Forensic psychiatric care (FPC) in Sweden constitutes a specific context in institutional health care in terms of the relationship between nursing staff and patients. Thus, FPC is a specialized field that is constructed and organized to protect society. Yet, an additional intention is to improve the health and quality of life of the patients. This study focuses on the relation between nursing staff's talk and FPC as an institution and the influence such talk has on patient care. Henceforth, rather than looking at talk as neutral, this study emphasized talk as a social activity. The term “nursing staff” will hereafter be used and refers to both registered nurses and enrolled nurses, as the two professions both work closely with patients.
From a caring standpoint, it is well known and widely recognized that the nurse–patient relationship is among one of the most essential aspects of patient care and is fundamental to promoting good health (Gildberg, Bradley, Fristed, & Hounsgaard, 2012; Hörberg, 2015; Martin & Street, 2003; Rose, Peter, Gallop, Angus, & Liaschenko, 2011). For these reasons, efforts have been made to increase patients' autonomy and to strengthen the relations between nursing staff and patients (Brunt & Rask, 2005). However, this process requires an evaluation of how language affects nursing practice, in particular when the language used is neither neutral nor value free (Cheek, 2000). This could be compared with the way in which beliefs and values about the patients come into play, when FPC as an institution controls and documents patients' daily activities, such as eating, sleeping, working, and leisure. Although considerable time has passed since Goffman's (1961) and Foucault's (1983) works were published, their writing is useful as a starting point to grasp aspects of FPC that are sometimes overlooked, such as the relation between language and context. For instance, Goffman does not specifically discuss the relationship between language and context; nevertheless, the theory on “total institutions” indicates that guards' use of words is related to their context. In addition, FPC could be thought of as a product of the 19th century and as a historical and cultural construction of the relation between criminality, medicine, and the individual (Foucault, 1983, 1995). These societal norms of patients could be linked to medical science's constructions of psychiatric diagnosis as a way to control the individual. In relation to FPC, it could be interpreted as the way in which the categorizing of an individual as a patient might appear as “truth.” For example, it is not uncommon for patients to be described as dangerous. However, what is occasionally neglected is how the discussion about patients as dangerous depends on the situation where it occur and the people involved in this situation (Potter, 1996). Thus, it might affect claims about what should be understood as deviant behavior, compromise beliefs, and shape a specific way of talking about the care given to patients.
Research about nurses' talk shows that talk regarding handover and ward rounds involves more than just relaying information about patients (Eivergård, Enmarker, & Hellzén, 2016; Manias & Street, 2000). These studies show that institutions can be considered crucial for nurses to conceptualize talk about patients in a specific setting. However, Mercer and Perkins (2014) emphasize that the institutional culture could underpin and reinforce a particular style of talk, with consequences for inequitable practice. Moreover, nurses' progress notes construct several “forms” of patients according to how these nurses conceptualize the setting, with consequences for the organization of nursing practice (Perron & Holmes, 2011). As shown by Jacob (2012), if nurses resent being part of the construction of a patient as, for instance, dangerous, they themselves might be exposed to comments and risk being ignored by their colleagues. Yet, although previous studies reveal how talk can affect nursing practice, we argue that analyzing talk as a social activity remains an unexplored area in FPC.
The aim of this study was to explore how nursing staff talk about patient care in Swedish FPC and the implications for the care given to patients.
The theoretical framework is based on social constructionism and sheds light on how language use can be understood as a social action (Burr, 2003). Adopting this framework means that it is possible to argue that knowledge and understanding about the social world are created through people's interactions. Proposing this standpoint initiates a discursive psychology (DP) approach, and consideration should be given to gender in the sense that our way of talking plays an active part in creating identities and relations (Allen & Hardin, 2001; Jörgensen & Phillips, 2002). In a simplified way, gender is relational and could be recognized as something that is incorporated into people's everyday lives as “natural performances.” How we are supposed to act as “females or males” is a process that starts early in life and is carried out in social relations in daily performance and talk and how we dress or use symbols (Connell, 1995, 2009; West & Zimmerman, 1987).
Discursive psychology is concerned with how people use discourses as resources for a given action and how, through language, people create structures for subjective experiences for which we experience memories, attitudes, thoughts, and emotions (Wetherell, Taylor, & Yates, 2001). We refer to the concept of discourse, according to the definition of Jörgensen and Phillips (2002), as a “particular way of talking about and understanding the world” (p. 4). Yet, a discourse could be considered as a framework in which “reality” is to be understood, perceived, and thought about in a certain way (Cheek, 2000). Central to DP is how the concept of interpretative repertoires (IRs) is used instead of discourse. One reason is that IRs place more focus on human agency and emphasize language use as flexible (Edley, 2014; Jörgensen & Phillips, 2002). In this study, IRs should be understood as “building blocks” or a cluster of terms or descriptions often gathered around metaphors for people to use when constructing meaning about the world (Edley, 2014; Potter & Wetherell, 1987). Drawing on IRs shows how nursing staff members' talk is “put to work” and used as a flexible resource through which meanings about patient care are achieved. However, when making descriptions that become established as stable representations, there is always something at stake and there are implications for how descriptions are to be perceived as reliable (Potter, 1996). Thus, talk itself is not just about the descriptions that are presented but also about what these descriptions accomplish in the situation (Potter, 1996; Wetherell, Taylor, & Yates, 2015). Another concern relating to how nursing staff establish talk as reliable is how categories are constructed and how they are used to characterize a person or group with specific characteristics (Potter & Wetherell, 1987). Yet, the categorization of patients in FPC is twofold: It both constitutes a certain meaning around patients and also presents nursing staff with a certain category entitlement as “experts” about patient care (Potter, 1996).
This study was conducted with a qualitative approach, using semistructured interviews to explore how nursing staff talk about patient care. Data were gathered in two different wards at maximum-security forensic psychiatric clinics in southern Sweden.
FPC in Sweden is located at the intersection of health care and the Swedish legal system. This intersection affects nursing work and how nurses are required to treat and rehabilitate patients with complex psychiatric pathologies and simultaneously protect society from further criminal recidivism. Under Swedish law, all persons are held responsible for their behavior, including persons with a psychiatric illness. However, a person with a serious mental illness cannot be sentenced to prison. In such cases, the person will be handed over to FPC with no specific time limit (Swedish Government Official Report SOU, 2008). Most (83%) patients are men, and 17% are women (Swedish Government Official Report SOU, 2014).
The data were obtained from interviews with 12 members of the nursing staff. The interviews were part of more extensive data materials, including participant observations, field notes, and focus group interviews. Conducting participant observations provided opportunities to recruit participants for interviews while they performed their daily practice. This approach created a background that was useful when constructing questions for the interviews. Participants who had joined the participant observations and fit the inclusion criteria were identified and selected in consultation with support from the ward managers. The inclusion criteria were as follows: permanently employed for at least 6 consecutive months, part of the participant observations on the ward, and gave informed consent to participate in the study. Before giving consent, all participants were given written and oral information about the study. An overview of the demographics of the participants is presented in Table 1. The interviews were conducted, audio-recorded, and subsequently transcribed by the first author. The interviews lasted between 50 and 75 minutes, followed a semistructured format, and were conducted in a secluded room in the clinical area away from the wards. Questions were focused on patient care in relation to activities, security and protection, relationships with patients, and rules and routines.
The method for analysis focused on the talk itself rather than on the interviewees' answers (Rapley, 2016). Specifically, talk was considered to be a fundamental activity among people to construct knowledge about the social world. This standpoint leads to investigating language use to analyze meaning (Jörgensen & Phillips, 2002). The process of analysis started with the first author, who read and reread the transcripts to identify themes. In the second stage, several settings in the talk about patient care were identified by constructing a mind map for each interview. This procedure made it possible to develop an overview and to consider how nursing talk was related to various situations in FPC. During this process, some themes were rejected, whereas others were emphasized (Jörgensen & Phillips, 2002). The analysis involved observations of critical points, such as repeating a statement, hesitation, silence, or a sudden change in pronouns such as “I” or “we” in various situations or looking for phrases and metaphors (Edley, 2014; Jörgensen & Phillips, 2002). Identifying the relation between talk and context supported the analysis of how talk is organized to perform particular actions (Hepburn & Wiggins, 2007). The purpose of this stage of the analysis was to gain an understanding of how different situations offered nursing staff opportunities to draw on various IRs. These IRs were then used as “building blocks” with which nursing staff were able to construct meaning about patient care and to allow them to enable and justify their own behavior as credible (Burr, 2003). Examples from the analysis are presented when describing the results. To establish trustworthiness, the process of analysis and the groundwork for IRs were discussed among the research team.
Ethical approval to conduct the study was granted by the regional ethical review board in Uppsala, Sweden (Ref. 2013/112). After gained approval from the directors of FPC and the manager of the wards, all participants were provided with written information about the study. Because the first author conducted participant observation with the knowledge of nursing staff, it was important to provide an opportunity to discuss the study with the participants, and what it might mean for the first author to assume the role of interviewer. Before the interviews took place, each participant received verbal information and had an opportunity to discuss the content. Informed consent was secured; all participants gave their clearance both orally and in writing before they were approved to participate. Participation was voluntary, and the participants were informed that they could terminate their participation at any time during the study. To ensure confidentiality, all information that might reveal identity, such as clinics, names, and participants' ages, were concealed (Swedish Research Council, 1990).
Our analysis shows that nursing staff use IRs as flexible resources to create meaning in a nursing environment that focuses on both safety and care. Another part of the analysis makes aspects of gender visible through their talk about patient care. The extracts included herein were selected to exemplify how talk is related to different situations that occur in FPC in which talk about patient care can be understood as distinct and simultaneously ambiguous and contradictory. The results show that the care given to patients can be understood from several perspectives. These findings are concluded and presented in three IRs: “taking responsibility for correcting patients' behavior,” “justifying patient care as contradictory practice,” and “patients as unpredictable.”
Taking Responsibility for Correcting Patients' Behavior
This repertoire provides insight into how nursing staff (female) conceive patient care as taking place in an environment that is focused mainly on protecting society from persons who are considered to be a risk to that society. Upholding this repertoire could be strengthened by historical norms and values regarding views on women's work in a healthcare setting. For example, their talk was often oriented toward taking responsibility for the relationship with patients. The relationship is considered to be an essential part of patient care. Thus, talk about taking responsibility is shown, for instance, around daily situations such as meals, and from this perspective, it could be understood as gendered.
The extract presented below is from an interview with one (female) participant.
Interviewer (I): One of the situations that I noted was that meals took a lot of your time. Can you tell me how you look at it?
Interviewee person (IP): Eh (.) Thus, they [the patients] get very tense because this is a XXX [Institution's name]) institution, but we try, anyway I try to do it, as nice as it can be, because it's important to have calm and peace and one should be able to eat in peace and quiet, er…
The initial question shows the interviewer's insight that daily routines are a significant part of patient care. The question enables the interviewee to respond that “they [the patients] get very tense.” Given the statement, “this is” and naming the clinic “XXX” provides an understanding of how the physical environment affects patients' behavior. These statements allow the interviewee to show an engagement: “but we try.” Then, a shift of pronoun occurs, from “We” to “I try.” A possible understanding of this shift might be that the interaction between the interviewer and the interviewee is strengthening the interviewee's credibility as a member of the nursing staff. This process is exemplified by the use of “anyway I try,” indicating that this interviewee takes responsibility for patients even if others do not. As a result, this statement reveals a contradiction in how patient care is performed. When using statements such as “nice as it can be” and “important, calm and peaceful,” she reinforces her credibility as a member of the nursing staff. What is at stake is the development of trustworthiness, in a situation in which the relationship with patients is considered to be one of the most important aspects of patient care.
…we have er (.) we did get a new patient and er in their culture, it's very okay what he did, he sat at the table and blew his nose and burped and then he farted and the others thought it was terrible, er, so we had to explain later [the patient] that it was not okay what he did.
Using details such as “new patient” and “in their culture” communicates an understanding of differences within the group of patients. When the statement “their culture” is followed by “it's very okay what he did,” this supports a categorization of this patient's behavior as contrasting with that of other patients. Providing detailed information such as “blew his nose, burped, and farted” both values the patient's behavior and functions as a demonstration that the information comes from a witness and, as such, appears neutral. A consequence of providing information as a witness is that attention is diverted from the interviewee toward categorizing the patient. Applying “others thought it was terrible” is using statements of fact (“others”) and value (“terrible”) to appear reliable and strengthens the practice as striving to do good. This interpretation is underpinned by “we had to explain and we had” and how these statements constitute a rationale for why the nursing staff had to correct the patient's behavior. What is at stake is a need to establish credibility without being exposed for categorizing patients.
Justifying Patient Care as Contradictory Practice
This repertoire sheds light on ethical dilemmas appearing in FPC regarding crimes committed and nursing staff advocating for patients' best interests. This indicates that talk might be influenced by general attitudes in society about individuals who are handed over to FPC. It also shows how FPC as an institution justifies a “normal and acceptable” way of categorizing the individuals as patients with certain characteristics. As a consequence, nursing staff might not find themselves needing to locate or strengthen the relationship to promote good health. This extract is from an interview with a (male) participant when he talks about values in FPC. This talk could be interpreted as a contradictory and inconsistent way of describing patient care.
I: Another thing I noticed was that nursing staff often said that one should see the person behind the crime, what are your thought(s) about that?
IP: There is no one who would talk about their [the patients'] crimes (.) or, er we should be professional, and we should consider the person thus and we ought to see beyond….
At first, the interviewer shows awareness of the key value “see the person behind the crime” and how this plays an important role when nursing staff describe patient care. The way the question is asked empowers the interviewee to emphasize that “there is no one,” showing that nursing staff as a collective uphold this value. This is followed by “who would talk about their crime,” showing that his focus is on the patient instead of the crime committed. The phrase “professional” is then used to reinforce these statements and make them appear as a “truth.” What is at stake is the trustworthiness of how nursing staff perform patient care. Then, the repetitive use of “we should” and “we ought to” indicates a shift occurring because it shows a representative way rather than a principal value of patient care. This statement could be understood as the interviewee struggling with contradictory feelings about upholding this value.
…as paedophiles, where it's difficult, it's very difficult I can say, really it is they've ruined someone's life, it is (.) they are difficult, it's much like that, mostly people have difficulties with paedophiles er one does the work but considers other things meanwhile…
When the interviewee chooses to use the term “paedophile” in describing patients in FPC, it leads to certain consequences. First, it creates differences within the group of patients; “it's very difficult” emphasizes and values these differences. Second, it correlates with public and general values about how these patients' identities are reduced to their crime: “they are difficult, they've ruined someone's life.” When statements appear in this form, the context is understood to justify the categorization of patients as pedophiles instead of trying to get to know “the person behind the crime” to gain knowledge and reduce recidivism. When statements are connected to “mostly people” and “have difficulties,” this could be understood as factual descriptions appearing as neutral information, which strengthens the trustworthiness of these descriptions. An important aspect of patient care is that nursing staff are supposed to promote patients' best care, for example, by emphasizing the mutuality within a relationship. However, the statement “one does the work but considers other things” shows that the categorizing of such a patient justifies this statement as an appropriate behavior when the patient is considered to be his crime.
Patients as Unpredictable
One possible understanding might be how patient care is given a particular meaning by male nursing staff in a caring profession commonly associated with female characteristics. This repertoire shows how the distinction between protecting society and care is upheld by various constructions of patients' characteristics. One possible interpretation is how talk about safety is influenced by a discourse of masculinity that presents a certain view of male identity as nurses. Given the variances between men as nursing staff, this repertoire challenges their relationships in an environment where they are in the majority. The extract presented below is from an interview with one (male) participant talking about daily routines.
I: I experienced that nursing staff had different approaches to daily routines depending on the situation.
IP: Yes, it's a huge problem (.) /…/ we go through and talk about all these things /…/ and it's always about things like er Nisse allows soured milk when he works but Kalle doesn't and Nisse gets angry and feels accused and says what does it f***ing matter and then Kalle argues….
The interviewer's statement invites the interviewee to endorse daily routines as “a huge problem.” The interaction between the interviewer and the interviewee could have influenced the interviewee to choose to present examples of nursing staff (male, with the pseudonyms Nisse and Kalle) having arguments. In turn, this interaction and the examples given contribute to achieving an understanding of daily routines as a problem: “talk about all these things” and reinforced by “always about.” Using the phrase “always” could be understood as a way to illustrate that daily routines are a major problem. Using examples such as “Nisse” and “Kalle” focuses on male relationships and outlines a variation in practice. However, when followed by descriptions of emotions such as “gets angry, feels accused, what does it f***ing matter,” this shows a disagreement around men as nursing staff for not upholding daily routines. When he uses these specific feelings as an example, this could be understood as a way for the interviewee to show how different forms of masculinity can create problems for nursing staff's relationships. What is at stake is reaching an agreement on the necessity of upholding daily routines and, indirectly, a certain understanding of what it takes to do so.
…they [nursing staff] don't have the power to resist, some of these patients can surely be damned threatening and unpleasant and stupid and one is supposed to be a special kind [of man] to have the strength to resist these kinds of people
The use of “don't have the power” works in two ways. First, it categorizes some nursing staff as “not having power,” and second, it categorizes patients. Using the word “power” is justified by describing patients as “damned threatening, unpleasant and stupid,” and it reflects an understanding of patient care. That is, the categorization of patients is given legitimacy by the context of FPC, and in turn, this creates an understanding of the necessity for (male) nursing staff to have power. The categorizing of patients enables the interviewee to indirectly claim a certain entitlement as nursing staff—“one is supposed to”—which is reinforced by statements such as “special kind” and “have the strength.” When describing patients as “resist these kinds of people,” it shows how categorizing a patient ascribes certain characteristics to nursing staff. A consequence of these statements is that they enable the interviewee to present patient care in FPC as going beyond a “traditional” view of patient care, and in turn, these descriptions accomplish a certain understanding of men as nursing staff in FPC.
When FPC is organized both to protect society and to provide care for individuals, the findings are interesting in the sense that nursing staff's talk about patient care appears diverse in various situations. When nursing staff separate their talk in accordance with their paradoxical assignments, it has consequences for patient care. For example, findings show that nursing talk leads to “stereotyping” the patients with characteristics such as “in their culture,” “very difficult,” or “unpleasant.” A plausible interpretation is that these descriptions are established as stable representations when given meaning by their context (Burr, 2003; Potter & Wetherell, 1987). How talk is used in a situation makes things happen, such as providing nursing staff with specific characteristics (Potter, 1996). As a result, when this categorization of patients is endorsed by FPC as an institution, it can create obstacles to strengthening the nurse–patient relationship, meaning that it may direct the way in which nursing staff neglect to see the need for individual patient care, as exemplified by Manias and Street (2000) and Eivergård et al. (2016).
It is not unusual for presumptions about FPC to proceed from descriptions of patients as violent or dangerous. However, previous research by Peron and Holmes (2011) and Jacob (2012) show how these assumptions are given specific meaning when occurring in a specific setting. What is striking in our study, and in agreement with previous research, is how the categorizing of patients is justified by various situations according to nurses' talk about safety. This process leads nursing staff to create a particular understanding of their practice or of “how it is.” Thus, talk has both a function when describing patients and an effect on how those descriptions can be used to perform actions (Potter, 1996). For instance, nursing staff know they are expected to address violence, directly or indirectly. We do not dispute that violence exists in FPC; rather, we consider that nursing staff are situated in an institutionalized context in which a specific form of beliefs and thoughts about patients as dangerous could appear as “truths” (Foucault, 1983, 1995). How nursing staff construct patients as dangerous might affect a particular way of talking about patient care and how this talk supports their own behavior as reliable. For instance, it is through categorization that a specific sense of something is constituted (Potter & Wetherell, 1987). From this perspective, the construction of “truth” about patients' characteristics will emphasize “a shared common knowledge” that could complicate the nurse–patient relationship.
When previous research reveals alternative ways to understand patient care and when findings point to women and men using different repertoires, we can argue that nurses' talk can be further problematized in terms of how gender appears in various situations. Although the use of words can be understood as neutral, Mercer and Perkins (2014) illustrate that how male nurses talk in a high-security hospital setting promotes gender inequality. Their study highlights how talk and words are used in relation to values and norms of masculinity and femininity in a specific context. Using Connell's (2009) gender theory in relation to the repertoire “taking responsibility for correcting patients' behavior” could be interpreted as female nursing staff being oriented toward constructing a certain kind of femininity in FPC. This concept can be compared with West and Zimmerman's (1987) depictions of how gender is constituted in daily interactions, and the public sphere as a division of labor. In comparison, the repertoire “patients as unpredictable” might be interpreted as a discourse around hegemonic masculinity, underpinned by values and attitudes around the physical body (Connell, 1995, 2009). Upcoming studies should problematize how gender can be part of constructing nurses' identities in FPC and how this can influence patient care.
According to the frame of social constructionism on how knowledge of “reality” is created through people's interactions, the knowledge from this study could be related to the interviewer–interviewee interactions (Burr, 2003). Yet, presenting the theoretical perspective with its theory, method, and analysis alongside extracts enables the reader to follow the process of research. One possible limitation related to the theoretical standpoint is that the data were collected in a specific setting and the interviews were transcribed and interpreted in the participants' original language by the first author. It is possible that translating from the original language of Swedish into English may have affected and changed the transcribed text of the results. Therefore, the meaning, nuances, sequences, or conditions that occurred during the interviewer–interviewee interaction might be neglected when the analysis and writing are translated into another language and context.
Implications for Clinical Forensic Nursing Practice
When talk is understood as a social activity, nursing talk needs to be recognized and cannot be separated from patterns and structures within the environment. If this is not examined critically, it can lead to negative consequences for both patients and nursing staff in FPC. For instance, when talk about patients is justified and given meaning by its context, it could lead to “stereotyping” patients with certain characteristics associated with a crime rather than acting to support the patients' best interests. Yet, when gender is relational, this can be shown in, for example, how nursing staff, both female and male, construct various forms of masculinities and femininities in accordance with norms and values surrounding FPC as an institution as part of their socialization into the profession. If nursing staff are striving to strengthen the nurse–patient relationship, they must begin to address issues of how their talk is not neutral and plays an active part in producing knowledge for patient care. As a possible consequence, patients' individual care needs may be neglected.
This study shows that talk is not merely a description of “reality.” The results of this study lead us to consider how various situations in FPC influence nursing staff to construct multiple perspectives and contradictory ways of understanding patient care. This shows that how an individual becomes a “patient in FPC” is a result of nursing staff's talk and how it affects thoughts and beliefs about the care given to the patients. The results indicate that talk itself may be a problem when patients become both the subject and object of talk. We argue for the need to further address talk as a social activity to increase insight into the care given to patients. From our perspective, when nurses' talk is involved in constructing gender, it should be related to the nurse–patient relationship and how these results could be applied to patient care in other healthcare settings.
The authors would like to thank nursing staff in the forensic psychiatric care units who participated in this study.