Abstract
Background
Forensic mental health (FMH) serves as a critical juncture between the mental health and criminal justice systems. Factors on multiple levels – including sociopolitical, organizational, and individual— pose challenges to conducting implementation research in these settings. This hinders the uptake of evidence-based interventions and improvements to patient outcomes. This study examined implementation research conducted in FMH settings to understand its current state and inform future implementation research and practice.
Methods
We conducted a scoping review following the Joanna Briggs Institute methodology. A comprehensive literature search was performed across seven databases from their inception through April 2024, supplemented by searches in Google Scholar and six review studies, to identify relevant research. We analyzed included studies descriptively to explore determinants, strategies, and outcomes associated with the implementation of evidence-, or policy-based interventions in FMH.
Results
Of the 1327 records retrieved, 41 implementation studies were included. All studies were conducted in high-income countries and focused on interventions such as risk assessment, rehabilitation, patient support, and technology interventions, primarily using qualitative approaches. Key determinants for implementing interventions in FMH included individual characteristics (e.g., motivation, capacity) and inner setting factors (e.g., intervention compatibility with existing practices, access to knowledge and information). Various strategies, such as using evaluative and iterative strategies, training and educating stakeholders, changing infrastructure, and engaging consumers have been used to facilitate intervention uptake in FMH. Implementation outcomes primarily focused on uptake, fidelity, and acceptability.
Conclusions
There is a clear need for more implementation research using rigorous study designs in FMH. Multilevel implementation strategies should be employed to address barriers from both the inner settings and individual characteristics, thereby promoting the successful implementation of interventions in FMH. Future implementation research should incorporate a health equity lens throughout the research process to enhance inclusivity and improve reporting on implementation strategies to support replications of interventions in FMH.
Supplementary Information
The online version contains supplementary material available at 10.1186/s43058-025-00772-3.
Keywords: Forensic mental health, Implementation science, Scoping review, Implementation determinants, Implementation strategies, Implementation outcomes
Contributions to the literature.
All included studies were conducted in high-income countries with qualitative designs being the most common. This indicates a need for more implementation studies using rigorous study designs in FMH.
Individual characteristics (e.g., motivation, capacity) and inner settings (e.g., compatibility with existing practices) were the key determinants for implementing interventions in FMH, and multilevel strategies were commonly used to address implementation challenges.
There is a need to incorporate a health equity lens throughout implementation research processes to enhance inclusivity, and to provide more detailed reporting of implementation strategies to support replications of interventions in FMH.
Background
Forensic mental health (FMH) represents a unique healthcare setting that focuses on assessing and addressing the mental health and criminogenic needs of individuals involved with the legal and criminal justice systems. This includes people deemed unfit to stand trial, those found not criminally responsible due to mental illness, mentally ill individuals within correctional facilities, persons exhibiting severe aggression that cannot be managed in general adult mental health services, and, in some regions, individuals detained under mental health laws such as compulsion orders [1]. From a global perspective, FMH settings vary widely depending on legal, economic, and sociopolitical factors. They typically include specialized psychiatric hospitals, forensic units within general psychiatric hospitals, secure units in prisons, and, in some jurisdictions, community-based forensic services [1].
FMH settings are often confused with incarcerated environments like prisons, but they serve distinct purposes —especially in North American contexts such as Canada and the United States. While both involve individuals who have interacted with the criminal justice system, FMH settings are healthcare environments where individuals with mental health disorders receive specialized treatment and support. These facilities emphasize psychiatric assessment, therapeutic intervention, and rehabilitation, delivered by multidisciplinary teams comprising psychiatrists, psychologists, nurses, and other healthcare professionals in a secure setting. The primary aim is to address the complex mental and physical health needs of patients and facilitate their recovery and reintegration into society. In contrast, prisons are correctional facilities focused on punishment and confinement for individuals convicted of crimes, without the same emphasis on mental health care.
FMH settings differ from other mental health and healthcare environments in several critical ways. First, the setting is inherently restrictive, with patients detained under legal orders for an extended period. Data indicates that 18% of patients spend over five years in medium-security FMH settings and 22% over ten years in high-security FMH settings [2, 3]. This security-focused environment significantly limits patients’ autonomy, affects their treatment engagement, and poses challenges to building therapeutic alliances. Second, patients in these settings often face dual stigma — mental health conditions exclude them from meaningful participation in healthcare decisions and justice involvement isolates them from essential social support networks [4]. These challenges, exacerbated by the entrenched power imbalance between health professionals and patients [5, 6] and longstanding psychiatric paternalism [7], hinder the exercise of patient rights and deepen experiences of health inequity. Third, FMH professionals must navigate dual roles [8], which involve ensuring patient well-being and addressing legal and public safety concerns. This duality often leads to ethical dilemmas as professionals attempt to reconcile their responsibilities to patients and the justice system.
These factors collectively contribute to the challenges in conducting clinical research in FMH settings, particularly implementation research which aims to promote the uptake of evidence-based interventions into routine practice. Due to their mental health conditions and justice involvement, patients in FMH settings have been historically excluded from clinical trials, resulting in substantial gaps in evidence-based practices tailored to their needs. The restrictive nature of FMH settings, where safety and security are prioritized, further limits the flexibility required to test and implement new interventions. Researchers must navigate stringent regulatory procedures to introduce or adapt practices [9]. Furthermore, the ethical and legal complexities of working with a legally mandated population present additional challenges, such as obtaining informed consent from individuals with serious mental illness or developmental disabilities.
Despite these challenges, implementation research is urgently needed in FMH to meet the unique and often complex needs of patients, and ensure the delivery of high-quality, patient-centered care [10, 11]. By identifying context-specific barriers and tailoring implementation strategies accordingly, implementation research can help bridge the gap between evidence-based practices and real-world applications in FMH [10, 12]. For example, trauma-informed care, which has demonstrated efficacy in reducing re-traumatization and improving therapeutic outcomes [13–15], remains underutilized in FMH due to barriers such as organizational culture, limited training, and constrained resources [16]. Addressing these barriers requires effective implementation strategies that are often developed and tested through rigorous implementation research designs, such as clustered randomized trials. Moreover, implementation science is closely linked to health equity [17], which is particularly relevant in FMH. Patients in FMH often face multiple intersecting vulnerabilities—such as poverty, systemic racism, and social exclusion—that contribute to significant health disparities [18]. To address these disparities, culturally sensitive interventions and co-designed implementation research are essential to meet the spiritual and cultural needs of marginalized and Indigenous populations. Embedding a health equity lens into the design, execution, and evaluation of implementation research in FMH helps ensure that services are inclusive, responsive, and accessible to all patient groups.
Systematically monitoring the state of implementation research through a scoping review can help identify knowledge gaps to inform policy and improve practice. Specifically, synthesizing the methodological features (e.g., study design) and the participant profiles (e.g., patient demographics) provides essential context for interpreting the scope and relevance of implementation research in FMH. This enables the identification of potential population groups or contexts that are underrepresented, which is critical for advancing equity and tailoring future implementation efforts [19]. Examining implementation determinants, strategies, and outcomes offers a comprehensive understanding of why evidence-based or policy interventions in FMH succeed or fail in practice, the actions used to address barriers and support uptake, and the extent to which implementation success is achieved. Altogether, these elements support the development of more context-sensitive and effective implementation approaches, ultimately enhancing the translation of evidence-based interventions into routine FMH practice. However, to our knowledge, no review studies have systematically examined the progress of implementation research in FMH. This study aimed to fill this gap with the following objectives: 1) Examine the study characteristics, as well as the characteristics of patients and healthcare professionals involved in implementation research; 2) Identify and synthesize the determinants (barriers and facilitators) influencing the implementation of evidence- or policy-based interventions FMH; 3) Categorize the strategies employed for implementing these interventions; and 4) Examine the extent to which outcomes are reported in implementation studies.
Methods
We conducted a scoping review following the Joanna Briggs Institute scoping review methodology [20]. This review has been registered in the Open Science Framework (https://osf.io/2fh3c). Reporting of the findings followed the PRISMA-ScR guideline [21]. The scoping review approach is appropriate for our study in that it aims to identify available evidence and examine the research progress in a specific field – implementation research in FMH settings [22].
Eligibility criteria
Participants
We included implementation studies in which patients from either inpatient or outpatient FMH settings were participants. We also included studies focusing on FMH staff, regardless of whether they provided clinical or non-clinical services.
Concept
Given that implementation research is a broad term, we operationalized the concept into three categories based on existing literature [23–25] and team discussion: 1) studies that assessed the determinants (barriers and/or facilitators) for implementing evidence-based or policy-based FMH interventions, including forensic risk assessment; 2) studies that developed, and/or evaluated implementation strategies, or examined implementation mechanisms; 3) studies that promoted the sustainment, or scaling-up of evidence-based or policy-based FMH interventions.
Context
FMH settings are dedicated to assessing risks and providing treatment for individuals who have experienced mental illness and have been involved in the criminal justice system. This study exclusively considers FMH settings and does not address incarcerated settings in general.
Types of evidence sources
We included primary studies in peer-reviewed journal articles and theses/dissertations in the English language. We excluded book chapters, conference abstracts, commentaries, editorials, and studies without full text.
Search strategy
We (JZ & SJ) conducted a comprehensive search across seven databases: Medline (Ovid), PsycINFO (Ovid), Embase (Ovid), CINAHL (EBSCO), Criminal Justice Abstracts (EBSCO), Sociological Abstracts (ProQuest), and ProQuest Dissertations and Theses, covering literature from the inception of each database up to April 2024. To ensure thoroughness, we also searched Google Scholar and hand-screened references from six review articles [5, 26–30]. The search strategies were developed through team discussions and consultations with a research librarian specializing in FMH. See Appendix One for the search strategies used in Medline. All retrieved records were uploaded to Covidence [31] for screening and data extraction.
Data screening
All team members (JZ, BB, SJ, CC & ZH) participated in the study screening and selection process. A group meeting was held to review and clarify the eligibility criteria, followed by a pilot screening of 15 records to reach a consensus. We performed the title/abstract screening in duplicate, independently by two reviewers. Any disagreements between the reviewers were resolved through discussion between the two reviewers or, if necessary, adjudicated by JZ. Interrater reliability for the title and abstract screening was calculated using Cohen’s Kappa, yielding a value of 0.93 which indicates a high level of agreement. Full-text screening was subsequently conducted using the same process, resulting in a Kappa value of 0.77.
Data extraction
We developed a preliminary data extraction form, which was refined following a pilot data extraction independently by two reviewers (SJ & BB) with three included studies. The following information was extracted: 1) study characteristics: year of publication, journal, country, theoretical frameworks, study designs, setting(s); 2) characteristics of participants (patients and staff) based on the PROGRESS-Plus framework [19]; 3) Implementation barriers/facilitators and the data collection methods; 4) evidence-based or policy interventions (“the thing” [32]), implementation strategies (“how to do the thing” [32]), and development approaches for these strategies; 5) outcome measures and their evaluation methods. All team members participated in the data extraction. Each article was extracted independently by one reviewer (JZ, SJ, BB) and verified by a second reviewer (ZH, CC). Any discrepancies were resolved through discussion or adjudicated by a third reviewer (JZ).
Analysis of the evidence
We tabulated the study characteristics and participants’ characteristics (i.e., PROGRESS-Plus components) using frequencies and proportions. For implementation determinants, we coded them into the five domains of the Consolidated Framework for Implementation Research (CFIR) 2.0 [33] – inner setting, outer setting, innovation characteristics, individual characteristics, and process. We calculated the number of studies mapped to each of the determinants in CFIR and visualized the results. We categorized implementation strategies into the nine categories of the Expert Recommendations for Implementing Change (ERIC) taxonomy [34] and calculated the number of studies mapped to each category. Guided by the implementation outcome taxonomy proposed by Proctor and colleagues [35], we calculated the number of studies for each outcome indicator.
Results
Study characteristics
Of the 1265 records retrieved from database searches and 62 records from other sources, 459 duplicates were eliminated (444 by Covidence, and 15 by hand), leaving a total of 868 records included for screening. We included 41 full-text records for final analysis (See Appendix two for the included records). The process of the literature search and screening is shown in Fig. 1. Study characteristics of the 41 records are summarized in Table 1. The earliest forensic implementation research identified was published in 2005, and the year 2020 saw the highest number of publications (10/41, 24%). All the included implementation studies were conducted in high-income countries, with the United Kingdom (9/41, 22%) and the United States (9/41, 22%) accounting for the most publications. Forty-one percent included studies employed a qualitative design (17/41), followed by quasi-experimental (7/41, 17%), multimethod (7/41, 17%), and mixed method approaches (6/41, 15%). Notably, only one study used a hybrid efficacy-implementation controlled trial [36]. These implementation studies were conducted across FMH settings with varying security levels (i.e., low-, medium-, and high-security), focusing on diverse interventions such as risk assessment, rehabilitation, patient support, and technology interventions. The most commonly used implementation framework was the CFIR framework (7/41, 17%).
Fig. 1.
PRISMA diagram
Table 1.
Basic characteristics of included studies
| Basic characteristics | No. of studies (n (%)) | Basic characteristics | No. of studies (n (%)) |
|---|---|---|---|
| Year of publication | Journal/thesis | ||
| 2005 | 1 (2%) | Thesis | 6 (15%) |
| 2011 | 2 (5%) | International journal of forensic mental health | 3 (7%) |
| 2014 | 1 (2%) | British journal of occupational therapy | 2 (5%) |
| 2015 | 2 (5%) | Frontiers in psychiatry | 2 (5%) |
| 2016 | 5 (12%) | International journal of offender therapy and comparative criminology | 2 (5%) |
| 2017 | 3 (7%) | Journal of forensic psychiatry and psychology | 2 (5%) |
| 2018 | 5 (12%) | Journal of medical internet research | 2 (5%) |
| 2019 | 4 (10%) | Journal of substance abuse and treatment | 2 (5%) |
| 2020 | 10 (24%) | Psychiatric services | 2 (5%) |
| 2021 | 2 (5%) | Settinga | |
| 2022 | 3 (7%) | Forensic mental health facility | 17 (41%) |
| 2023 | 3 (7%) | High secure inpatient | 5 (12%) |
| Country | Medium secure inpatient | 8 (20%) | |
| United Kingdom | 9 (22%) | Low secure inpatient | 3 (7%) |
| United States | 9 (22%) | Forensic outpatient program | 6 (15%) |
| Netherlands | 7 (17%) | Acute forensic unit | 2 (5%) |
| Canada | 3 (7%) | Community forensic mental health setting | 2 (5%) |
| Australia | 2 (5%) | Correctional facility | 2(5%) |
| Finland | 2 (5%) | Residential youth care center | 2 (5%) |
| Norway | 2 (5%) | Topic of focusb | |
| Singapore | 2 (5%) | Risk, aggression, violence | 17 (41%) |
| Sweden | 2 (5%) | Rehabilitation and reintegration | 10 (24%) |
| Belgium | 1 (2%) | Safety and crisis management | 8 (20%) |
| Germany | 1 (2%) | Treatment | 7 (17%) |
| New Zealand | 1 (2%) | Patient support system | 6 (15%) |
| Study designs | Technology intervention | 6 (15%) | |
| Qualitative design | 17 (41%) | Safewards program | 4 (10%) |
| Quasi-experimental design | 7 (17%) | Implementation theories/frameworks/models | |
| Multimethod | 7 (17%) | Consolidated Framework for Implementation Research (CFIR) | 7 (17%) |
| Mixed methods | 6 (15%) | The Ottawa Model Of Research Use | 3 (7%) |
| Case study | 2 (5%) | Reach, Efficacy, Adoption, Implementation, Maintenance (RE-AIM) | 2 (5%) |
| Retrospective evaluation | 1 (2%) | Theoretical Domains Framework | 2 (5%) |
| Hybrid efficacy-implementation controlled trial | 1(2%) | WHO Guidelines For Quality Improvement | 2 (5%) |
| Non Adoption, Abandonment, Scale-Up, Spread, And Sustainability (NASSS) | 1 (2%) | ||
| Proctor Outcome Framework | 1 (2%) | ||
aseveral studies are conducted in multiple settings
bsome studies included more than one topic
Of the 41 included records, 17 reported patient characteristics, covering a total of 1,983 patients (see Table 2). Seven studies provided data on the sex of patients, and only one study reported data on gender. Among the 965 patients with sex data, 660 (68%) were identified as male and 305 (32%) as female. Of the 36 patients with gender data, 33 (92%) were identified as men and 3 (8%) as women. Among the 998 patients in the seven studies that reported age, the average age was 40.2 years, with a range from 18 to 88 years. On average, patients stayed in FMH settings for 3.2 years, with a range of 0.14 to 8.3 years. Only four studies reported patient race, with the majority of patients identified as White (401/944, 42%). Eleven studies provided data on patients’ mental health conditions, including a total of 1,705 patients. Among them, 707 patients had schizophrenia, and 555 patients had substance use disorders.
Table 2.
Patient characteristics of include studies
| Patients characteristics | No. of Studies (n(%)) | No. of patients (n (%)) | Mean (SD) | Range (n) |
|---|---|---|---|---|
| Total | 17 | 1983 | 117 (230) | 1—750 |
| Sex (n) | 7 (41%)a | 965 (49%) | ||
| Male | 7 (41%) | 660 (33%) | 451 (152) | 3—94 |
| Female | 3 (18%) | 305 (15%) | 299 (140) | 2—102 |
| Gender (n) | 1 (6%)b | 36 (2%) | ||
| Men | 1 (6%) | 33 (2%) | 33 | 33 |
| Women | 1 (6%) | 3 (0%) | 3 | 3 |
| Age (Years) | 7 (41%)c | 998 (50%) | 40.2 (6.6) | 18—88 |
| Length of Stay (Years) | 5 (29%)d | 225 (11%) | 3.2 (3.4) | 0.14—8.3 |
| Race | 4 (24%) | 944 (48%) | ||
| White | 4 (24%) | 401 (20%) | ||
| Black | 4 (24%) | 150 (8%) | ||
| Asian | 3 (18%) | 146 (7%) | ||
| Hispanic | 2 (12%) | 145 (7%) | ||
| Other | 4 (24%) | 102 (5%) | ||
| Mental health condition | 11 (65%) | 1705 (86%) | ||
| Substance use disorders | 7 (41%) | 555 (28%) | ||
| Schizophrenia | 6 (35%) | 707 (36%) | ||
| Concurrent disorders | 5 (29%) | 38 (2%) | ||
| Major depressive disorder | 3 (18%) | 86 (4%) | ||
| Psychotic disorders | 3 (18%) | 94 (5%) | ||
| Bipolar disorder | 2 (12%) | 134 (7%) | ||
| Other | 9 (53%) | 91 (5%) | ||
| Education | 1 (6%) | 3 (0%) | ||
| Bachelor's degree | 1 (6%) | 3 (0%) | ||
| Place of Residencee | 15 (88%) | |||
| Forensic psychiatric hospital | 5 (29%) | |||
| Community forensic mental health setting | 3 (18%) | |||
| Multilevel security facility | 3 (18%) | |||
| Medium secure | 2 (12%) | |||
| Correctional facility | 1 (6%) | |||
| High secure | 1 (6%) |
aA total of 9 studies referenced sex of patients, but only 7 studies specified No. of patients per sex
bA total of 2 studies referenced gender, but only 1 study specified No. of patients per gender
cOf the 8 studies reporting age, only 7 studies reported total No. of patients
dOf the 7 studies reporting length of stay, only 5 studies reported total No. of patients
eFew studies clarified the No. of patients in each place of residence
Of the 41 included records, 32 reported forensic staff characteristics, covering a total of 1,175 staff members (see Table 3). Twelve studies provided data on the sex of staff, with a total of 295 staff members. Of these, 111 (38%) were identified as male and 184 (62%) as female. Two studies reported gender identification for 32 staff members, with 17 (53%) identified as men and 15 (47%) as women. The average age of staff, reported across 13 studies involving 280 individuals, was 40.9 years, with a range of 18 to 72 years. Staff working experience in forensic units varied from 0.5 to 29 years, with an average of 9.8 years. Five studies reported the race of staff, covering a total of 104 staff members. Among them, 60 (58%) were White and 40 (38%) were Black. A variety of forensic professionals participated in these implementation studies, including psychologists, psychiatrists, nurses, social workers, and others.
Table 3.
Staff characteristics of include studies
| Staff characteristics | No. of Studies (n(%)) | No. of staff (n(%)) | Mean (SD) | Range (n) |
|---|---|---|---|---|
| Total | 32a | 1175 | 37 (49) | 6—259 |
| Sex (n) | 12 (38%)b | 295 (25%) | ||
| Male | 10 (31%) | 111 (9%) | 9 (7) | (2–25) |
| Female | 12 (38%) | 184 (16%) | 14 (6) | (3–26) |
| Gender (n) | 2 (6%) | 32 (3%) | ||
| Men | 2 (6%) | 17 (1%) | 8.5 | (8–9) |
| Women | 2 (6%) | 15 (1%) | 7.5 | (4–11) |
| Age (Years) | 13 (41%) | 280 (24%) | 40.9 (5.3) | 18—72 |
| Years of Experience in a Forensic Unit (Years) | 11 (34%) | 206 (18%) | 9.8 (5.6) | 0.5—29 |
| Race | 5 (16%) | 104 (9%) | ||
| White | 5 (16%) | 60 (5%) | ||
| Black | 4 (13%) | 40 (3%) | ||
| Hispanic | 1 (3%) | 4 (0%) | ||
| Occupation | 29 (91%)c | 1079 (92%) | ||
| Staff nurse | 18 (56%) | 58 (5%) | ||
| Social worker | 14 (44%) | 39 (3%) | ||
| Occupational therapist | 9 (28%) | 4 (0%) | ||
| Clinical manager | 3 (9%) | 3 (0%) | ||
| Psychiatrist | 13 (41%) | 18 (2%) | ||
| Psychologist | 17 (53%) | 44 (4%) | ||
| Other | 31 (97%) | 916 (78%) | ||
| Education | 6 (19%) | 164 (14%) | ||
| Master's degree | 2 (6%) | 27 (2%) | ||
| Bachelor's degree | 1 (3%) | 17 (1%) | ||
| High school graduate | 1 (3%) | 3 (0%) | ||
| Other | 5 (16%) | 117 (10%) |
aA total of 35 studies reported staff participants, only 32 studies specified No. of staff
bA total of 15 studies referenced sex of staff, only 12 studies specified No. of staff per sex
cA total of 35 studies reported staff occupation, only 29 studies specified No. of each occupation
Barriers and facilitators for implementation
Among the 41 studies, 38 reported barriers and/or facilitators for the implementation of interventions in FMH. Specifically, 35 studies identified barriers and 30 identified facilitators. These studies employed various methods to identify barriers and/or facilitators: interviews (26/38, 68%), focus groups (14/38, 37%), surveys (6/38, 16%), document reviews (4/38, 11%), and observations (2/38, 5%). We classified these barriers/facilitators into the constructs and domains in CFIR. A visual representation is presented in Fig. 2.
Fig. 2.
Visualization of barriers and facilitators
The most frequently reported barriers stemmed from the individual characteristics (27/35, 77%) and inner setting (26/35, 74%) domains. Specifically, individual capability (18/35, 51%), motivation (17/35, 49%), and compatibility of the intervention with existing practices (14/35, 40%) were the most common barriers. For example, in a qualitative study involving FMH staff on the implementation of clinical guidelines for co-occurring substance use and major mental disorders [37], participants noted that "the staff's attitudes toward SUD (substance use disorder) varied, and disparate attitudes were considered problematic for work team efficiency and morale (P4)." They also pointed out that “no staff members had time in their schedule dedicated to working with SUD assessment or treatment, and that other staff members did not consider SUD treatment to be part of their job description and were therefore uninterested in SUD-related work tasks (P5)”. These observations highlighted a lack of motivation and the incompatibility with existing practices as key barriers to implementing the co-occurring disorder guidelines.
Most facilitators for implementing interventions in FMH came from the inner setting (23/30, 77%), individual (16/30, 53%), and innovation characteristics (16/30, 53%) domains. Specifically, access to knowledge and information (10/30, 33%), individual capability (10/30, 33%), motivation (10/30, 33%) and innovation relative advantage (9/30, 30%) were the most common facilitators. For example, in a qualitative study with staff on their perceptions of the use of a risk assessment instrument in forensic psychiatry [38], staff highlighted the importance of continuous support for education and supervision by highly trained and experienced psychologists in conducting the assessment. In another qualitative study of staff members’ perspectives towards the use of Modified Overt Aggression Scale (MOAS) [39], participants stated that “the introduction of the MOAS helped to get everyone on the same track…. the analysis of aggressive incidents could better inform intervention and prevention policy (e.g., introducing de-escalating strategies) and handling the work climate of the staff members (e.g., psychosocial well-being, and a healthy work environment) (P666)”. These studies emphasized the access to knowledge and innovation relative advantage as key facilitators for implementing interventions in FMH.
Implementation strategies
The evidence-based or policy-based interventions implemented in FMH settings fell into five categories (see Table 4): therapeutic Interventions (13/41, 32%) such as Moral Reconation Therapy; assessment tools (10/41, 24%) such as the dynamic appraisal of situational aggression; organizational approaches (7/41, 17%) such as Safewards; support services (6/41, 15%) such as forensic housing first programs; and technology-based interventions (5/41, 12%) such as virtual reality.
Table 4.
Implementation strategies and outcomes of included studies
| Interventions and implementation strategies | No. of Studies Reporting (n(%)) | Outcomes | No. of Studies Reporting (n(%)) |
|---|---|---|---|
| Interventions implemented | 41 (100%) | Evaluation method | 21 (51%) |
| Therapeutic interventions (e.g.: moral reconation therapy) | 13 (32%) | Interviews | 8 (20%) |
| Assessment tools (e.g.: dynamic appraisal of situational aggression) | 10 (24%) | Survey | 8 (20%) |
| Organizational approaches (e.g.: safewards) | 7 (17%) | Focus groups | 6 (15%) |
| Support services (e.g.: forensic housing first programs) | 6 (15%) | Data/record review | 6 (15%) |
| Technology-based interventions (e.g.: virtual reality) | 5 (12%) | Other | 6 (15%) |
| Implementation strategies | 21 (51%) | Implementation outcomes | 18 (47%) |
| Use evaluative and iterative strategies | 11 (27%) | Uptake | 10 (24%) |
| Train and educate stakeholders | 11 (27%) | Fidelity | 9 (22%) |
| Change infrastructure | 11 (27%) | Acceptability | 6 (15%) |
| Engage consumers | 10 (24%) | Sustainability | 5 (12%) |
| Support clinicians | 7 (17%) | Penetration | 5 (12%) |
| Develop stakeholder interrelationships | 5 (12%) | Appropriateness | 4 (10%) |
| Adapt and tailor to context | 4 (10%) | Feasibility | 4 (10%) |
| Utilize financial strategies | 3 (7%) | Costs | 2 (5%) |
| Provide interactive assistance | 1 (2%) | Adaptation | 1 (2%) |
| Development approaches | 12 (29%) | Readiness | 1 (2%) |
| Interviews | 7 (17%) | Service outcomes | 4 (10%) |
| Focus groups | 5 (12%) | Safety | 2 (5%) |
| Surveys | 3 (7%) | Ward climate | 2 (5%) |
| Effectiveness | 1 (2%) | ||
| Conflict and containment | 1 (2%) | ||
| Patient outcomes | 2 (5%) | ||
| Patient cohesion | 2 (5%) |
We classified the extracted implementation strategies into the nine categories in the ERIC taxonomy. Twenty-one studies reported the implementation strategies employed to facilitate the uptake of interventions in FMH. Among these, the commonly used strategies were using evaluative and iterative strategies (11/21, 52%), training and educating stakeholders (11/21, 52%), changing infrastructure (11/21, 52%), and engaging consumers (11/21, 52%). For example, Kipping et al. illustrated the use of the Safewards evaluation strategy and methods available on the Safewards website as part of their implementation evaluation plan [40]. Blonigen et al. described the creation of a partnership with a broad network of collaborators to facilitate Moral Reconation Therapy adoption and maintenance [41]. DeBeuf et al. required all frontline staff to record the risk assessment results as a way to promote implementation [42]. Kroppan et al. reported the first step for implementing the Short-Term Assessment of Risk and Treatability tool at the clinic was to train and educate staff about the tool [43].
Outcomes
Of the 41 studies, 21 (51%) reported outcomes related to the implementation of interventions in FMH. Among these, 18 (18/41, 47%) reported implementation outcomes, defined as “the effects of deliberate and purposive actions to implement new treatments, practices, and services (P65)” [35], four (4/41, 10%) reported service outcomes, and two (2/41, 5%) reported patient outcomes.
Among those 18 studies reporting implementation outcomes, uptake (10/18, 56%), fidelity (9/18, 50%), and acceptability (6/18, 33%) were the most frequently reported ones. The four studies examining service outcomes focused on aspects such as safety, ward climate, effectiveness, and conflict within the ward. The two studies reporting patient outcomes centered on patient cohesion. These 21 studies employed various methods to evaluate outcomes, including interviews (8/21, 38%), surveys (8/21, 38%), focus groups (6/21, 29%), and data/record reviews (6/21, 29%).
Discussion
Our purpose in conducting this review was to understand the current state of FMH implementation research and inform future implementation research and practice in FMH settings. Through a scoping review, we identified 41 implementation studies. All studies were carried out in high-income countries and focused on interventions such as risk assessment, rehabilitation, patient support, and technology interventions, primarily using qualitative approaches. The most common barriers to implementing interventions in FMH were individual characteristics (e.g.: motivation and capacity) and inner setting (e.g.: compatibility of interventions with existing practice). The most common facilitators for implementing interventions in FMH were the inner setting (e.g. access to knowledge and information), individual characteristics (e.g., capability and motivation), and innovation characteristics (e.g., relative advantage). Various strategies, such as using evaluative and iterative strategies, training and educating stakeholders, changing infrastructure, and engaging consumers were used to facilitate intervention uptake in FMH. Implementation outcomes primarily focused on uptake, fidelity, and acceptability.
Gaps and needs for implementation research in FMH settings
Overall, there has been a limited number of implementation studies conducted in FMH settings. A key contributing factor is the lack of strong evidence-based interventions that improve care for this highly stigmatized patient group [44, 45]. The quality of evidence for some core FMH interventions, such as psychological therapies, pharmacotherapy, and the use of seclusion and restraint, remains insufficient [45]. For instance, a systematic review of nine randomized trials on psychological and psychosocial interventions offered to FMH patients found no significant reduction in violence or risk [46]. Similarly, another systematic review of pharmacological interventions for FMH patients highlighted a lack of evidence regarding their effectiveness [47]. These findings underscore the urgent need to build the evidence base for interventions in FMH through rigorous randomized trials using standardized outcome measures [46], and adaptive naturalistic studies for circumstances where trials are not feasible and appropriate [45]. Such designs are crucial for evaluating the effectiveness of interventions in FMH [44, 48] and serve as the foundation for subsequent implementation studies.
In our review, we identified ten records that focused on implementing various risk assessment tools in FMH, particularly the Short-term Assessment of Risk and Treatability tool [38, 42, 43, 49, 50], and several records on the implementation of risk reduction interventions, such as Safewards [40, 51–54] and de-escalation strategies [55, 56]. This emerging trend is promising, as structured risk assessment and management are core components of FMH care and are essential for patient safety and successful community reintegration. Moreover, effective risk management helps reduce exposure to violence and secondary trauma among FMH staff [57]. Despite these advancements, we observed that few studies actively involved patients in the risk assessment and/or management process to ensure that their voices and lived experiences were meaningfully incorporated. Notably, one study described the use of co-creation principles in implementing the Safewards model, whereby both staff and patients were integral members in the design and implementation process [40]. Currently, co-creation and patient-oriented research approaches have been highly advocated in FMH research [3, 58, 59]. Incorporating such approaches in risk assessment and management implementation research not only enhances intervention relevance and acceptance but also fosters a more collaborative and person-centered research culture [60]. Future research should prioritize the integration of patient participation in risk assessment and management implementation projects by allowing sufficient time for patient engagement, building trust-based relationships, and using emancipatory research methods such as storytelling [61] and photovoice [62] to amplify patients’ voices.
We identified in our review that inner settings and individual characteristics were the two major determinants for implementing interventions in FMH. This finding aligns with a survey of FMH nurses in the UK, which reported that the greatest barriers to research utilization in FMH were related to the workplace environment and nurses' personal attributes [63]. The complexity of FMH environment presents a significant barrier to successful implementation [42, 52], particularly due to the dual focus on both treatment and security [64], and the rigid structures and procedures that govern daily operations. Additionally, challenges such as resource constraints, staff shortages, and burnout further complicate the implementation of evidence-based interventions [65]. To address these multi-level barriers and enhance implementation effectiveness, our review supports the use of multilevel implementation strategies. At the organizational level, interventions such as infrastructural changes can help alleviate environmental constraints, while at the individual level, engaging and educating stakeholders is essential to foster a culture that supports the adoption of evidence-based practices. This finding is consistent with Kip et al. who suggested a more holistic approach toward implementation strategies in FMH — one that integrates considerations of organizational structure, technological infrastructure, and workforce dynamics [66]. This finding is also consistent with the broader literature on implementation research in mental health. For instance, Powell et al. identified in a systematic review that, among 11 included studies, ten employed multifaceted implementation strategies to address barriers related to both individual and inner setting domains [67].
Our review revealed a lack of use of equity-informed implementation science frameworks, an absence of outcome measures specifically addressing health equity, and a scarcity of studies including Indigenous and racialized populations as participants. This indicates a critical need to incorporate a health equity lens into future implementation research in FMH. Overall, limited research and established guidelines have been available to inform working with diverse patient populations in FMH [68]. A recent scoping review found only six studies that focused on providing culturally sensitive treatment for FMH patients [69]. Chatterjee et al. adapted an equity, diversity, and inclusion framework developed by Seeleman et al. [70] to the FMH contexts, which is composed of six domains: organizational commitment, staff/workforce competencies, service access and delivery, promoting responsiveness, community outreach, and data collection [71]. To ensure health equity is fully considered throughout the implementation process, Presseau et al. [72] identified exemplar frameworks for key implementation phases within which researchers can embed an intersectional perspective; for example, the Iowa Model of Evidence-Based Practice to Promote Quality Care [73] for identifying the implementation problem, CFIR [74] for assessing barriers/facilitators, and the Behaviour Change Wheel [75] for selecting implementation strategies. For outcome evaluation, an extension of the RE-AIM framework has also been developed to integrate health equity considerations [76].
Better reporting of implementation studies in FMH is necessary to accumulate knowledge in this field. In our review, we found that very few papers reported both the sex and gender of participants. Among those studies that did report sex or gender, misuse of these terms was common, such as using man/woman as the sex categories. Additionally, there was frequent confusion between race and ethnicity in the included studies. These demographic details are essential for reviewers to identify the social determinants of forensic health. Future implementation research in FMH can refer to the PROGRESS-Plus framework [19] to systematically report participants’ demographic data. Greater transparency on the development methods, process, and reporting of the implementation strategies is also essential for advancing the understanding of promising strategies that can be applied to FMH contexts.
Limitations
This scoping review has several limitations. First, in our review, we operationalized implementation research into three common types of studies referring to published literature [23]. However, we acknowledge that implementation research is a broad field with no strict or always clear boundaries. As such, we may have overlooked some relevant implementation studies. Second, the context of FMH varies widely across nations due to differences in legal frameworks and healthcare systems. These differences sometimes made it challenging to determine whether to include certain studies. For instance, we excluded papers in which patients received treatment in mental health units within prison settings, as it was difficult to determine whether these individuals were considered criminally responsible for their actions. Third, our review was limited to studies published in English, which may have led to the exclusion of relevant research published in other languages.
Conclusion
Through a scoping review, we identified 41 implementation research studies in FMH. Despite this body of work, there remains a clear need for more methodologically rigorous and theory-driven implementation research to guide practice in FMH settings. Multilevel implementation strategies should be employed to address barriers from both the inner settings and individual characteristics, thereby promoting the successful implementation of evidence- and policy-based interventions in FMH. Future implementation research should incorporate a health equity lens throughout the research process to enhance inclusivity and provide more detailed reporting of implementation strategies to support replications of interventions.
Acknowledgements
We would like to express our gratitude to Jolene Wintermute for her assistance with the literature search and to Laura Ball for her constructive feedback on the manuscript.
Information
Authors’ contributions
JZ conceived and designed the review, overseeing the entire project. BB, SJ, CC, and ZH actively participated in all stages of the review process. JZ took the lead in drafting the manuscript, which was subsequently critically reviewed and revised by all team members. All authors approved the final version of the manuscript and agreed to its submission.
Funding
CIHR operating grant: BK2–191179. The funder had no role in the design, collection, analysis, and interpretation of data; in the writing of the manuscript; and in the decision to submit this manuscript for publication.
Data availability
Further details of the included studies will be available upon reasonable request.
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
All co-authors agreed to the submission.
Competing interests
None.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Further details of the included studies will be available upon reasonable request.