Commentary on Forensic and non-forensic psychiatric nursing skills and competencies for psychopathic and personality disordered patients. Bowen, M and Mason T (2012) Journal of Clinical Nursing doi: 10·1111/j.1365-2702·2011·03970.x


  • Seamus Cowman PhD, MSc, FAAN

    Professor of Nursing and Head of Department, Corresponding author
    1. Faculty of Nursing and Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland
    • Correspondence: Seamus Cowman, Professor of Nursing and Head of Department, Faculty of Nursing and Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland. Telephone: +3531 4022180.


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Psychopathic and personality disorder patients present one of greatest challenges to the practice of psychiatric and mental health nursing today. Clinically, there is no agreement on care pathways or an appropriate therapeutic care environment which best fits this client group. Bowen and Mason (2012) correctly expressed concern about a lack of definition in the modalities of management and treatment of the broad clinical groups of psychopathic and personality disordered patients. However, the authors themselves appear to add further to the vagueness in diagnostic and therapeutic approaches, through bundling psychopathic and personality disorders and including forensic and non-forensic aspects in a single investigation. There is no doubt that the published and indeed the grey literature highlights a tension between staff training and treatment options for psychopathic and personality disorder patients.

In their efforts to identify a preferred nursing model for this clinical area, Bowen and Mason (2012)get to the heart of the matter when they highlight an abundance of approaches used by mental health nurses to promote therapeutic interventions; this serves to demonstrate that nurses have tended to superficially reflect nursing values with this client group. Rigorous nursing research aimed at enhancing therapeutic engagement with this client group is deficient, with research tending to focus on more generalised outcomes such as understanding attitudes and interactions. Indeed, the survey method is the predominant approach to data collection and fails to decisively engage with the therapeutic role of the nurse. I tend to agree with Bowen and Mason (2012) when they suggest that the clinical application of nursing interventions for patients diagnosed with psychopathic and personality disorder patients is rooted in little more than therapeutic optimism. Mental health nursing research is obliged to move the profession beyond this mindset and towards best practice evidence-based options for nursing interventions with this client group.

Bowen and Mason (2012) make a distinction between clinical and management in nursing approaches, which, in my opinion, does not measure up to objective appraisal as the role of the psychiatric nurse is ill-defined. Over many decades, there has been much professional discourse expressing concern about the role of the psychiatric nurse (Cowman et al. 2001). The literature generally concludes that nurses overall hold negative views and find it hard to endorse positive effective statements about personality disorder patients (James & Cowman 2007).

Bowen and Mason (2012) used a survey approach in their study, thus limiting the available data for clinical application. The research questions were entirely focused on the views of a large sample of 1,500 nurses as providers of care; in my opinion, similar outcomes might have been achieved with a smaller cohort of respondents. The authors indicated that a postal survey was used in the study; however, later in the paper, they indicate that a variety of data collection methods were used, with little clarification on what such methods were.

An interesting finding in the large study sample was that men outnumbered women in forensic nursing by 2:1. I am not aware of any other clinical nursing specialist area where such a gender balance exists. Notably, this is occurring during a period when there is a general decline in the number of men in the nursing profession with a particular focus in recruitment campaigns to attract more men to enter nursing. This finding raises an important question as to why there are more men than women in this clinical nursing area and what is the impact of gender balance on clinical nursing practice. Historically, it was the case that a predominant number of men provided psychiatric nursing services; however, this no longer prevails.

Consistent with some of the previous literature (James & Cowman 2007), it must be of concern to forensic and non-forensic mental health service providers and policy makers that nurses identified some of their main weaknesses as inability to engage, and lack of skills and understanding and knowledge in managing patients with psychopathic and personality disorder. Such findings are consistent with the lack of a consolidated basis upon which to build a robust nursing clinical practice model for this specialist area. This should be of concern to forensic nursing interest groups and nursing regulators who uphold standards for the protection of the public. Strategic initiatives in psychiatric nursing education and training are required, with a designated postgraduate specialist nursing education programme in caring for psychopathic and personality disorder patients. Similar to other progressive areas of clinical nursing activity for example coronary care nursing, emergency nursing, the undertaking of a professionally recognised postgraduate specialist education programme should be compulsory for all nurses entering practice in forensic nursing.

The authors Bowen and Mason (2012) conclude that the capacity to form a therapeutic relationship is the bedrock of nursing personality disorder patients. However, if nurses are to provide effective care, as recommended by mental health policy, it is important that psychiatric nurses receive better education on clients with psychopathic and personality disorder patients, as well as ongoing support and supervision to help them to cope better with this complex client group.