The professional competence profile of Finnish nurses practising in a forensic setting
- Forensic nurses in Finland work in the two state-maintained forensic hospitals. The main function of these hospitals is to perform forensic psychiatric evaluation and provide treatment for two groups of patients: violent offenders found not guilty by reason of insanity, and those too dangerous or difficult to be treated in regional hospitals. Although the forensic nurses work with the most challenging psychiatric patients, they do not have any preparatory special education for the work.
- This paper describes the development of nurses who participated in a 1-year further education programme that was tailored to them.
- The nurses experienced that the 1-year education had a significant impact on their overall competence level. They found that their skills for observing, helping, teaching and caring for their patients had increased during the education.
- Conversely, it was found that the nurses collaborated little with their patients' family members. They were also not familiar with utilizing research findings in improving their care of patients.
Forensic nursing is a global and relatively young profession that combines nursing care and juridical processes. There are, however, significant differences in the qualifications of forensic nurses internationally. The aim of the study was to describe the professional competence profile of practising forensic nurses in Finland and to explore the effects of a 1-year further education programme on that competence profile. The data were collected in 2011–2012 using the Nurse Competence Scale comprising seven competence categories, and analysed using the software package SPSS version 19.0 (SPSS, Inc., Armonk, NY, USA). The participants were 19 forensic nurses and their 15 head nurses. The assessed overall scores from both informant groups indicated a high level of competence across the seven categories. The nurses felt that the overall competence level had increased during the education programme. The increase seen by the head nurses was smaller. The less frequent competence items included utilization of research and involvement of family in care. It can be stated that the 1-year further education programme was effective in developing the nurses' competence profile and, in particular, affected their professional self-confidence. It will, however, be essential to strengthen their skills for working with families and their awareness of evidence-based forensic nursing.
The International Association of Forensic Nurses (IAFN 2006) defines forensic nursing as ‘the practice of nursing globally when health and legal systems intersect’, and a forensic nurse as a professional who liaises between the medical profession and criminal justice system, including forensic evidence collection, criminal procedures and legal testimony. Gaffney (2005) states that, in its broadest definition, forensic nursing reflects the intersection of nursing practice and the legal system.
Although forensic nursing is a cross-cultural profession, the literature shows significant differences internationally regarding the role, scope of practice and qualifications. In Australia, the United Kingdom (UK) and many European countries, forensic psychiatric nurses (FPN) work mainly with mentally disordered offenders, whereas in the USA, the work focus is on the victims of crime (Bowring-Lossock 2006). In the USA, FPN may work among victims of interpersonal violence or act as sexual assault examiners or death investigators (IAFN 2006). The American Nurses Association has recognized forensic nursing as a specialized area of nursing practice since 1995 (Peternelj-Taylor & Bode 2010), but in many countries, no special FPN education exists.
In Finland, there are two state mental hospitals with approximately 450 beds. According to the law, the main function of the state mental hospitals is to perform forensic psychiatric evaluation and provide treatment both for patients who are violent offenders found not guilty by reason of insanity and those who are too dangerous or difficult to be treated in regional hospitals (Eronen et al. 2000). Forensic psychiatric patients represent a highly selective group. Most of these patients have a history of severe violent behaviour that often continues in spite of regular treatment. Aggressive and suicidal acts are often sudden and unpredictable. Nearly all these patients suffer from schizophrenia, mostly the paranoid form (Paavola & Tiihonen 2010). There are approximately 465 members of nursing staff working in these forensic settings.
Despite the exceptional challenges of forensic nursing, there is currently no national specialization or educational standard for the competences of forensic nurses in Finland (Tenkanen et al. 2011). This shortcoming led to a project during which a 1-year [15 European Credit Transfer and Accumulation System (ECTS) credit] advanced education programme was planned and conducted with a group of practising forensic nurses in Eastern Finland. In the ECTS for higher education, one credit corresponds to 27 h of work. The National Apprenticeship Centre financed the education, and the employer provided 1–2 days in a month off (14 days in total) for the school days and a mentor to scaffold the professional development.
This study aimed at exploring the professional competence profile of Finnish forensic nurses and investigating the effects of the 1-year further education programme on that professional competence profile.
Forensic nursing is a young profession and specialty. Therefore, conflicting ideologies, complex roles, role tensions and identity confusion occur among the profession. Kent-Wilkinson (2009) found that there have been studies since the early 1980s indicating the need for education to strengthen the role and competences of forensic nurses. Although little research has been done on forensic nursing education, some literature exists that attempts to define the role and competences required in the area.
Mason & Coyle (2008) noted that the forensic nursing role is compounded by such issues as custodial concerns, compulsory detention, forced treatment and the risk to others, and that it is comprehended differently by forensic nurses and those outside the profession. Similarly, Mason's (2002) literature review categorized the constituent parts of forensic practice into six themes: negative vs. positive views, security vs. therapy, management of violence, therapeutic efficacy, training and cultural formation.
Conversely, Rask & Aberg's (2002) research results among Swedish forensic nurses emphasized the interprofessional patient–nurse relationship, including trust, empathy, responsibility and respect for patients' resources as the essence of forensic nursing care. Miller (2007) used the three-dimensional competence framework (del Bueno et al. 1987), thus broadening the scope of forensic nursing competences. In this model, psychomotor skills are needed to provide care for patients, interpersonal skills to interact both with patients and staff, and critical thinking skills for operationalizing the care.
Bowring-Lossock (2006) increased the clarity of competences needed in forensic nursing in the UK by developing a four-dimensional competence framework. The task-oriented area includes such competences as assessment/management of safety, security and risk; awareness of therapies, offending behaviour and legislation; practical skills in reporting; first aid; escorting and searching patients. The knowledge area comprises competences related to the criminal justice system, litigation procedures and relevant legislation. Interpersonal area entails skilful and therapeutic use of self, including self-awareness, reflection and honesty. The personal area considers a person's maturity and ability to use common sense. A personally competent nurse demonstrates respect for the humanity of the patient regardless of the background.
Rask & Aberg's (2002) research results showed that the main educational needs of forensic nurses were related to the treatment techniques (e.g. cognitive therapy). In Brennan's (2006) research, however, the five educational needs of forensic nurses were risk assessment skills; management of aggression and violence; awareness of suicide; legal issues and first aid. When condensing the earlier studies, Tenkanen et al. (2011) found that the most critical competence areas, in terms of further education, among the Finnish forensic nurses were pharmacotherapy; knowledge of forensic psychiatry/violent behaviour; treatment of violent patients; processing patients'/own emotions and need-adapted treatment of patients.
The competences required in forensic nursing are changing along with the cultural change of the field. The findings of Brennan's (2006) study suggest that participation in training increases forensic nurses' self-confidence and morale. These are essential competence areas, yet difficult to define and describe. Gillespie & Flowers (2009) in Scotland and Timmons (2010) in Ireland found that the forensic nurses are moving from the ‘old’, previously accepted custodial culture of practice to a ‘new’ humanistic and interpersonal perspective. The new forensic nursing is based on the principles of interventions and recovery, and provides individualized, patient-centred and health-promoting care that is more therapeutic than the old forensic nursing.
The aim of the study was (1) to describe the professional competence profile of practising forensic nurses in Finland, and (2) to explore the effects of the 1-year further education programme on that professional competence profile.
The 1-year further education programme comprised two modules: patient-centred, health-oriented forensic nursing, and evidence-based forensic nursing. The instructors were Finnish experts in forensic nursing, forensic psychiatry and psychology. The learning outcomes of the programme were to deepen participants' professional forensic knowledge and to strengthen their skill related to client centeredness and mental health promotion in forensic nursing. The design of the programme was inspired by the research results from the recent study (Tenkanen et al. 2011) on the core competences of forensic psychiatric nursing in Finland. The programme was not designed on the basis of the specific competencies embedded within the Nurse Competence Scale (NCS).
The data were collected using the Finnish version of the NCS (Copyright © R. Meretoja 2003). The NCS is a generic instrument to assess nurse competence, identifying the attributes that are crucial to effective nursing care. The instrument has been scientifically developed to measure nurse competence in different phases of the nursing career and nursing contexts. The instrument is based on Benner's (1984) work ‘From Novice to Expert’, in which the nurse's career development is described as a sequence from the novice level through advanced beginner, competent and proficient levels to the expert level. The psychometric properties of the NCS instrument have been scientifically tested, and it has been proven as valid, reliable and sensitive to measure nurse competence at the generic level in a wide range of work experience and clinical care contexts (Meretoja et al. 2004a, b, Cowin et al. 2008, Hengstberger-Sims et al. 2008, Dellai et al. 2009, Istomina et al. 2011, Stobinski 2011, Meretoja & Koponen 2012), and also in the psychiatric and mental health care setting (Heikkilä et al. 2007, Numminen et al. 2013).
The 73-item scale consisted of seven competence categories: helping role, teaching–coaching, diagnostic functions, managing situations, therapeutic interventions, ensuring quality and work role. Each competence item requested responses on a visual analogy scale format (VAS 0–100). Additionally, the intensity of using each of the competences was requested with a four-point scale (not at all 0, very seldom 1, occasionally 2 and very often 3). There were eight background questions: two on demographics, three on work experience and three on professional activity. The questionnaire was sent to the respondents' email using the virtual Webropol instrument (http://www.webropol.com).
The study was conducted among the group of 19 practising forensic nurses and 15 head nurses. One head nurse could assess one to three nurses depending on how many nurses from a unit participated in the education programme. The age of the nurses was 23–56, work experience 1–33 and work experience in a forensic hospital 0–8 years. Of these, 12 had a psychiatric/mental health background, two an adult, two a perioperative and one a nurse/midwife background. The age of the head nurses was 34–58, work experience 1–25 and work experience in a forensic hospital 2–35 years.
Nurses assessed their competence using the NSC before and after the education programme in September 2011 and May 2012. The nurses responded to the questionnaire during a theory day. The first assessment was conducted prior to any form of learning. The same assessment was done by their head nurses and was not based on a period of observation, but on the co-worker relationship. When comparing the nurses’ and their head nurses' results, the results of the first measurement were used. In comparing answers of the two informant groups, only the results of complete participant pairs (n = 12) were used.
The data were analysed using the software package SPSS version 19.0 (SPSS, Inc., Armonk, NY, USA).
In all 73 items of the NCS, the means of the assessed competence and utilizing frequency were calculated. Additionally, in each category, the mean or summative score of all items was calculated both for nurses and head nurses. Comparison of assessments from the nurses and head nurses was done using measures of summative scores. The non-parametric related samples Wilcoxon signed-rank test was used for comparison. Correlations between the items of the scale and some background variables were calculated. In the analysis, the non-parametric Spearman's coefficient of correlation, ρ, was used.
The study was approved according to the protocol of the university through which the research was conducted. Permission to conduct the study among the nurses and head nurses was also given by the forensic hospital. Both respondent groups were informed about the research in a one-page guideline attached to the questionnaire. All gave oral consent to their participation. The results have been written by carefully removing the details enabling the identification of persons.
To guarantee the reliability in describing the effects of the 1-year further education programme on the professional profile of the nurses, only complete before and after measurements of nurses (n = 8) were used. In the assessment by head nurses, only cases in which the same head nurse assessed the same nurse both in the first and second measurement were used (n = 6). Non-parametric methods were used in the analysis because of small amounts of responses.
The validity of the NCS has been verified in earlier studies conducted in the psychiatric and mental health care setting (Heikkilä et al. 2007, Numminen et al. 2013).
Professional competence profile
Both the nurses and head nurses (12 pairs) gave high competence scores in all seven competence areas when assessing the competence profile of the participating nurses (Table 1). When comparing the summative scores, there were no statistically significant differences between the responses of the two respondent groups in the five competence areas: helping role, teaching–coaching, diagnostic functions, therapeutic interventions and work role. Conversely, the difference between medians in the responses of the two groups was statistically significant in the managing situations (P = 0.025) and ensuring quality (P = 0.041) competence areas. The head nurses assessed the competence higher than the nurses themselves.
Table 1. Summative VAS scores (0–100) of competence categories by nurses and head nurses, first measurement (n = 12)
|Overall mean||69.2||66.7||11.7||71.6||71.0||11.6|| |
The highest and lowest (Table 2) medians and averages of competence items and their average frequencies assessed by nurses (n = 18) show that the higher the assessed competence item, the more frequently it was performed.
Table 2. Highest and lowest medians and averages, including standard deviations, of competence items and their average frequencies, assessed by nurses (n = 18)
|Utilizing information technology in my work||90.0||82.8||17.3||3.0|
|Taking active steps to maintain and improve my professional skills||90.0||80.1||18.7||2.7|
|Professional identity serves as a resource in nursing||88.0||81.3||13.1||2.7|
|Prioritizing my activities flexibly according to changing situations||87.0||80.4||13.4||2.8|
|Utilizing research findings in the further development of patient care||55.0||56.0||17.3||1.8|
|Evaluating patient education outcomes with family||52.5||51.6||18.7||1.4|
|Systematically evaluating patients' satisfaction with care||52.5||60.0||16.0||1.6|
|Ability to recognize family members' needs for guidance||50.0||52.7||15.8||1.7|
|Acting autonomously in guiding family members||50.0||53.2||18.4||1.6|
When calculating the correlations and significance between the background variables and competence items, it was shown that the age of nurses correlated positively (ρ = 0.507, P = 0.038) with the ability to critically evaluate their own nursing philosophy, and negatively (ρ = −0.663, P = 0.003) with developing documentation of patient care. Work experience correlated positively (ρ = 0.499, P = 0.041) with the ability to provide expertise for the care team.
Change in the professional competence profile
The effects of the 1-year further education programme on the professional competence profile of the nurses were explored among the nurses and head nurses (six pairs). According to the responses of the nurses, the increase of competence, based on the difference between medians of the summative score of the competence category, was statistically significant (P < 0.05) in six competence areas (Table 3). There was no change in the ensuring quality competence category (P = 0.095). The overall VAS mean of all categories increased from 72.4 to 84.9.
Table 3. Summative scores (VAS 0–100) of competence categories and the overall mean by nurses in the first and second measurement (n = 8)
|Overall mean||71.3||72.4||5.1||83.8||84.9||3.7|| |
The overall increase of competences was seen also by the head nurses, although the change was smaller. The overall VAS mean of all categories increased from 67.1 to 74.8. However, only in the helping role category was the change statistically significant (P = 0.028) (Table 4).
Table 4. Summative scores (VAS 0–100) of competence categories and overall mean by head nurses in the first and second measurement (n = 6)
|Overall mean||65.3||67.1||10.2||75.6||74.8||15.5|| |
Forensic nursing is a global and culture-bound profession, in which caring processes are intertwined with criminal justice systems. It is a unique nursing area because it occurs among the group of most vulnerable psychiatric patients. Therefore, personal maturity and interpersonal skills are as important as the mastery of special knowledge and tasks inherent in forensic nursing (Bowring-Lossock 2006). According to the literature, European forensic nursing seems to be at a turning point, in which the old custodial culture of practice will cede to the new humanistic, therapeutic and interpersonal culture of practice (Gillespie & Flowers 2009, Timmons 2010). Forensic nursing is often comprehended differently by nurses and those outside the profession (Mason & Coyle 2008), and it is still compounded by forced treatment, compulsory detention and risk to others (Bowring-Lossock 2006, Tenkanen et al. 2011). Therefore, a systematic competence assessment, such as the one here, is essential to assist forensic nurses in maintaining and improving their practice by identifying their strengths and areas that may need to be further developed.
This pilot study was conducted with a small group of Finnish forensic nurses and their head nurses. Thus, it provides only a small step in the development of guidelines for the forensic nursing competence profile in Finland. In this study, the assessed overall scores from both informant groups indicated a high level of competence across the seven categories. Particularly, high competence scores were found in the helping role competence area, which indicated the provision of ethically and holistically high-quality forensic nursing care. Similar competence profiles and specially very high competence scores in the helping role category have been shown earlier when the NCS was used with Finnish nursing cohorts in mental and psychiatric health care setting (Heikkilä et al. 2007, Numminen et al. 2013).
Age and work experience seemed to increase maturity both for evaluating critically one's own nursing philosophy and providing expertise for the care team. Conversely, age weakened patient care documentation skills, which may relate to the rapid development of virtual and systematic documentation models. This challenges the employers in the development of information and communication technology (ICT) support systems, especially for aging nursing staff.
The most often-performed competencies revealed that forensic nurses saw themselves as modern, independent, active and flexible professionals who found their professional attitude a resource (Table 2). The least-performed competencies, however, displayed a job role in which the forensic nurses underutilized research findings and patient feedback in the development of care. They also recognized family members' needs for guidance less, and scarcely guided family members autonomously. This study strongly indicates that family-oriented work and evidence-based nursing constitute less-performed competence areas among the group of nurses in this study and possibly in forensic nursing in Finland. The further education did not develop these competence areas.
The nurses experienced that their overall competence level had increased during the further education programme in all competence categories, but the head nurses only identified this change in competencies related to teaching and coaching categories. It seems that the 1-year further education programme increased the professional self-confidence of participating nurses. A similar finding about the effect of further education in forensic nursing was made by Brennan (2006). Education provided the necessary support to the nurses of this small speciality area greatly lacking systematic education. The nurses practising in forensic hospitals in Finland are from diverse educational backgrounds and may not have any special education in mental health care (Tenkanen et al. 2011). Therefore, the further education programme, presented in this study, can be seen as the first effort in responding to the lack of tailor-made education for Finnish forensic nurses.
The findings are based on a pilot study and cannot be generalized without further studies that are focused on identification of the role and competencies of Finnish forensic nurses. The group of nurses was heterogeneous in terms of age, work experience and work history. The lack of experience in forensic nursing as well as the fact that the last measurement was conducted during the final day of school may have had effect in the response interest of some nurses. The NCS is a validated tool in the Finnish nursing context, but this was its first use in a forensic nursing setting. Nevertheless, the lack of family involvement, for instance, was broadly identified. Conversely, it can be asked whether the generic NCS entirely covers the special features of forensic nursing and measures its core competences such as the skills for risk assessment or management of violent behaviour (e.g. Tenkanen et al. 2011).
The overall scores of both forensic nurses and their head nurses indicate a high level of competence across the seven competence categories of the NCS. The competence areas that were related to patient care skills and work community skills are higher than family work skills and developments skills. Age and work experience increase maturity for improving personal nursing philosophy and providing expertise for the care team. Age weakens the development of patient care documentation, which may relate to the increasing pressure to learn new ICT skills and stress to keep them updated. In this cohort of forensic nurses, there is a need for strengthening competences such as working with families and awareness of evidence-based forensic nursing. The 1-year further education programme was effective in developing the competence profile of the nurses and, in particular, affected their professional self-confidence. The head nurses clearly identified increase in competence categories related to teaching–coaching. This result is in line with the aim of the education intervention to increase nurses' competencies in patient-centred and health-oriented forensic nursing care.
We would like to thank Head Nurse Asta Halonen from Niuvanniemi Hospital for her invaluable input towards the development of the further education programme for forensic nurses described in this paper.