Nursing in a Secure Environment: A British and Australian Perspective

By Les Storey

In July 1998, together with Colin Dale, I undertook a research project examining nursing in secure environments for the UKCC, the body which regulated nursing in the United Kingdom. The study was to provide a comprehensive overview of the educational, occupational and professional practice expectations placed on nurses working in secure environments, including secure mental health services and prison services at all levels of security across the UK.

This work involved running focus groups in the four UK countries, conducting a series of focused interviews, producing a literature review of more than 680 papers, undertaking healthcare audits in prisons and secure healthcare services and developing questionnaires circulated to employers, education providers and nurses.

The study was the first of its type that had been undertaken in relation to nursing in secure environments, an area of nursing that is developing across the globe. Nurses in this area are working with difficult client groups and are regularly the subject of media attention. (The final report "Nursing in Secure Environments" is available in PDF format at www.nmc-uk.org.) 

Since the publication of the report in November 1999 there has been international interest in the outcomes, and replication studies are being undertaken in Australia and the United States. The U.S. study is being conducted by Deborah Shelton of the Catholic University of America.

In order to contribute to the study in Australia, I undertook a professional study tour, funded by the Florence Nightingale Foundation.

I visited secure mental health and prison services in Victoria, Western Australia, New South Wales and Queensland. I interviewed a number of nurses and conducted focus groups to establish a snapshot of the issues faced and the roles and functions of nurses in correctional and secure mental health settings.

Some of the general issues that emerged related to:

• Education preparation: the comprehensive education programs used in Australia do not encourage nurses to enter forensic care as a preferred option
• Recruitment and retention: in some areas there is little movement of staff and some nurses have been in post for many years
• Age profile of nurses: the mean age of nurses in some areas is 50- plus, which could result in deficits in experience in the next decade
• Continuing professional development: this is seen by many employers and some nurses as an optional extra

Issues Facing Nurses in Australia

Regulation. As a result of a serious breach of conduct and security at two NSW prisons, the Independent Commission Against Corruption drew attention to the need for regulatory and guidance statements in relation to professional boundaries for healthcare staff, and the NSW Correctional Health Service subsequently revised its code of conduct and ethics, which specifies minimum standards of acceptable behavior. However, no state or national organization — governmental, legal or professional — has produced a statement as  to the role or responsibilities of nurses in forensic settings, and no statement as what an employer can expect in terms of skills and services. It is hoped that the findings from the replication of the secure-environments project might provide some guidance for dissemination to employers and regulators.

The workforce. The mean age of mental health nurses in NSW is currently 47 years; when it is taken into account that this includes new graduates, (who stay only a short time and are replaced by another similar group), and a cadre of young nurses working in promotion and prevention, rather than with long-term or acute seriously mentally ill patients, it becomes clear that the main body of the workforce is in its mid-50s. This group includes the majority of nurses who trained under the old system and hold a psychiatric qualification and nothing further. Many who would have jumped at the chance of working in forensics 20 years ago are now simply maintaining a steady work pattern and planning for retirement.

Experienced clinicians with additional qualifications are hard to find and are almost always utilized in roles that do not involve direct care, such as introducing clinical outcome measurement across the local health service, quality assurance roles and clinical data collection roles. At this late stage in their careers, many nurses feel they are too old to cope with the risks encountered in forensic or acute settings, or the new challenges and increased expectations, so these services tend to get left to the younger, inexperienced nurses without psychiatric qualifications who either leave once they have enough psychiatric nursing experience to travel the world as an RN, or when they become burned out and disillusioned. The vast majority of these new recruits are female, and this is also problematic, especially in relation to forensic services. The new recruits are not enough to keep pace with attrition, let alone make up the serious shortfalls. Not surprisingly, people working in mental health services are referring to a crisis.

Similar situations were described in other states where the problem of retention is related to staff retaining their posts rather than new blood coming into the service. In many of the services, staff was reluctant to move to other positions because of the higher levels of pay they attracted. Many of the nurses had more than 25 years in the same service; that brings with it problems of stagnation and a reluctance to embrace change and to move the service forward.

Conclusion and Future Developments

There are many areas of commonality between the services in Australia and the UK. In some respects the UK is more advanced, while in others, Australian service demonstrates good practice.

Clinical Implications

The suggestion is that preparing and/or developing the nursing competency base (by incorporating the defined competency framework) will lead to an enhancement of the skill base, understanding and attitudes of a significant part of the workforce in most direct and regular contact with the patient group and consequentially enhance the patient care available.

The gap between service and education has widened since nursing education has moved into higher education institutions and the physical separation causes problems for clinical staff, students and lecturers.1 Nurse practitioners in the UKCC study felt that education staff members were out of touch with developments in contemporary practice, policies and service delivery. One way to address this is to re-focus activity on the development of skill-based competencies which would require improved links between education and services and new ways of working.

With the move to greater integration of health and prison healthcare, opportunities should be taken within clinical settings for greater use of inter-disciplinary and inter-agency teaching and learning opportunities.²

The competency framework described in this study outlined 45 competencies which were thematically grouped into 11 sections, namely: Communication and Relationships; Assessment; Care Planning, Implementation and Evaluation; Health and Primary Health Care; Discharge and Community Support; Providing and Developing Therapeutic Environments; Safety; Helping Manage Change and Loss; Staff Support; Professional Development; and Management.

These groupings reflect the fundamentals of nursing practice and given that the introduction of a competency framework into practice would require the demonstration of successful role performance within these dimensions, it would provide some assurance that nurses held the capacity to carry out the task in a competent manner to a given standard. It is suggested therefore that the implementation of the framework would have the effect of driving up standards and consequentially improving patient care by providing for a more assured skill base within the clinical setting.

Implications for Education

It is in the area of education that this study presents the greatest prospects for change and development, offering as it does an analysis of current practice in this area and suggestions of an alternative framework for educational focus. Education providers must consider the manner and style of their educational programs to embrace some of the principles, which a competency framework such as the one described in the UKCC study, is based upon. Programs must be sufficiently flexible to acknowledge that skills, knowledge and attitudes developed in one clinical setting are generalized and transferable to other settings by ascertaining students’ prior knowledge and understanding and award advanced standing and credit for prior learning.

Within a competency framework much emphasis is placed on the workplace as a learning environment, and the availability of appropriately supervised practice placements would be essential. Students should be able to both observe skills in practice and be facilitated to perform supervised activities and integrate this new knowledge into practice.

The government stresses the need for more flexible mechanisms and structures for continuing professional development (CPD) for nurses as they and employers are confused by the proliferation of courses and levels, and by the lack of clear links to career paths.³

This is a finding also of this study; that the forensic courses that were identified had little commonality and it was unclear what skills or competencies of staff were developing as a result of attendance. Too much emphasis is placed on gaining qualifications at the expense of meaningful education and training within service-based settings that may not always be the most appropriate way of gaining the relevant forensic skills required for practice. CPD programs need to meet local service needs as well as the personal and professional development needs of individuals. Flexible approaches are required to better support changing roles and career pathways and to foster professional ownership.⁴

In overall terms the staff group concerned may be relatively small in number yet no individual HEI will have sufficient expertise to provide the range of support required. Practitioners may want to access different institutions and gain credit cumulatively towards an award. To facilitate this and to make effective use of resources, HEIs could usefully develop collaborative pathways.

The competency framework lends itself for adaptation to a model of work-based learning. Teaching strategies will need to focus on finding solutions to practical problems, often unique within services that deal with patients with problems and needs at the edge of current psychiatric knowledge and understanding. Such strategies might include: learning sets; work based projects; job rotation and shadowing; mentoring; and coaching.

Future Needs and Developments

The ultimate challenge for forensic mental health nurses is to develop a research agenda which will produce a unique nursing body of knowledge. Forensic mental health nursing is viewed as an evolving nursing speciality from which new theory and models of health care delivery will emerge. The challenge for forensic mental health nurses is how to ensure that evidence-based judgements inform and improve their practice.⁵

Studies show greater emphasis is needed on the dissemination and application of research findings to practice4 and that to maximize the impact of research and development services need to ensure that this knowledge is transferred to practice and education. To achieve this, information management must be given a higher priority. Education programs must be developed and delivered to prepare and support professionals to understand and use information systems, including critical appraisal of evidence and review of audit data. Services also need to review and develop the infrastructure for information dissemination and explore more user-friendly ways of presenting findings than is currently seen with clinical guidelines.

The development of alliances between researchers, educators and clinicians must be encouraged by the health service and higher education sectors that will help to facilitate the closing of the research to practice gap.

Educational providers must work more closely with service providers to ensure programs evolve that meet the needs of the nursing staff. A competency-based approach offers some hope of a flexible framework to encompass many of the aspects under consideration. Full use should be made of existing programs in the health, social and criminal justice sector.

While the principal focus of this study has been on qualified nursing staff, much of the workforce in secure mental health services is made up of unqualified staff (as high as 40 percent in some hospitals) they have specific career needs that are not met. The competency framework presented in the UKCC study is aimed at building on a current skill base achieved during initial registration, however an adapted program using similar methodology for identifying the competencies and training needs of the unqualified nursing workforce would prove to be a valuable contribution.

Implications for Management

The implications for management from this study are closely allied to the clinical, education and research implications. Management of forensic services and prison healthcare are charged with the responsibility of ensuring that outcomes of such a study can be facilitated and the necessary change implemented in practice.

A competency framework offers significant benefits and gains to the manager in providing the specification for developing their workforce in technical expectations, managing contingencies, managing different work activities and managing the constraints, quality measures and working relationship.

Managers must understand the standard that practitioners achieve. The competency framework could provide a starting point in establishing a national standard for units and modules related to forensic care. Competences are also needed to provide recognition of learning and provide links between individual and organizational requirements, enabling cost-effective education and training programs to be delivered. It is suggested that managers consider job descriptions that reflect the individual’s level of proficiency..

With the advent of consultant nursing posts in the UK, increasingly services are looking for ways to determine what constitutes competency and excellence in practice. The model is helpful to managers to help them appreciate that learning is an ongoing process and used strategically, can assist with succession planning.

The UKCC study and the subsequent exploratory study in Australia are a considerable contribution to the understanding of the current educational preparation of nurses to work in secure mental health and prison settings and provides a valuable competency framework for practice. Much work still lies ahead in the implementation and evaluation of such a framework and the necessary developments in pre-registration and post registration practice, to paraphrase the words of Winston Churchill, "This is not the end, nor is it the beginning of the end but it is the end of the beginning."

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