The concept of person-centred care is the foundation of contemporary nursing practice (McCormack and McCance, 2016) and is now codified by the Nursing and Midwifery Council (2018) within the seven standards of proficiency for registered nurses. Person-centred care seeks to enhance the partnership between patient and clinician. It acknowledges the patient's beliefs and values regarding their care, and looks beyond their primary health needs towards a more holistic approach (Delaney, 2018; Marklund et al, 2020).
Person-centred nursing and forensic mental health care have historically been considered to be incompatible – to exist at opposite ends of the spectrum regarding patient autonomy and empowerment (Hui et al, 2013). Most forensic patients have committed a crime (Askola et al, 2018) or need to be cared for in a highly institutionalised and secure environment due to the complexity of their needs and risks (Tomlin et al, 2018). Structurally, there is perceivably little room for patient participation or ‘person-centredness’ (Söderberg et al, 2022).
Policy definitions
To understand the impact of person-centred nursing policy on forensic mental health care, one must first forge a definition of person-centred nursing policy. Smith-Merry et al (2007) defined policy as the process by which governments or institutions ‘translate’ political objectives into tangible ‘outcomes’. This simplistic definition provides a strong basis for understanding the motives behind policy creation but it fails to consider how such ‘outcomes’ feed back to further develop policy.
Drawing on a wider range of literature, Baggott (2015) argued that health policy is not always the result of ‘positive action’ and can also result from inaction. Baggott (2015) referred to reactive health policy, which stems from public inquiries such as that of the Winterbourne View scandal in 2011, which set out a person-centred framework around the care of people with learning disabilities and autism (Department of Health (DH), 2012). Calnan (2020) took a broader perspective, arguing that health policy can be seen to focus on ‘social, economic, political and environmental’ factors as influencers of health.
In contrast, Smith-Merry et al (2007) and Baggott (2015) view health policy as a strictly political process with political ‘outcomes’, which is reductionist but nonetheless important to recognise.
Person-centred policy
Person-centred care policies, however, cannot be uniformly applied to forensic mental health settings and therefore have a limited impact on the delivery of care in this area. Person-centred care policies such as ‘No decision about me, without me’ (DH, 2012) and the Person-centred Approaches framework (Health Education England et al, 2017) set out to codify what person-centred care means in practice, and to act as a reference point for practitioners. They are written in generalised language because they are intended to be applied across all physical and mental health care settings.
O'Brien (2022) highlighted that there may be a dearth of empirical evidence to support the efficacy of ‘No decision about me, without me’ in mental health care because of the regular omittance of ‘patients without capacity’ from relevant research. This brings into question differences in the standards of evidence between physical and mental health, in that mental capacity as an issue is more frequently found in mental healthcare, thereby suggesting that omission of such patients from research has led to a misunderstanding of the needs of such patients (Shepherd, 2016).
Forensic mental health
This is especially true for forensic mental health, as most cared for in this setting are detained under the Mental Health Act 1983 and most are subject to further restrictions from the Ministry of Justice (Parole Board, 2020), meaning that they exist at the intersection of both health and justice policy (Alexiou et al, 2018). Marazia et al's research (2022) supported this as it found that just 34.5% of forensic patients had ‘high treatment-related capacity’. This is a strong comparative study which draws on a breadth of data from European countries including England. However its extrapolatory potential is weakened by its lack of female participants, who make up 12% of the forensic mental health population (Ministry of Justice, 2022). Regardless, the evidence highlights that person-centred care policy and the evidence that underpins it cannot confidently be applied in its entirety to forensic mental health settings, thereby weakening its subsequent impact.
Some 60% of forensic mental health patients in 2021 had committed offences of violence against the person (Ministry of Justice, 2022) which underpins the unique responsibility faced by forensic mental health practitioners. This dual responsibility to both patient and public puts forensic mental health practitioners in the difficult position of balancing the conflicting priorities of ‘patient-centredness’ and public/staff safety (Hui et al, 2013; Askola et al, 2018).
Patient-centred care policy fails to provide appropriate guidance for or recognition of this practical reality. Forensic mental healthcare policies such as See, Think, Act (Department of Health Secure Services Policy Team, 2010) and Standards for Forensic Mental Health Services (Royal College of Psychiatrists, 2019) are entirely focused on safety and security, with minimal engagement with person-centred care principles. Therefore, the distinct lack of bespoke policy and requisite evidential grounding have partially limited the impact of person-centred nursing policies on forensic mental health care. However, core theoretical principles have still been able to permeate daily practice (Markham, 2020). Although the impact of specific person-centred nursing policies on forensic mental health care is somewhat limited, aspects of person-centred theory have still had a positive impact. Person-centred nursing policy and person-centred nursing theory are different, in that policy outlines clear guidance and instructions on how care should be practised (Calnan, 2020), and theory outlines the key philosophical concepts that provide a principled foundation on which practice is based (McCormack and McCance, 2016).
‘Maslow's holistic approach holds considerable weight as a general framework for understanding the wants and needs of forensic mental health patients, with a focus on basic human needs forming a key part of de-escalation and ‘talk-down’ methods practised daily by clinicians’
Theories
One such theory is Abraham Maslow's (1943) seminal theory of human motivation, which represents a philosophical pivot toward viewing humans and human needs holistically, in that he described human behaviour as being the result of a series of met or unmet needs. The principles of Maslow's theory are still highly relevant in contemporary mental health practice (Henwood et al, 2015) and have aided the modern understanding of what constitutes mental wellness (Obeid et al, 2022). Maslow's contribution to the holistic approach to forensic mental health care is significant, in that environmental and social factors are now viewed as equally as important as physical health factors in mental wellbeing (Alexiou et al, 2018).
However, Maslow's hierarchy is arguably an oversimplification of human needs in that it sees all humans as being on a quest to achieve ‘self-actualisation’ or ‘transcendence’, the stage where all needs have been met (Maslow, 1943). This theory cannot therefore be applied to some complex cases found in forensic mental health where patients do not wish to collaborate with clinicians around their care and have become passive recipients rather than active participants (Holley et al, 2020).
Regardless, Maslow's holistic approach holds considerable weight as a general framework for understanding the wants and needs of forensic mental health patients, with a focus on basic human needs forming a key part of de-escalation and ‘talk-down’ methods practised daily by clinicians (Bennett and Hanna, 2021).
Another person-centred care theory by Carl Rogers (1979) outlines the three core conditions that practitioners must exhibit for effective person-centred care: empathy, congruence and unconditional positive regard. These core conditions, partnered with the recognition of the individual's ability to understand their own needs, empowers the patient to make their own decisions while working with clinicians towards positive, mutually established health outcomes (Rogers, 1979).
This theory, primarily concerned with the philosophy of how staff view and treat patients, has had a positive impact on forensic mental health in that over the past decade staff attitudes to forensic patients have shifted significantly to a more empathetic, compassionate and caring approach (Hillbrand et al, 2006; Hui et al, 2013) For example, Bennett and Hanna's (2021) qualitative study found that when staff acted empathetically and honestly with patients, it led to strong therapeutic relationships and positive health outcomes. Furthermore, it contributed to a deeper, non-judgemental understanding between patient and staff members on how to effectively manage patient risk, leading to less restrictive practice (Bennett and Hanna, 2021). This study is reliable as it used a wide range of qualitative data from 30 forensic inpatients from across high, medium and low security levels in England (Bennett and Hanna, 2021).
Another strength of this study is that it focused primarily on forensic patients as human beings, looking at their emotions and experiences before anything else. This is an area that research into forensic mental health severely lacks, often focusing on risk and safety factors while missing the complex and human stories that each of the thousands of forensic mental health patients represents (Ministry of Justice, 2022). Regardless, the core principles of these theories have had a positive impact on forensic mental health practice despite the aforementioned limitations of person-centred care policy in this field, although more bespoke policy and theory would allow this to go even further.
Conclusion
Person-centred care policies and theories have had a limited but positive impact on forensic mental health care. This is because there is an absence of policy guidance specific to forensic mental health care that tackles the conflicting dichotomy of ‘person-centredness’ and security. Person-centred care is important because it empowers patients to make decisions about their care and work collaboratively with care providers (McCormack and McCance, 2016). This ‘person-centredness’ allows clinicians to better understand their patients and ultimately leads to more positive health outcomes (Livingston et al, 2012; Alexiou et al, 2018). Person-centred care in forensic mental health can go much further. Therefore the authors recommend that a bespoke, person-centred care policy framework is needed for forensic mental health care.