- 18 March 2019
- 15 min read
What is Forensic Mental Health, and how did I end up working in it?
Laura works in Forensic Mental Health. In this blog, she explains the whats, the whys and the hows of what it involves and how she got into it.
I am not entirely sure how I ended up working in the fascinating field of forensic psychiatry, it has been a series of career choices and academic pursuits which increased my interest and commitment to working with offenders.
In the following article, I will provide an overview of what forensic mental health is and what it is like to be a nurse in this specialist area of practice.
Forensic mental health is concerned with the management and treatment of offenders with mental health issues.
Those patients who encounter the criminal justice system because of their mental health or who become unwell following a criminal offence.
Central to the field of forensic mental health is the assessment and management of risk, in particular, the risk posed to others.
Mental health services can be found across the entire criminal justice pathway. Supporting people at the point of arrest in police stations, through custody, within prisons or in secure hospitals.
Forensic mental health services also cover law courts, probation services, and community mental health services.
At times, professionals working in forensic psychiatry will be asked to provide expert opinion
What kind of nurses and other staff work in Forensic Mental Health?
Forensic services will employ Registered Mental Health Nurses (RMNs) within the range of services offered.
Nurses can work within forensic services from qualifying, although previous experience in similar settings may be desirable.
Unique to forensic services is the range of professionals working together.
Teams will include Forensic Consultant Psychiatrists, Occupational Therapists, Social Workers, Pharmacists, Support Workers, Activity Coordinators and Nurses.
There is significant psychological input from both Clinical Psychologists and Assistant Psychologists.
Psychologists will often undertake assessments of a patients criminal offending behaviour and contribute to the prediction of future risk.
Forensic Psychiatry and the NHS?
The NHS provides forensic services up and down the country.
Local NHS trusts will be commissioned by NHS England to deliver both inpatient and community mental health services.
The funding of forensic mental health is different to general adult services due to being centrally commissioned by NHSE rather than local CCGs.
Clinical outcomes for patients within forensic services are therefore reported nationally to NHSE and there are specific key performance indicators for all forensic services within England and Wales.
Since 2017 there has been a change in how some secure services are delivered.
The establishment of “new care models” creates large geographical areas in which NHS trusts work in partnership with private providers with the aim of reducing the number of patients placed in beds miles from home and also reduce the cost of delivering forensic services.
A notable difference between forensic services and general adult mental health is the collaboration with private sector providers.
In 2018 there were an estimated 7000 secure beds with 37% of those independently provided.
As before, it is easiest to view forensic workplace settings across the criminal justice pathway, where patients can be diverted, assessed, treated and managed.
You may work in Police custody as part of a Police and Liaison service.
This will involve assessing people in police cells and making recommendations to the judge regarding possible diversion into mental health services or to a hospital bed rather than prison. Read this blog post about life as a custody nurse practitioner to find out more.
Many NHS trusts provide mental health services in prisons and nurses can work inside the prison establishment itself or provide in reach mental health support from specialist community services.
Most nurses in forensics will work in a secure hospital setting.
Forensic inpatient units deliver care in differing levels of security from High Secure, Medium Secure and Low Secure units.
The level of security a patient is admitted to is based on the assessment of risk they pose, or the criminal offence committed.
There are only 3 High Secure hospitals within England, and these are reserved for those people who pose a risk of immediate and grave danger to the public.
Nursing within High Secure Hospitals poses challenges but significant rewards.
Those admitted to High Secure Hospitals will have committed serious crimes and can continue to be violent.
The majority of forensic inpatient beds are within Medium Secure Units.
Nurses will be involved in assessing a person’s suitability to be admitted and decide on which level of security people should be admitted to.
Patients can be admitted from prisons, general adult wards or other secure wards in either high or low secure units.
Further settings a Forensic Mental Health Nurse may work in is Low Secure Units or Locked Rehabilitation units.
Forensic mental health units, or “secure hospitals” have a range of facilities to support an individuals’ recovery journey.
In comparison to other mental health hospitals, patients in forensic services can stay up to two to three years. Many hospitals have on-sight gyms, gardens and allotments, workshops and cafés run by patients.
The facilities provide opportunities for patients to engage in meaningful activities and undertake occupational work and training. Nurses will work as part of a multidisciplinary team to deliver group activities and 1:1 work.
Within all Forensic services, Mental Health Nurses will build therapeutic relationships.
The forming of relationships within forensics allows nurses to assess an individual’s risk, develop care plans in collaboration with the patient and support the patient towards discharge.
Central to any interventions is the ongoing assessment of risk.
Nurses are required to assess the complex relationship between a person’s mental health and their offending behaviour.
Nurses work with people to gain insight into their past and how they ended up in a secure hospital setting.
To gain insight means a person begins to take responsibility for their behaviour and this significantly reduces future risk hence supporting discharge from secure services.
I personally work as a prison nurse - read my blog post, what to expect from a job as a prison nurse, for more information on what that's like!
Skills and Qualifications
In reality, working as a nurse in forensic mental health settings is similar to other mental health settings.
You will be a qualified Mental Health Nurse (RMN) registered with the Nursing and Midwifery Council.
Some nurses will have a particular interest in working with offenders and undertaken degrees in criminology, psychology or law.
You may undertake specific training in advanced risk assessments and equip yourself with skills in working with violence or specific offenses such as sexual offenses.
During my time as a Charge Nurse, I undertook a master’s degree in Forensic Psychiatry and this developed skills and knowledge in all aspects of forensic mental health including risk assessments, neuroscience, forensic treatment approaches, and mental health law.
I have worked with individuals who have committed serious and violent crimes.
It can perhaps seem counter-intuitive to the wider public that individuals are supported in a hospital setting and shown compassion.
As a nurse, however, an understanding of the complexities of offending behavior and mental health, support a non-judgmental and empathic attitude to working and engaging with offenders.
Some individuals are incredibly unwell at the time of committing an offence and mental health nurses will walk alongside patients as they begin to come to terms with not only their mental health difficulties but the offences they may have committed.
An advanced ability to communicate with people, self-awareness and an ability to be assertive when needed are skills forensic mental health nurses rely on in their day to day work.
Resilience is often overlooked in nursing, yet nursing asks us to deliver care daily, listen to another’s narrative and provide compassion unconditionally at times.
For nurses working in forensic mental health it is important to look after our own wellbeing and to build resilience to manage the emotional labour of the work.
How did I end up as a Matron working in FMH?
I am not sure anyone chooses forensic mental health nursing early in life, it just kind of happens.
I was always fascinated by the outside walls of prisons and wondered what happened on the other side.
During my training to be an RMN I had two practice placements in secure hospitals. I learnt about risk and how, at times, mental health crisis can lead to offences being committed.
I also worked with people whom imprisonment had brought them to the edge and they suffered a mental health crisis as a result.
After qualifying as an RMN I worked in a Psychiatric Intensive Care Unit (PICU) for nine years.
This semi-secure environment admitted men in an acute stage of illness who demonstrated violent and disturbed behaviour as a result of serious mental illness, namely psychosis or mania.
During this time some patients needed transferring to forensic services due to on-going violence or increased risks.
Some patients were transferred to the PICU from the local prison. I became interested in the mental health of prisoners and would undertake the assessments which decided if men were suitable for PICU or needed to go to forensic services.
After seven years I decided to return to studying and did a part time MSc in Forensic Psychiatry.
This immersed me further into forensic mental health with my research project focusing on transferring prisoners to hospital.
I left the PICU to manage a prison health care service before moving to my current job as Matron within a forensic hospital where we have three medium secure units and a low secure unit.
Discover prison nurse jobs like mine on the job board.
What are the challenges?
People admitted to forensic mental health services face double stigmatisation, their mental health issues and the crime they have committed.
Working as a nurse in forensics requires you to advocate for your patients and continue to deliver safe, effective and high-quality nursing care.
This may require you to challenge public perception or challenge some of your own beliefs.
Professionals working in forensic services are understandably risk adverse and decisions regarding discharge can take a long time.
This can be frustrating at times and requires nurses to engage in reflective practice and clinical supervision to manage feelings of frustrations and maintain therapeutic relationships with patients over a long period of time.
People admitted to secure hospital are detained under the Mental Health Act and are held under sections which are managed by the Ministry of Justice (MOJ).
This places restrictions and time constraints on an individual’s freedom and progress from admission to discharge.
At times the directions regarding treatment or progression from the MOJ may differ from your view as a nurse and you will be required to consider the wider landscape of public protection alongside the your own assessment of your patients recovery.
What are the rewards?
It is always rewarding to see a person progress through the forensic pathway and out into the community to live an independent life, knowing that the nurse-patient relationship has been central in that journey.
One of the most rewarding aspects is working with the families and carers of my patients.
The period of time leading up to an admission to secure services is often difficult and traumatic for families.
Part of the nursing role is supporting contact with families and working together to support patients.
What are the opportunities?
Forensic Mental Health services offer a range of opportunities for RMNs.
You can work within a hospital setting in the differing levels of security or choose to work inside the prison estate or community.
Many NHS trusts offer rotational posts for newly qualified nurses, allowing you to experience the range of settings and gain valuable experience.
You will have the opportunity to train in advanced risk assessments and work closely with psychologists to develop risk formulations and plans.
Due to the length of stay within secure hospitals, nurses have an opportunity to develop therapeutic relationships over a long period of time.
This allows nurses to see a significant and sustained change which provides meaning to what we do as mental health nurses.
There are career development opportunities with pathways for newly qualified nurses to work towards Band 6 Charge Nurse posts or Band 7 Ward Manager posts.
Many forensic teams will employ Clinical Nurse Specialist roles and Band 8a Matron posts offer leadership and managerial roles whilst maintaining clinical expertise.
Some NHS Trusts have Forensic Nurse Consultant posts, with these senior nurses providing expertise in clinical practice, research, teaching and nursing strategies.
If I'm training as a RMN what would be a good next step if this is the area of nursing I want to get into.
If you are interested in forensic mental health, then ask to visit your local forensic services.
Don’t be afraid to ask for placements or spoke days in secure settings and gain experience as a student nurse as a support worker or nursing assistant.
Do some background reading and research into offender health and look at national polices into the mental health of prisoners or those involved in the criminal justice system.
There is often a lot of public and political interest into mental health services so stay connected with the news and social media to keep up to date with emerging polices which impact offender mental health.
I always get asked “how do you nurse people who have committed crimes?” or “are you not scared?” and I am able to reply with no hesitation that it is a privilege to hear the narratives of the people I work with and I am reminded daily that to be a human being is a complex and difficult thing.
Many, if not all of the people I work with have led difficult and painful lives and are often more frightened than I have ever been.