‘Difficult’ Patients: Disciplinary Power and Nursing Practice in Forensic Hospital Settings

ABSTRACT

Nurses practicing in forensic mental health hospital settings work with patients involved in the criminal justice system who are also diagnosed with psychiatric illnesses. Nurses work towards collaborative and therapeutic relationships with patients with an eventual goal of recovery and successful discharge to the community. Though the majority of patients in these settings in Canada are diagnosed with psychotic disorders, a smaller proportion may be diagnosed with antisocial personality disorder (ASPD), a patient population often described as ‘difficult’ or even ‘untreatable’ by nurses. In this paper, we offer a critical examination of forensic mental health nursing practice with this patient population, based upon a qualitative study, using discourse analysis methodology of nursing practices in a Canadian high security forensic hospital setting. Nurse participants described those challenges faced and strategies employed when working with patients diagnosed with ASPD, and who had been found not criminally responsible on account of mental disorder (NCRMD). Michel Foucault's poststructuralist concept of disciplinary power provides the theoretical lens in which both patient behaviours deemed ‘difficult’ and nursing practices are interrogated. Our findings indicate that the secure forensic mental health hospital environment represents a highly disciplinary space, wherein constant observation of patients occurs, and attempts are made to ‘normalize’ behaviours deemed abnormal. Patients diagnosed with ASPD regularly violate hospital rules and behavioural expectations, leading to frustration amongst nursing staff. Tensions existed in proposed strategies for working with these patients between strict adherence to unit rules and the disciplinary order, and a willingness to loosen these rules in attempts to improve nurse–patient relationships. The nursing implications of these opposing strategies are critically examined, with proposals for practices that exist both within and outside the disciplinary order are offered.

The forensic mental health setting presents unique challenges for nursing practice, where the duty to both provide care and maintain the rules and restrictions of the carceral environment poses moral dilemmas for nurses. This dual role of acting as both an agent of care and an agent of control is the defining characteristic of the nursing practice milieu in secure forensic hospital settings, across multiple jurisdictions (Holmes 2002; Jacob et al. 2009; Mason 2002; Peternelj‐Taylor 1999). Nursing practices focus on providing care for patients living with complex mental health challenges who have also been accused of committing or convicted of criminal acts. Practice settings include secure forensic hospitals (the focus of this paper), specialized mental health facilities in correctional institutions, and community‐based services. Here a focus on risk management, ensuring public safety, adhering to the conditions of a patient's detention, and enforcing institutional rules and expectations often clash with nursing mandates—both professionally and ethically. In essence, to provide care that is ‘inclusive, collaborative, and egalitarian’ (Livingston et al. 2012, p. 346) to work collaboratively towards patient recovery and eventual discharge.

Patients within forensic hospital settings often present with highly complex, treatment‐resistant diagnoses, including psychotic disorders (Charette et al. 2015; Haag et al. 2016), coupled with comorbid personality and/or substance use disorders (Bowers et al. 2011; Howard et al. 2013). Though nurses are typically successful in the provision of care and facilitating patient progress towards discharge, some patients are resistant to care, may be uncooperative with nurses and their approaches, and may exhibit acts of violence or aggression (Aiyegbusi and Kelly 2015; Dickens et al. 2013; McKeown et al. 2016). While these patients may constitute a small proportion of the overall patient population (McKeown et al. 2016), their actions negatively affect nursing staff, often causing long‐lasting emotional and physical consequences (Murphy and McVey 2010). Bowers et al. (2011) described the range of negative effects on nursing staff, including physical injuries, negative views towards patients, fear, decreased job satisfaction, anxiety, posttraumatic stress disorder (PTSD), substance use and, in some cases, resignation from employment. Murphy and McVey (2010) noted that nurses, who spend the greatest amount of time with patients in forensic hospital settings, are most significantly affected. Newman et al. (2020) described burnout, cynicism and emotional exhaustion amongst nurses working in these settings.

While most patients in forensic mental health settings show a willingness to engage with nurses in rehabilitation and recovery, and work towards transition to community settings and discharge (Chandley et al. 2014; Ferrito et al. 2012; Livingston et al. 2012; McKenna et al. 2014, 2016; Simpson and Penney 2011), a small minority of patients pose disproportionate challenges to nursing staff. McKeown et al. (2016) described this small group of patients as the ‘determined recalcitrant’ (p. 240), dedicated to ongoing refusal to cooperate, demonstrate dismissive attitudes and aggressive behaviours. A lack of cooperation and aggressive behaviours are typically managed with chemical and/or environmental restraints (Dickens et al. 2013; Holmes et al. 2015; Perron and Holmes 2011), which Bowers et al. (2011) suggested can limit further patient engagement in more constructive and pro‐social unit activities. The restrictions placed on patient freedoms and privileges may trigger continued acts of aggression or violence, further perpetuating the use of restrictive or punitive measures. In forensic hospital settings, these ‘difficult’ or ‘recalcitrant’ patients are typically relegated to high security units aimed at ongoing management of their (mis)behaviours (Murphy and McVey 2010).

A specific group of patients frequently identified in forensic mental health hospital settings as particularly ‘difficult’ for nurses are those diagnosed with antisocial personality disorder (ASPD) (Bowen and Mason 2012; Byrt 2013; McRae 2013; McVey 2010; Moran and Mason 1996). The American Psychiatric Association (APA) (2013) defined ASPD as ‘a pervasive pattern of disregard for and violation of the rights of others’ (p. 659) and includes traits such as deceitfulness, aggressiveness, impulsivity and irresponsibility as diagnostic criteria. They also acknowledge that persons diagnosed with ASPD may be referred to as psychopathic or sociopathic by clinicians, a highly stigmatizing description, though the interchangeability of these terms is debated (Lykken 2018). The treatment and management of this group of patients presents significant challenges for nurses in secure forensic settings and may occupy much of a nurse's time and energy, at the expense of other assigned patients (Moran and Mason 1996; Murphy and McVey 2010). Nurses often view patients diagnosed with ASPD as ‘untreatable’ and shift their practice to prioritize management of (mis)behaviours (McVey 2010). Martin et al. (2020) examined the style of documentation utilized by forensic mental health nurses and found many negative themes in the documentation that discounted, pathologized or paternalized the clients that they were caring for.

In this paper, we provide a critical examination of nursing approaches to working with patients diagnosed with ASPD in a secure forensic hospital setting. To do so, we mobilize the results of a qualitative study conducted by the first author in the context of their thesis work in nursing (Johansson 2020), which examined strategies used by nurses to work with patients perceived as ‘difficult’ in a high security forensic hospital setting in Canada. French philosopher Michel Foucault's (Born 1926–Died 1984) (1995, 2004, 2006) conceptualization of disciplinary power provides the theoretical framework for the consideration of patients diagnosed with ASPD in forensic mental health settings, and the role of nursing in providing care. This paper is divided into four sections. The first describes the forensic hospital system in Canada, specifically persons found not criminally responsible on account of mental disorder (NCRMD), and the review board system that determines their conditions of confinement or release. The second section describes the methodological approach taken in the original study, and develops the theoretical framework mobilized in considering nursing work with this population. The third section presents the results and positions patients and nurses within the disciplinary power framework. The final section considers implications for nursing practice and offers opportunities for alternative approaches.

1. Forensic Mental Health Hospitals in Canada

In Canada, persons charged with criminal acts while suffering the effects of mental illness may be found NCRMD if it is determined that their symptoms prevented them from understanding the nature and consequences of their crime (Criminal Code, R.S. 1985, c. C‐46, s. 16). Instead of being committed to a conventional correctional institution, these individuals are held in secure forensic hospitals for the dual purpose of treatment provision and maintaining public safety (Latimer and Lawrence 2006). Though this legal status is rarely actualized in Canadian criminal courts—less than 1% of cases result in an NCRMD status (Miladinovic and Lukassen 2015), they still account for a sizeable number of individuals with this status across the country. The most recent data available stated that between 1992 and 2004 there were nearly 7000 individuals found NCRMD across 7 of 13 Canadian jurisdictions (Government of Canada 2022). An NCRMD status is typically reserved for more serious crimes; for instance, in the province of Alberta, Haag et al. (2016) noted most index offences for NCRMD were for violent crimes, including homicide, attempted homicide, and weapons offences. They also determined that psychotic disorders, such as schizophrenia and schizoaffective disorder, accounted for the majority of diagnoses observed in this population. A diagnosis of ASPD accounted for 15.1% of the NCRMD population in this province.

The authority of care and subsequent freedoms permitted to those found NCRMD fall to provincial or territorial Review Boards, whose mandate is to impose the least restrictive measures possible while maintaining public safety (Cheng et al. 2022; Crocker et al. 2015). Domingue et al. (Domingue, Jacob, Perron, Pariseau‐Legault, et al. 2023; Domingue, Jacob, Perron, Foth, et al. 2023) explored in depth, the make‐up and functioning of these Review Boards, who consider information provided on individual patients by their treatment team, including patient behaviours, adherence to treatment regimens, risk assessments, and insight into their diagnoses. Decisions are then made, typically on an annual basis, on the fate of the patient, based on three options: detention in hospital, conditional discharge to the community, and absolute discharge (Cheng et al. 2022). Most individuals found NCRMD transition from forensic hospital care to community placement and eventual absolute discharge: in Alberta, for instance, the average length of time to absolute discharge was 5.7 years (Haag et al. 2016). However, transition to community and discharge are not guaranteed if the Review Board determines an individual continues to pose a risk to public safety. Some individuals remain in forensic hospitals indefinitely (Latimer and Lawrence 2006). Within the hospital setting a multi‐disciplinary team provides treatment to individuals found NCRMD, working to address both their mental health concerns and potential risk to the public, including psychiatrists, psychologists, occupational therapists, social workers and nurses. However, the majority of time spent with patients, and treatment provided, is done so by forensic mental health nurses (Domingue, Jacob, Perron, Pariseau‐Legault, et al. 2023, Domingue, Jacob, Perron, Foth et al. 2023).

2. Methodological and Theoretical Framework

A discourse analysis methodology was chosen because it permits interrogation of the power relations that shape practice settings, nursing practices and perceptions of patients in highly restrictive settings (Mercer 2013). Considered from a Foucauldian perspective, Mills (2001) described discourse as ‘groupings of utterances or sentences, statements which are enacted within a social context, which are determined by that social context and which contribute to the way that social context continues its existence’ (p. 11). Power relations are integral to these social contexts and allow for certain discourses to be privileged, whereas others are marginalized (Cheek 2004). In the forensic hospital setting, these discourses of the disciplinary milieu ‘shape and maintain certain representations of patients’ (Berring et al. 2015, p. 298). Patients who present as difficult to manage, who fail to adhere to institutional rules and expectations are described as difficult, deviant or even dangerous (Domingue, Jacob, Perron, Pariseau‐Legault, et al. 2023; Murphy and McVey 2010). These discourses and the shaping of patient subjectivities in turn affect nursing practice, and may result in custodial approaches to nursing care with these patients (Perron and Holmes 2011). Discourse analysis methodology permits interrogation of texts—in this case, transcribed interviews—to understand the power relations operating within the forensic hospital context and how they shape the perspectives of patients.

Participants were recruited from two high security forensic mental health units in a psychiatric hospital in Western Canada. Given that they have the most contact with, and are responsible for both the ‘custody and caring’ of patients in these settings, nurses were chosen as the sample profession. The patient perspective is excluded from this study, as ethical approval for studying this population is more complicated (Coughlin et al. 2016) and was beyond the scope of this study. The forensic facility in which this study was conducted consisted of multiple units of differing mandates and security levels, including the two units included here. The high security units housed patients of various legal statuses, though the NCRMD patient population was the primary focus of participants. On both units, patient activities are highly regulated and supervised by forensic mental health nurses, 24 h per day. Patients are not able to leave the units unsupervised and are searched upon their return. Regular searches of patient rooms are also conducted. Nurses practice out of central secure nursing stations that provide visibility to all areas of the units. The two high security units were staffed primarily by nurses and psychiatric aides. Staff nurses carried a designation of either Registered Nurse (RN) or Registered Psychiatric Nurse (RPN), with both designations possessing identical scope of practice.

Nurses in the study were assigned four to five patients per shift, and were responsible for the provision of nursing care, including establishing a nurse–patient relationship, medication administration, documentation, creation of care plans, observation of patient activities, and enforcement of unit rules and expectations. Seven (n = 7) participants were recruited for the study. The primary researcher visited the units to speak with nurses and placed information posters in the unit's nursing stations. This effort resulted in an initial group of participants, with subsequent interviews occurring in the spring of 2020, which was complicated by the onset of the COVID‐19 pandemic. As a result, all interviews occurred via telephone. With pandemic restrictions, further visits to the units were forbidden by the hospital authority, which complicated further recruitment. In a discourse analysis methodology, sample size is not prescribed (McCloskey et al. 2008). Instead, as Wodak and Meyer (2001) suggest, sampling occurs until a diversity of perspectives is collected. Upon completion of the seventh interview, data were reviewed and the research team concluded that a sufficient diversity was represented. Participants consisted of either RNs or RPNs who had worked full‐ or part‐time on either unit, or had done so in the past 6 months. Both male and female identifying nurses participated, ranging in age from early 20s to late 50s, with years of nursing experience ranging from 2 to over 20 years. Demographic information of individual participants was not recorded out of concerns for confidentiality. Participants were randomly assigned numerical identifiers. Ethics approval was obtained from both the University of Saskatchewan Behavioural Research Ethics Board and the research ethics board of the hospital's health authority. All participants provided informed consent.

Single qualitative, semi‐structured interviews with all seven participants were conducted between March and April of 2020. All interviews were conducted via telephone due to pandemic‐related restrictions. The average length of recorded interviews was approximately 30 min. Interviews followed a set of seven guiding questions asking participants to describe their practice setting, the patients they worked with, and what constituted a ‘difficult’ or challenging patient. They were then asked to describe strategies they had either utilized themselves (or witnessed) that led to both positive and negative outcomes with ‘difficult’ patients. Participants were also asked to describe their feelings towards this patient population and their perspectives on what contributed to challenging behaviours. All interviews were audio recorded and securely stored. All interviews were transcribed verbatim by the first author and reviewed multiple times to ensure accurate transcription. All transcripts were reviewed multiple times, an iterative process of moving back and forth between texts. Extensive notes were written on the margins of printed transcripts, including notation of oft‐repeated terms, common themes and specific language relevant to the study that indicated assumptions and taken‐for‐granted practices. These were then organized into more structured topics. Not only did the interviews provide concrete descriptions of the practice setting and patient population, but a discourse analysis methodology allowed insight into the social processes of the texts and the power relations in which the texts were generated.

2.1. Disciplinary Power

This discourse analysis methodology, which functions via the analysis of texts, in this case, participant interviews, correlates with a Foucauldian poststructuralist framework focused on the role that power relations play in producing these discourses (Crowe 2005; Fairclough 2003). More specifically, Foucault (1995, 2006) concept of disciplinary power, which has been identified elsewhere as prevalent in forensic settings (Holmes 2002, 2005; Hörberg and Dahlberg 2015; Perron 2012). In his classic text Discipline and Punish (1995), Foucault traced the shifting forms of power that existed in the 17th and 18th centuries as the rule of sovereigns gave way to the emergence of democracies and the necessary management of larger populations during the industrial revolution. Disciplinary power emerged as a means of controlling individual bodies within defined spaces over long periods of time, a necessity of professional militaries, industrial workers and students; the barracks, the factory and the boarding school all represented sites of the emergence of disciplinary power. In these settings, disciplinary power operated as a form of total control, with constant observations of individuals producing detailed understanding of their behaviours and the necessity to normalize these behaviours. Punishment shifted from spectacular public displays of physical violence, common under sovereign power, to quiet and private corrections of (mis)behaviours; it was no longer necessary to enact punishment on the body, but to correct and shape the individual's soul. This is enacted via normalizing judgement, where only the slightest departures from expected behaviours result in punishment aimed at the correction of these (mis)behaviours. Through strict control of individual activities, constant observation and documentation, the individual could be understood and trained into a proper subject.

The ultimate manifestation of this form of power, to Foucault (1995), was Jeremy Bentham's (1995, Born 1748–Died 1832) conceptualization of the panopticon. To Bentham, the panopticon represented the ideal architecture for the prison: a circular building with a central watchtower and individual cells comprising the outer ring of the building. From this watchtower all inmate activities could be observed at all times. The slightest (mis)behaviour could be instantly observed by the anonymous tower guard and corrected. Knowledge of individual inmates would become so well developed that the slightest (mis)behaviours could be identified before they occurred. Similarly, the inmate becomes so accustomed to being observed that the prison could function without anyone actually watching; the inmates, so trained into this disciplinary model, simply police themselves. Such a model, it was proposed, would produce corrected individuals, suitable for release back into society, their souls corrected, their conduct re‐shaped into that which is acceptable. According to Foucault (1995), within this model of disciplinary power based on constant observation, not only are the inmates under perpetual watch, so too are those working within the space. As he noted, ‘since by its very principle it leaves no zone of shade and constantly supervises the very individuals who are entrusted with the task of supervising’ (p. 177). Those who do the watching are also watched—none can escape—what he described as ‘the spatial “nesting” of hierarchized surveillance’ (pp. 171–172). It is within this conceptualization of disciplinary power that we interrogate the ‘difficult’ patient in high security forensic hospital settings and the role of nurses in providing care.

3. Findings

Participants offered a diversity of perspectives on their work and the patient population in the high security forensic mental health setting. Though these units housed patients of a variety of legal statuses, participants spoke primarily of patients with a status of NCRMD as the most challenging or difficult to work with. Of these patients, two primary groups were identified as most challenging: patients with a diagnosis of ASPD, and patients living with long term, treatment‐resistant psychotic disorders, primarily schizophrenia. This first group of patients, those with a diagnosis of ASPD (and often described with co‐occurring substance use) comprised most of the discussion with participants, and are the focus of this paper. Though patients in these settings may possess multiple diagnoses, with some persons diagnosed with schizophrenia also diagnosed with ASPD, participants in this study distinctly separated these two groups.

3.1. Difficult Patients

This group of patients, those diagnosed with ASPD, were described by participants as capable of controlling their actions and behaviours, but willingly choosing to not do so. Participants described lying, deceitful and manipulative behaviours as causing challenges in the provision of nursing care. Participant 1 noted that ‘these patients normally do not always tell the full truth, and I find that very difficult’. A sense of entitlement was attributed to this group of patients. Participant 7 summarized:

The typical social norms don't make any sense to them. So, they…do things, whatever they want to do, and if you try to cue them for what is acceptable they just don't like it and they…escalate from there…they're absolutely entitled – it seems like the world is, you know, revolving around them.

Personal attacks and verbal abuse were attributed to this patient group, at times motivated by a nurse's ethnicity, gender or age. This patient group was also described as intrusive and not respectful of nurses’ privacy. Participant 2 stated ‘what you said to someone else, and they overheard it and now they're, you know, repeating your personal information, sharing it with other patients’.

Challenges with substance use were frequently attributed to this patient group. Those with an NCRMD legal status must abide by the provisions and privileges granted by their Review Boards (Cheng et al. 2023; Domingue, Jacob, Perron, Pariseau‐Legault, et al. 2023; Latimer and Lawrence 2006), which typically require abstention from the use of drugs and alcohol. Despite this, participants described substance use as widespread. As this violated both hospital rules and Review Board expectations, patients would be reprimanded for these actions. A consequence of this substance use was described as the movement of patients from lower security units to the high security units. These lower security units were described as more open and more capable of granting patient privileges. Patient substance use on these units is subject to sanctions via the transfer to the high security units and subsequent limited access to privileges. Participants described this group of patients diagnosed with ASPD as frequently cycling through these units; transfer from more open units to high security as sanctions for misbehaviours like substance use, eventual appropriate behaviour allowing transfer back to lower security, and so on. This was viewed as a source of frustration amongst nurses. Participant 6 noted:

It's frustrating for them to be shuttled back and forth in the system…usually it's the result of some sort of altercation, manipulation, anything. It often times involves drugs…it's quite frustrating to have all this work done and sending them down [to a lower security unit], and then right away they shoot themselves in the foot and they're brought back to us.

The highly restrictive setting and lack of patient freedoms on the high security units were described as a source of tension with this patient group. Nurses are responsible for the supervision and enforcement of strict unit rules, which Participant 3 described, ‘can develop the negative rapport between the staff and the patients here’. The ongoing frustration of seeing patients brought back to the high security units, abusive behaviours, and perceptions of manipulative behaviour led some participants to give up hope on this patient group. According to Participant 7, ‘there's no medication for them. They are just, you know, they're antisocials and psychopaths so there's nothing you can do for them’. These continuous negative interactions with patients can steer nurses away from developing therapeutic relationships towards more negative, even antagonistic relationships with patients, in addition to a sense of resignation that no treatment options are available.

What the participants in this study described was a highly disciplinary setting, correlating with Foucault (1995, 2006) conceptualization of this form of power. As described previously, the purpose of this disciplinary apparatus is to correct the (mis)behaviours of those individuals described as delinquents. In such a setting, strict adherence, at all times, to the rules and expectations of the setting is enforced by those tasked with their ongoing assessment and observation, in this case, the nurses. Within such settings exist systems of classification, based on an individual's ability to adhere to protocols, meet expectations and follow prescribed care plans. Within the forensic hospital system described here, a patient's assigned unit represents this form of classification. Well‐behaved patients enjoy the relative freedoms of low security units, whereas those who will not, or cannot, are relegated to the high security units, where the disciplinary apparatus continues the work of correction. However, as Foucault (2006) described in his lectures on psychiatric power, within such a system exists a form of residue, those who are unclassifiable. He noted that ‘disciplinary systems…come up against those who cannot be classified, those who escape supervision, those who cannot enter the system of distribution, in short, the residual, the irreducible, the unclassifiable, the inassimilable’ (p. 53). The ‘difficult’ ASPD patients described by participants are those who cannot be properly shaped according to the goals of a disciplinary power apparatus. Indeed, as Participant 7 offered, ‘not all the antisocials are really receptive to teaching. They just think the entire world is wrong and they're the only one that's right. So it's very, very, very challenging to teach them, because they're never gonna be receptive’.

The result of these ongoing antagonistic relationships with patients, and the focus on their various misbehaviours is prolonged detention within the forensic hospital system. As noted, jurisdictional Review Boards determine the parameters of patient privileges and freedoms, based upon assessments provided by the treatment teams, including nurses. As Domingue et al. (Domingue, Jacob, Perron, Pariseau‐Legault, et al. 2023; Domingue, Jacob, Perron, Foth, et al. 2023) observed, psychiatrists assess levels of risk to the public if individual NCRMD patients are considered for release from hospital. Nurses, primarily via their continued observation and documentation of patient conduct, contribute to these assessments, with patient deviations from institutional rules contributing to findings of higher levels of risk. These authors described the prolonged detention of NCRMD patients via this highly custodial approach. Indeed, disciplinary power is evident in these observations. Foucault (1995, 2006) described the importance of constant observation and detailed documentation of individual (mis)conduct as contributing to their classification. This classification serves as a motivator for individuals to achieve higher rankings, a means of ‘bending behaviour towards a terminal state’ (Foucault 1995, p. 161). NCRMD patients described as ‘difficult’ via their ASPD diagnosis are continually ranked or classified as high risk, justifying their continued detention in the forensic hospital via Review Board decisions. This leads, as participants here observed, to increased patient frustrations and continued (mis)behaviours, further perpetuating their detention ad infinitum.

3.2. Nursing Strategies

When working with this patient population, participants emphasized the importance of building a therapeutic relationship as a means of preventing or minimizing challenging behaviours. Participant 1 offered that ‘with that therapeutic rapport you're able to deescalate the situation without having to get security involved’. Participant 2 added that ‘just building that rapport with them, rather than just being an authority all the time. That way when you did need them—their cooperation—they approach you’. As Schafer and Peternelj‐Taylor (2003) noted, the therapeutic relationship is the foundation of nursing practice in forensic settings, and participants here noted that such relationships provide opportunities for constructive work with ‘difficult’ patients.

Rule enforcement was a point of contention amongst participants in this study, and not all nurses agreed on the extent to which rules should be enforced. In an effort to codify the expectations for ‘difficult’ patients, participants described the development of care plans. However, Participant 6 cautioned:

I've seen it done where perhaps the care plan becomes way too restrictive and punitive as well…like, you can't – if you do this, then you get punished, if you do this, then these privileges get taken off for an extreme amount of time, and it gets to the point where they feel suffocated and they react.

Such a strict enforcement of rules was described to produce patient (mis)behaviours, leading to some participants suggesting that a flexibility of rule enforcement is a preferred approach. Participant 4 explained the rationale behind this approach, stating ‘what works for me is I can compromise…I'm not going to throw down the rules. I can give some leeway, but I expect some cooperation back…and I find that usually works for me’. A recognition of the patient's situation, their long‐term confinement, often in high security settings, provided context to patient (mis)behaviours. As Participant 4 continued:

I understand that everyone has a bad day. I understand everyone has the right to be angry and frustrated. I understand that, you know, sometimes they need to voice out that frustration. I mean, I don't agree with how they voice out, or carry out, or act out their aggression and frustration if it's, you know, inappropriately. But I understand they also, you know, they're locked up. They need to vent.

This recognition of patient situations, a willingness to be less strict in rule enforcement was identified by some participants as an appropriate strategy when working with these ‘difficult’ patients.

However, not all participants agreed with this flexible and rule‐bending approach. Others insisted that strict adherence to rules and expectations was the appropriate means for working with these ‘difficult’ ASPD patients. Participant 6 offered ‘when you're dealing with individuals who are antisocial…they need a lot more stability than that, and a lot more routine regularity’. The highly structured care plans developed for ‘difficult’ patients, according to participants, did not include patient involvement. Participant 5 added ‘I think consistency is probably the number one problem on the unit. Because what one nurse will do tonight, another will…‘oh, you're not allowed to do that’…we need to tighten our team up’. A tension existed between these two approaches, with some participants suggesting that a flexible approach only exacerbated situations with these ‘difficult’ patients. This tension is not unique to this study setting. Moran and Mason (1996), in their examination of the nursing management of psychopathic patients, proposed the use of humour and rule flexibility as effective approaches. However, McVey (2010) disputed this approach, cynically suggesting that such an approach assumes ‘that all patients have the capacity to be grateful’ (p. 180). They, too, suggested the development of a structured care plan by a primary nurse, without input from the patient.

At the heart of this debate over approaches to nursing practice with ‘difficult’ patients is disciplinary power. Those who suggest strict routines and enforcement of rules—via care plans—are simply proposing the implementation and continuation of disciplinary power. As Foucault (2004) described, ‘discipline allows nothing to escape. Not only does it not allow things to run their course, its principle is that things, the smallest things, must not be abandoned to themselves’ (p. 45). It is all‐encompassing; every action, every behaviour, every moment of the disciplinary subject's existence must be monitored and recorded, the most miniscule of deviations to be corrected. And as Foucault (2006) identified, this strict routine‐based approach to the correction of mental illness has been viewed for centuries as an appropriate course of treatment. The underlying assumption in this approach is that the delinquent, ‘difficult’ patient can be corrected, their body and soul trained into actions and behaviours that are deemed appropriate. Yet, as Foucault (2006) noted, in any disciplinary apparatus there will exist this ‘residue’, these ‘inassimilable’ individuals who expose the margins of disciplinary power. Within a disciplinary logic, ‘supplementary disciplinary systems [are invented] to retrieve these individuals, and so on to infinity’ (p. 54). The development of these punitive care plans by nurses working with ‘difficult’ ASPD patients represents supplementary systems aimed at finally capturing these individuals within the disciplinary apparatus. Yet such approaches, in many cases, are futile, leading to both participants here and authors elsewhere to suggest that these patients are untreatable (McRae 2013; McVey 2010). And while this may appear true, it is only within a disciplinary logic that they are untreatable. Foucault (2006) stated that the deserter did not exist before the invention of the disciplined army. These ‘difficult’ patients are a product of a disciplinary forensic system.

3.3. The Role of Nurses

Nurses situated themselves within this disciplinary system. They acknowledged that they, too, were subject to scrutiny, their practices criticized by both their peers and hospital management if they deviated from disciplinary approaches. Participant 5's criticism of a lack of consistency and the expressed need to ‘tighten up’ practices provided a prime example. Furthermore, participants noted challenges with hospital management and administration in wishing to pursue alternative forms of practice. Participant 6 described the ‘dissonance between upper management…the health authority as a whole, as their policies and procedures’ as interfering with preferred nursing practices. This included, as the same participant observed, the potential to implement harm reduction approaches regarding patient substance use, wherein substance use is not specifically forbidden, but is permitted in a manner that minimizes risk or harm to the patient, other patients and unit staff. However, this would represent a significant departure from a disciplinary approach that aims to control everything (Foucault 1995). This scrutiny of nursing practices and insistence on conformation to policies and procedures is the continued functioning of disciplinary power. In the panopticon, not only are the inmates under constant surveillance, so, too, are those responsible for this surveillance. Disciplinary power ‘is everywhere and always alert, since by its very principle it leaves no zone of shade and constantly supervises the very individuals who are entrusted with the task of supervising’ (Foucault 1995, p. 177). This power functions not only from the top down, but also both upwards and laterally, a ‘spatial “nesting” of hierarchized surveillance’ (Foucault 1995, pp. 171–172).

Yet participants also identified this existence within the same power structure as an opportunity to better build relationships with ‘difficult’ patients, based on empathy and solidarity. Nurses are also subject to methods of surveillance and control, particularly those who wish to be flexible in their approach and deviate from the rules. Participant 7 shared:

At times, you know, I just feel like I am on their side…what I do is kind of make them, kind of feel like me. I say you know, what you're asking…man, I can't do this because I'm a healthcare professional. I can't meet this request. But if you put yourself in my shoes, man…if I go, you know, do something that I'm not supposed to be doing I'll be losing my job and all that. And they're understanding that. I just, you know, tell them if you were me how would you feel right now…I can empathize with you.

By placing themselves within the same power relations as the patients, participants noted opportunities to build a sense of solidarity and highlight how they, too, are subject to consequences for (mis)behaviours.

4. Nursing Implications

We have dedicated much time and energy to a group of patients comprising a small proportion of the overall forensic hospital patient population. While this may be true, it must be noted that this patient group presents a disproportionate amount of stress, burnout and effort amongst forensic psychiatric nurses. McRae (2013) described this patient group as both a drain on unit resources and disruptive to the treatment of other patients; noting this patient group required the most time of nurses and contributed to increased nurse burnout. Furthermore, they identified that the setting they studied would actively work against the admission of this patient group in the first place. Murphy and McVey (2010) attributed fear of personal injury, traumatization, a loss of professional integrity, and shame and humiliation to those working with personality disordered patients. They noted that nurses are most likely to face these difficulties as they carry the most responsibility for patient care. Nurses in the present study expressed frustration, resignation and concerns over personal attacks. Perspectives on treatment varied, suggesting splitting amongst staff over perceived appropriate approaches.

Perspectives on how to adequately provide care for this patient group acknowledge the significant challenges presented, particularly to nurses. As McVey (2010) observed, ‘their behaviour is frequently subjected to moral scrutiny, resulting in the patient being labelled “bad,” rather than being considered within the context of a clinical formulation’ (pp. 177–178). In concert with the various day‐to‐day difficulties presented here, they noted that patient care tends more toward management than actual treatment. Therapeutic goals are abandoned in favour of strategies aimed to minimize disruptive (mis)behaviours; the pendulum of nursing practice swinging towards custody and away from caring. Despite widespread perceptions that ASPD patients are ‘untreatable’, McVey (2010) offered a series of treatment modalities and strategies for working with this population, the basis of which is a positive interpersonal relationship. Related is the recognition that most patients with a diagnosis of a personality disorder have experienced significant trauma, often in childhood, leading to ‘maladaptive’ behaviours, an acknowledgement mirrored by Aiyegbusi and Kelly (2015). These authors suggest that patient behaviours viewed as difficult are in fact a form of patient crisis, and should be met with validation and understanding, as opposed to punishment. This treatment of patients, in contrast to simple management, is ‘significantly more challenging than management for both staff and patients’ (McVey 2010) and requires additional education and training for nurses and commitment to a model of care. Similarly, Byrt (2013) proposed a holistic model of nursing care for patients with diagnoses of personality disorders, based on psychotherapies and therapeutic communities, but also acknowledged the significant nurse training required. Seitanidou et al. (2024) identified trauma‐informed care as a viable and important component of practices in forensic settings, acknowledging the significant histories of trauma affecting many patients’ behaviours and relationships with staff. With appropriate education, such approaches show potential to improve nurse–patient interactions and patient outcomes. Disappointingly, in the present study, participants did not indicate any form of specialized training for working with ASPD patients and, when asked to indicate a model of care guiding their practice, only one participant could answer.

While the evidence suggests that appropriate, holistic, collaborative treatment modalities do exist for ASPD patients in forensic settings, these options exist contrary to the tenets of a disciplinary power apparatus. The high security forensic hospital practice setting explored here correlated with this disciplinary system, where strict adherence to rules and expectations is required, patients are observed, assessed and classified, and failure to meet expectations resulted in patient punishment and prolonged detention. The proposed interventions described above, based on collaborative engagement, work to understand the source of patient (mis)behaviours, and a level of tolerance for patient outbursts, oppose this arrangement. In fact, the strategies proposed by some nurses in this study, such as flexible enforcement of rules, willingness to permit some patient outbursts, and harm reduction approaches to patient substance use were all described as opposed to hospital policy or Review Board expectations, or were criticized by other participants for their lack of consistency with preferred practices. If a disciplinary system lets nothing escape (Foucault 2004), how can such practices be permitted? What is required is a willingness to abandon this disciplinary approach altogether. We recognize that such a proposal may seem both radical and difficult to implement, particularly from the perspective of Review Boards, but, combined with more appropriate nurse education and training in therapeutic interventions, may result in a shift away from futile attempts to correct what Foucault (2006) described as the ‘inassimilable’. Furthermore, given that the therapeutic relationship provides the basis for more treatment‐focused nursing interventions, an acknowledgement that nurses, too, exist within the same power relations as patients provide opportunities to build both empathy and a sense of solidarity. While nurses may eventually work towards a relaxation of disciplinary measures, to start they can identify that they exist within the same disciplinary system as their patients.

5. Conclusions

In this paper, we provided a critical reflection on nursing practice with ‘difficult’ patients within two high security units, in forensic hospital setting, located in Western Canada. A discourse analysis methodology permitted the placement of participant discussions in the context of institutional power relations, specifically Foucault (1995, 2006) conceptualization of disciplinary power. Such an apparatus of power is all‐encompassing, capturing both patients and nurses within an ever‐present system of surveillance and assessment, where even the slightest deviation from acceptable norms is subject to correction. Patients with a diagnosis of ASPD were described by participants as the most challenging or ‘difficult’ to work with, primarily on account of their inability to function within this disciplinary system—Foucault (2006) concept of the ‘inassimilable’ delinquent. A failure to adhere to disciplinary expectations only led to the creation of new, more severe and punitive rules, in the form of non‐collaborative patient care plans. Proposals from participants on how to better engage with these ‘difficult’ patients and move from management to treatment relied on deviation from disciplinary logic. Here we propose an acceptance of this flexibility of nursing approaches and adoption of more holistic practices, including the patient in the development of care plans, while acknowledging that doing so stands in stark contrast to existing practices. However, if these ‘difficult’ patients are effectively the product of this disciplinary system, then shifting practices may provide long‐term solutions for a small but challenging patient population.

Ethics Statement

Ethics approval was provided by the University of Saskatchewan (ID 1629) and the health research ethics board of the study setting.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The authors have nothing to report.