Jim A. Johansson

Background: The use of seclusion and other restraints in forensic mental health settings are intended to be employed as a last resort and for the shortest time possible to achieve therapeutic effect. And yet, in Canadian forensic hospital settings, patients can remain in seclusion for weeks, months, even years. An ambiguous legal framework across Canadian provinces lacks mechanisms to limit or forbid the long-term seclusion of patients, which we define as any continuous confinement lasting 15 days or longer. Research objectives: The paper undertakes a critical examination of long-term seclusion practices in forensic hospitals, based on the results of a qualitative study examining nursing practices with ‘difficult’ patients. Agamben’s concepts of homo sacer and bare life and Guenther’s concept of social death provide the framework for this critical examination. Research design: A qualitative research design was employed, utilizing a critical discourse analysis methodology. Participants and context: 7 nurses working in a high security forensic hospital setting in Canada participated in qualitative interviews. Ethical considerations: The paradox of custody and caring is central to the considerable ethical challenges nurses face with patients in long-term seclusion. Findings/results: Integration of study findings with existing (limited) studies of this phenomenon illustrate that, though rare, patients in forensic hospital settings may be subject to lengthy and legally ambiguous periods of seclusion. Nursing practices and interventions are aimed at providing patients temporary reprieve from a state of bare life and to alleviate their social death. However, no mechanisms exist to prevent the use of long-term seclusion. Conclusions: Long-term seclusion represents a regrettable practice in forensic hospital settings aimed at the management of ‘difficult’ patients but is devoid of therapeutic value or intent. Existing nursing practices can only temporarily relieve patients from this state. More substantive and lasting solutions are proposed, focusing on the role of the nurse.

Prisons are debilitating and disorienting spaces. Temporal realities themselves are altered from those of the outside world. This paper builds upon a study of prison staff work with aging incarcerated persons in Canadian federal penitentiaries, wherein the prison environment itself contributes to accelerated aging and slow death. Simultaneously, temporal experiences in prison both slow and become cyclic, rhythmic. These multiple temporalities flow independent of the “outside” world, which, from the perspective of incarcerated persons, accelerates. To reconcile these multiple, conflicting simultaneous temporalities, we turn to science fiction, specifically the works of Philip K. Dick, to build a conceptual world where such paradoxical temporalities coexist. A bricolage approach is adopted to interrogate these temporalities, and their effects on incarcerated persons, including debilitation and institutionalization, and the production of persons often incapable of transitioning back to the “real” world outside of prison. Proposals for both nursing practice and future research possibilities are provided.

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 1991 film The Silence of the Lambs tracks the fictional pursuit of an American serial killer by a Federal Bureau of Investigation trainee, via the assistance of another incarcerated serial killer. It features psychologically disturbing themes, such as corpses, the mutilation of skin and monstrous persons. Incidentally, these are all themes regularly encountered by nurses in their day‐to‐day practices, including forensic mental health nurses. Despite regular encounters with these themes and phenomena, nurses continue to find them disturbing and troubling, but, at the same time, clinically fascinating. This paper will mobilize Kristeva's poststructuralist, psychoanalytic concept of abjection to relate the encounters in The Silence of the Lambs to those of nurses, to reconceptualize feelings of both disgust and fascination and to consider how vulnerability may benefit nursing practice. Of particular relevance are the breakdown of skin encountered in nursing practice, encounters with corpses and work with forensic patients considered monstrous. The film provides opportunity for nurses to conceptualize abjection in their own practice and to consider how a reconceptualization of boundaries and vulnerability may prove productive.

Within the context of neoliberal healthcare, nurses and other health professionals face working conditions that leave them perpetually feeling inadequate, as though they are not enough. They are consistently expected to achieve more with less resources. In such an environment, mere professionalism proves wholly insufficient, enforcing norms of altruism and kindness. Professionals must transcend this disciplinary tool and embody a ‘more‐than‐professional’ approach. This study, informed by critical posthumanism, employs three mythical archetypes—the Medusa, the Witch and the Siren—to illuminate potential avenues for resistance against prevailing trends in healthcare. Drawing on the perspectives of Hélène Cixous, Silvia Federici and Jacques Rancière, we introduce a process of resistance for healthcare professionals pushing back against the challenges of crumbling healthcare systems. Cixous' feminist reimagining of Medusa symbolizes intensified embodied sensory experiences, emphasizing the power of irony, laughter and writing in highlighting the daily struggles faced by healthcare workers. Federici's depiction of the Witch exposes clandestine alliances among healthcare workers and patients, akin to a pact with the devil, countering the individualistic, alienating approach to care provision and resisting neoliberal pressures. The Witch archetype embodies resistance grounded in creativity against the commodification of public healthcare. Finally, Rancière's ‘politics of the Siren' offers a strategy for disrupting entrenched hierarchies from the underworld. Like Sirens, healthcare workers and patients can subversively transform their silence into songs of resistance, simultaneously operating from beneath the surface of accountability measures. Our intention is to showcase the emergence of posthuman ‘professionals’ who adapt by forging new modes of social relations in response to neoliberal constraints, straying from conventional, apolitical notions of ‘professionalism’. Drawing lessons from mythical figures of resistance offers a fresh understanding of subversion as a catalyst for social and political transformation within the healthcare sector.

Nurses working in outreach capacities frequently encounter disaffiliated or ‘hard to reach’ populations, such as those experiencing homelessness, those who use substances, and those with mental health concerns. Despite best efforts, nurses regularly fail to find meaningful engagement with these populations. Mobilizing the work of Deleuze and Guattari, this paper will critically examine conventional outreach nursing practices as rooted in the royal science of psychiatry, which many ‘survivors’ of psychiatric interventions reject. The field of Mad Studies offers an understanding of patient resistance to outreach nursing interventions. Delueze and Guattari's concepts of packs and sorcerers provide a framework to envision alternative nursing practices as a form of resistance and creativity, where new alliances may be formed outside the coercive confines of traditional practices. In response to patient resistance, outreach nurses themselves must assemble packs and engage in acts of sorcery.

Online radicalization has gained considerable attention in the media and in academia. Much attention has shifted to so-called “homegrown terrorists.” Mental health concerns of those who display signs of online radicalization are identified as a potential contributing factor to this process. Although it seems both tempting to attribute mental health concerns, attempts to “make sense” of schizoposting (a bizarre and often violent form of online engagement) via conventional “clinical” analysis prove insufficient. This article offers a critical analysis of an extremely disturbing (online) phenomenon through the radical poststructuralist scholarship of late French philosophers, Deleuze and Guattari. Given that schizoposting and those individuals who engage in this behavior have yet to receive any attention in the nursing and health-related literature, it is critical that future research aims to better understand this population, such that appropriate interventions may be proposed.

Nurses working in correctional and forensic mental health settings face unique challenges in the provision of care to patients within custodial settings. The subjectivities of both patients and nurses are subject to the power relations, discourses and abjection encountered within these practice milieus. Using a poststructuralist approach using the work of Foucault, Kristeva, and Deleuze and Guattari, this paper explores how both patient and nurse subjectivities are produced within the carceral logic of this apparatus of capture. Recognizing that subjectivities are fluid and dynamic, and capable of change, Deleuze and Guattari's concept of deterritorialization will illustrate opportunities for resistance, where nurses can begin to practice outside the dominant carceral logic (and restrictions) of the system.

The Canadian federal prison population is increasingly aging within institutions that were never intended or designed to meet the complex medical and mental health needs of older incarcerated persons. Increasing numbers of incarcerated persons are “aging in place,” and many are dying within federal correctional institutions. Persons convicted of sexual offenses comprise a large—and growing—proportion of this aging population. The Correctional Investigator Canada has recently called for an expansion of access to compassionate release for the aging federal prison population, yet little progress has been made. In this article, we explore the significant challenges faced by the aging population in federal institutions, including insufficient access to appropriate care, challenges in application for compassionate release, and how questions of risk may affect the potential for community transfer. Questions of risk overshadow decisions on early release of incarcerated persons, especially those convicted of sexual offenses. Nurses play a central role in the provision of care to aging incarcerated persons and in advocacy for better access to services when a patient's needs cannot be met within the institution. This article presents a call to action for forensic nurses in Canada (and beyond) to advocate for both improved services within federal correctional institutions and for expedited access to compassionate release of aging incarcerated persons, especially those nearing end of life. The significant disparity in access to health care for aging incarcerated persons compared with their nonincarcerated counterparts represents a significant concern.

Nurses regularly encounter feelings of disgust in practice, from bodily fluids and wounds to the criminal histories of patients. Though these experiences are widespread in nursing practice, there exists a culture in which they are regularly and intentionally ignored by nurses, and have received little attention in the literature. French-Bulgarian philosopher Julie Kristeva described these feelings of disgust within her psychoanalytic concepts of abjection and the clean and proper self. When nurses experience abjection, they work to protect and maintain the boundaries of the clean and proper self. This paper will employ a conceptual analysis to explore the implications of abjection and the maintenance of the clean and proper in nursing practice, with a specific focus on forensic nursing. A literature review of scientific articles and monographs addressing issues of disgust and abjection was conducted. The work of Kristeva provides the theoretical framework for this analysis. The analysis illustrates that nurses erect boundaries between themselves and patients, with significant consequences for patient care. An enactment of rituals to avoid the uncomfortable feelings of abjection and an effort to maintain the clean and proper self is widespread in nursing practice. Acknowledging the presence of abjection in nursing practice, recommendations are given on how to both embrace and overcome this experience.