selvin et al., 2016). Our participants noted that focusing on patients’ perceptions of the situation and individual patients’ needs requires collaboration within the healthcare professional team. In addition, team collaboration that promotes feelings of togetherness, support and safety in stressful situations may strengthen healthcare professionals’ ability to fulfill patients’ individual needs. Healthcare professionals should invite patients to be fellow humans in a common world while being aware of the vulnerability and fragility of the situation at hand.

Healthcare professionals use violence risk assessment tools to become aware of early warning signs and changes in patients’ conditions and are supposed to help healthcare professionals foresee and prevent dangerous situations. Risk assessment scores are considered to be tools that can help healthcare professionals observe and document patients’ conditions as well as instruments that can help them interpret signs of changes in a patient’s condition (Anderson & Jenson, 2019; Fazel & Wolf, 2018; Fluttert et al., 2010; Rytterström et al., 2021). Our findings emphasize the importance of knowing the patient as a person and the patient’s lived lives. Risk assessment tools are not sufficient, and healthcare professionals ascribe significance to patients’ bodily expressions, such as eye contact, facial expression, body movement, and anxiety.

Our participants were open and responsive to patients, and the metaphor “window of tolerance” was used by one participant to explain how the healthcare professionals balanced care and therapy situations with the patient’s limits. This observation is consistent with Siegel’s (1999) Window of Tolerance, which encompasses both intense emotion and states of calm or relaxation in which emotions can be experienced as tolerable and experience can be integrated. Being open and sensitive in encounters with patients and listening to patients’ stories provide healthcare professionals with a better understanding of and insight into the patients’ lifeworlds (Marklund et al., 2020; Steinkopf et al., 2020).

Our participants noted that patients’ illnesses and social situations must be given value and meaning in the interpretation of risk assessments. Fosse et al. (2021) found that patients’ serious mental illnesses and lived lives entail the potential for violence in everyday life situations. Dangerous behaviour caused by severe childhood experiences and losses may occur in healthcare professional—patient encounters in forensic care, and the presence of qualities such as fellowship, togetherness, dignity, and self-respect may reduce violent behaviour, promote recovery, humanize patient behaviour in light of lived lives, and make care less stigmatized and rigid (Hammarström et al., 2022; Rytterström et al., 2021; Söderberg et al., 2022). Patients in forensic psychiatric settings express the need to feel a sense of belonging that allows them to be themselves and feel accepted (Aga et al., 2019; Hörberg, 2018).

Our participants noted that a safe and caring atmosphere reduces patients’ stress and anxiety and thus mitigates the risk of violent situations in daily life in the ward. Healthcare professionals who trust and feel support within the team can more easily address forensic care patients’ trauma-related expressions of vulnerability. Through their presence with patients and with less fear for their own lives, healthcare professionals can be more present and caring. Their calm and caring attitude may be the support that the patient can rely on and may allow patients to experience dignity, respect and understanding.

A feeling of being able to solve one’s own life challenges, such as managing one’s personal finances, having a job and feeling “normal”, may be important experiences for future hope, connectedness and recovery. Revealing embodied experiences of loss and shame to a caring healthcare professional helps patients experience concrete changes in their own receptivity, peace of mind, social capability and self-respect. The changes in self-esteem and the ability to include others that are illuminated by caring healthcare professionals during their interactions with patients in everyday life activities may give patients new experiences of social life that can decrease their anxiety, make aggression and self-protection less necessary and thereby lower the risk of violence.

Strengths and limitations

One limitation of the present study could be that the datasets it uses are from 2013. We consulted with two participants who have continued work at the ward to ensure that data remain relevant and that practice and routines have not changed significantly. In addition, the discussion and comprehensive understanding section presents our findings regarding relevant recent studies.

Forensic psychiatric care is governed and controlled by law and psychiatry, and relevant legal frameworks may differ across different countries. Therefore, our findings should be viewed as focusing on healthcare professionals’ experiences and the essential meaning of facilitating a safe and caring atmosphere in patients’ everyday lives in terms of forensic mental health in the Norwegian context.

Conclusion

This study provides insight into healthcare professionals’ experiences with regard to facilitating a safe and caring atmosphere in patients’ everyday lives in forensic care wards. Involvement in patients’ histories and lived lives is important both for understanding general social behaviour as well as for assessing signs, symptoms, and changes in patients’ conditions during daily life in the ward; furthermore, it provides valuable information for facilitating examinations and treatment. Acting as a team is essential to solve issues in a calm and safe way when signs of violence occur. In addition, our participants highlighted the need to be aware of individual patients’ vulnerability and windows of tolerance in the context of providing therapy and care to patients.

Clinical implications and suggestions for future research

We argue that the insights and knowledge gained from this study may benefit healthcare practice, education, and future research.

Healthcare professionals working shifts in mental health wards have an important influence on patients’ care needs and future recovery, but this context has rarely been highlighted as representing important knowledge in psychiatric therapy. We suggest that healthcare professionals influence who interacts with patients in daily life activities, are in a position to support patient recovery due to their familiarity with patients’ tolerance window and lived life experiences, and must be given attention as bearers of valuable knowledge that can decrease the risks of violence and strengthen recovery for patients in forensic care.

Acknowledgments

The authors would like to acknowledge and thank all the participants for their efforts and contributions to this research.

Disclosure statement

No potential conflict of interest was reported by the authors.

Data availability statement

Due to the sensitive nature of the questions asked in this study, participants were assured that their raw data would remain confidential and would not be shared.

Additional information

Funding

This work was supported by UiT, The Artic University of Norway.

Notes on contributors

Sylvie Anna Sollied

Sylvie Anna Sollied, RN, MSc, Associate Professor, research focused on encounters in forensic psychiatry

Jette Lauritzen

Jette Lauritzen, PhD Student, MSc, MScAH, CRNA, Senior Lecturer, research focused on support groups, caregivers and dementia.

Janne Brammer Damsgaard

Janne Brammer Damsgaard, RN, MSc, PhD, lecturer, research focused on care, arts and humanities

Monica Evelyn Kvande

Monica Evelyn Kvande, RN, MSc, ICN, PhD Associate Professor, research focused on critical care, humanizing, ethics, nursing philosophy, nursing theory