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

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.