Review Article

Evidence-Based Practice in Forensic Mental

Health Nursing: A Critical Review
Richard Byrt, RMN, RNLD, RGN, PhD, MA, BSc (Hons)1,2,3,
Theresa A. Spencer-Stiles, BA (Hons), PGCE4, and Ismail Ismail, RMN, BSc (Hons), DipHE3

Method: Literature searches of databases, particularly CINAHL, using key phrases were undertaken.
Results: Some authors argue that there is a lack of evidence in forensic mental health (FMH) nursing, with few
randomized controlled trials and other methods providing definitive, generalizable evidence. However, liter-
ature searches revealed randomized controlled trials of relevance to FMH nursing, many qualitative studies
by FMH nurses, and arguments for clinical experience and knowledge of service users, and the latter's views,
as sources of evidence.
Discussion and Implications for Nursing Practice: Research findings can be applied to practice, both directly
and indirectly. Examples are given of ways that evidence can be used to inform FMH nursing interventions re-
lated to therapeutic ward environments, including communication, therapeutic relationships, preventing
retraumatization, and enabling physical health. The complex nature of “evidence” is considered in relation
to risk assessment and management.
Conclusions for Nursing Practice: FMH nursing can be based on a wide range of sources of evidence. The types
of evidence used in practice depend on individual service users' needs and views. In evaluating evidence, it is nec-
essary to be aware of its complex, diverse nature. A distinction can be made between definitive, widely generaliz-
able research findings and evidence with limited generalizability, requiring FMH nurses' judgments about whether
it is applicable to their own area of practice. Recommendations for related education and research are made.
KEY WORDS:
Evidence-based practice; forensic mental health nursing; nature of evidence; risk assessment and management;
therapeutic ward environments

n this article, we consider the nature and application of databases, particularly CINAHL, sometimes combined with

I evidence-based practice (EBP) in forensic mental health

(FMH) nursing. It is based on literature searches of
Author Affiliations: 1School of Nursing and Midwifery, De Montfort
University; 2School of Health, Sport and Professional Practice,
University of South Wales; 3Arnold Lodge Medium Secure Unit,
Nottinghamshire Healthcare NHS Foundation Trust; and 4MSc
Student (Psychology), Online Learning, University of Derby.
The authors declare no conflict of interest.
Correspondence: Richard Byrt, RMN, RNLD, RGN, PhD, MA, BSc
(Hons), The North Bridge Tavern, 1, Frog Island, Leicester LE3 5AG,
United Kingdom. E-mail: byrtrichard@yahoo.co.uk.
Received September 14, 2017; accepted for publication February 20,
2018.
Supplemental digital content is available for this article. Direct URL
citations appear in the printed text and are provided in the HTML
and PDF versions of this article on the journal's Web site
(www.journalforensicnursing.com).
Copyright © 2018 International Association of Forensic Nurses
DOI: 10.1097/JFN.0000000000000202
MEDLINE, PsychINFO, and PsychARTICLES. Key phrases
used included combinations of “evidence-based” with
“forensic mental health nursing” or “forensic and secure
services” or “mental health and psychiatric nursing.”
Other literature searches were conducted on randomized
controlled trials (RCTs), risk assessment in FMH nursing,
therapeutic ward environments, and forensic service
users' substance use and experiences of trauma. A list of
all the databases used in this study and the major journals
explored can be found in Supplemental Digital Content 1,
http://links.lww.com/JFN/A24.
Consideration of the evidence base raises questions about
the nature of “knowledge” and “evidence” (Alzayyat, 2014).
Carrion, Woods, and Norman (2004) and Gournay, Benson,
and Rogers (2008) emphasize research findings as the
main source of evidence in FMH nursing. Others state
that “evidence” that mental health nurses apply to prac-
tice also includes their insufficiently acknowledged clinical

Journal of Forensic Nursing www.journalforensicnursing.com 1

Copyright © 2018 International Association of Forensic Nurses. Unauthorized reproduction of this article is prohibited.
 Review Article
experience and knowledge of service users (Fisher &
Happell, 2009, Hewitt, 2009), for example, FMH nurses'
knowledge of patients as a crucial part of “relational
security” (Allen, 2015). Addo (2010) states that EBP
in FMH nursing should be based on research findings,
practical skills, and ethical and legal concerns. The pio-
neering account of evidence-based medicine of Sackett,
Rosenberg, Gray, Haynes, and Richardson (1996) stressed
“…evidence… integrating…clinical experience from sys-
tematic reviews…” and service users' “rights and prefer-
ences” (p. 71).
Carrion et al. (2004) indicate that FMH nursing practice
is affected because nurses rarely use evidence based on re-
search findings. Zauszniewski, Bekhet, and Haberlein
(2012) refer to inaccurate and outdated ideas, for example,
applying identical restrictions to all service users, regardless
of individual levels of risk (Department of Health, 2014).
Gournay et al. (2008) argue that there are few research find-
ings that FMH nurses can apply as evidence. However, this
view depends on what counts as “evidence” and whether
findings from research by other disciplines, and in other
areas of mental health nursing, for example, the effects of
clinical supervision (White, 2010), are seen as relevant to
FMH nursing.
Some authors consider that research-based “evidence”
is composed of mostly quantitative findings, particularly
from RCTs (Hewitt, 2009), although the latter are not al-
ways widely generalizable (Tapp, Perkins, Warren, Fife-
Schaw, & Moore, 2013). A search of CINAHL and other
databases found many RCTs of possible relevance to
FMH nursing but few conducted by nurses working
with offenders (Sun & Hsu, 2016). The search revealed
many other research studies on FMH nursing: mostly
qualitative, often exploratory, involving small popula-
tions, and therefore with limited generalizability. Such
studies are placed in a low position in some “levels of evi-
dence” (Cochrane, 2017; National Institute of Health and
Care Excellence, 2017). However, assumptions that RCTs
and other quantitative methods are always superior sources
of “evidence” have been criticized (Hewitt, 2009). For
example, it has been argued that service users' experiences
and perspectives can be more effectively studied through
the use of qualitative methods (Fisher & Happell, 2009),
such as ethnomethodology (Coffey, 2012).
▪
Complementary Sources of Research
Evidence: Direct and Indirect
Applications
Our literature review and clinical experience suggest that a
▪ Therapeutic Secure Ward Environments
wide range of types of evidence can inform FMH nursing
practice (Addo, 2010), with different sources of evidence be-
ing complementary, not opposed. All assessment and inter-
ventions can be informed by nurses' clinical expertise and
2 www.journalforensicnursing.com
Copyright © 2018 International Association of Forensic Nurses. Unauthorized reproduction of this article is prohibited.
knowledge of service users, and the latter's views. Research
findings can be used in FMH nursing indirectly, with prac-
tice influenced by awareness of evidence, or involve its direct
application. The latter includes FMH nurses' use of valid
and reliable tools for risk assessment and other evaluations,
and interventions based on findings of RCTs and other re-
search. From their review of RCTs, Tapp et al. (2013) con-
cluded that, for high secure hospital patients, there is
evidence for the efficacy of antipsychotics, “psychoeducation,
and third-wave cognitive-behavioral interventions” (p. 68).
Arguably, these findings could be used as a basis for FMH
nurses' interventions, in relation to these therapies, and
the administration and monitoring of neuroleptics, at least
in high secure settings.
In contrast to the direct application of research findings,
Gerrish (2006), drawing on the work of Estabrooks (1998)
and Weiss and Bucuvalas (1980), concluded, “…in indirect
research use, practitioners become aware of research find-
ings, internalize them, and use them to inform their
practice…”(p. 499).
However, there appear to be few studies on the extent
that FMH nurses use research findings indirectly to influ-
ence practice, and this is an area needing further research.
Byrt (2007) outlines how an understanding of research on
the beneficial effects of low expressed emotion influenced
facilitation of a gardening group, which avoided excessive
demands on forensic service users, and enabled them to
choose the pace of their participation. Another example,
in Arnold Lodge medium secure unit Leichester, England,
is a substance misuse program run by nurses and other
professionals, in response to the high incidence of prob-
lematic substance use among forensic service users (De
Burca, Miles, & Vasquez, 2013), and based on awareness
of relevant research findings. Nursing assessment and in-
terventions are tailored to service users' needs, bearing in
mind their diverse experiences and backgrounds (Roy,
Fountain, & Sundari, 2008). A biopsychosocial model is
used, in line with research findings that a variety of biolog-
ical, psychological, and social factors contribute to indi-
viduals' substance use (Andrews, Felt, & Everitt, 2011)
and associated offending. This model enables an under-
standing of factors related to service users' decisions to
take drugs, and that may affect their ability to abstain
when living in the community, as indicated by Roy et al.
(2008).
We now consider research findings, mostly from studies
conducted by nurses, that can inform FMH nurses' facilita-
tion of therapeutic ward environments, including therapeu-
tic relationships and communication. Examples of evidence
are given, rather than a comprehensive review of all
findings.
Volume 00 • Number 0 • Month 2018

Findings from research, based on Foucauldian theories
of power and discourse and other theories, can heighten
FMH nurses' awareness and possible resolution of con-
▪
flicts and contradictions in FMH nursing, including the
difficulty of combining therapeutic and security roles
(Holmes, 2005; Jacob, 2012). However, Doyle, Quayle,
and Newman (2017) report, in their systematic review,
that findings from several studies, including surveys of fo-
rensic service users, indicate that they benefit from ward
social climates with a “secure base,” therapeutic staff–
service-user relationships, emphasis on therapy, and
avoidance of unnecessary restrictions. These conclusions
have clear implications for FMH nurses' facilitation of
therapeutic ward environments. Tonkin et al. (2012) indi-
cate ways that the Essen Climate Evaluation Schema
(Schalast & Tonkin, 2016), a valid and reliable tool, can
identify aspects of social climate on secure wards that staff
can improve and develop, including establishing thera-
peutic communication, increasing safety, and enabling ser-
vice users' mutual support. Also pertinent to FMH nursing
is Kilshaw's (1999) consideration of the relevance of
Goffman's (1968) “Asylums” to institutional processes in
secure hospitals and Clarke's (1996) research findings, indi-
cating the need for nurses to avoid either excessive preoccu-
pation with or disregard for physical security. In relation to
this, Price and Wibberley (2012) found that adverse effects
on the FMH nurse–service-user relationship, from body
and room searches, were reduced by nurses' communica-
tion skills, sensitivity, and avoidance of confrontation.
Maguire, Daffern, and Martin (2014) report that FMH
nurses ensured safety, when setting limits, through respect,
empathy, and nonauthoritarianism. Findings from these
studies have implications for nurses' maintenance of rela-
tional and physical security.
Doyle et al. (2017) identified the importance to service
users of “therapeutic relationships” (p. 131) as a crucial
aspect of FMH nursing and the theme most frequently
mentioned in research in their systematic review. Also
relevant are findings that FMH nurses' self-awareness
and positive attitudes are crucial to the therapeutic rela-
tionship and to effective interventions with service users
▪
experiencing personality disorder (Mercer, Mason, &
Rickman, 1999). Bowers (2002) found that FMH nurses
used many strategies to maintain professional attitudes,
including a determination to recognize service users' posi-
tive qualities. Walsh's (2010) research indicated that “clini-
cal supervision” enabled prison nurses to reflect on their
practice and manage their emotional responses to prisoners'
offenses. Evidence also highlights the importance, in
FMH nursing, of maintaining professional boundaries
(Peternelj-Taylor & Schafer, 2008) and aspects of
therapeutic communication, including establishing “trust”
and “validation” (Doyle et al., 2017, p. 130). The quality
of the therapeutic relationship has been shown to affect
Journal of Forensic Nursing
Copyright © 2018 International Association of Forensic Nurses. Unauthorized reproduction of this article is prohibited.
Review Article
the effectiveness of forensic psychotherapies, with implications
for FMH nurse therapists' practice (Thomas, Bracken, &
Timini, 2013; Yakeley & Wood, 2011).
Trauma-Informed and Holistic Care
Research has found a high incidence of severe trauma
among forensic service users (Bartlett et al., 2015), with im-
plications for ward environments and nursing interventions,
which avoid retraumatization (Rossiter, 2015). Gorsuch
(1999) indicates ways in which research on attachment
and childhood trauma can inform FMH nursing interven-
tions and ward environments, and provide a “secure
base” to reduce service users' anxieties, with opportunities
for rewarding activities. Also important are attempts to
minimize interventions, such as physical restraint, which
may result in retraumatization (Agenda: Alliance for
Women and Girls at Risk, 2017), with “early interven-
tions” to prevent violence and increased opportunities
for therapeutic communication (Meehan, McIntosh, &
Bergen, 2006). Lowdell and Adshead (2009) consider
ways that research findings on “institutional defenses
against anxiety” (p. 53) can be used by FMH nurses to in-
form therapeutic relationships, understand service users'
reenactment of previous abusive relationships, and ensure
reflective nursing practice so that their interventions are
not influenced by their own needs or anxieties.
Mahoney, Palyo, Napier, and Giordano (2009) state
that mental health services should be “healing environ-
ments” (p. 426) meeting service users' holistic needs, includ-
ing physical health. From a review of research findings, Byrt
(2013) found evidence that FMH nursing assessment and
interventions for people with personality disorder need to
be holistic to meet their physical health and other needs.
Evidence of forensic service users' poor physical health
(Cormac, Ferriter, Benning, & Saul, 2005) has clear implica-
tions for FMH nurses' assessment and interventions related
to healthy diets (Puzzo, Gable, & Cohen, 2017), smoking
cessation (Dickens, Staniford, & Long, 2014), and exercise
(Long & Mason, 2014), with fresh air and gym access as
an integral part of secure therapeutic environments.
Risk Assessment and Management
What counts as evidence to inform nursing practice
depends, in part, on researchers' methodologies. This will
now be considered in relation to risk assessment and
management.
Nurses have made significant contributions to develop-
ing risk assessment tools (Dickens, 2015) and testing them
for validity and reliability. These include a “Short Anger
Measure” (Gerace & Day, 2014) and “Short-Term As-
sessment of Risk and Treatability” (Gunenc, O'Shea, &
Dickens, 2015). Other tools, produced by FMH nurses,
www.journalforensicnursing.com 3
 Review Article
include the “Behavioral Status Index” (Reed & Woods,
2000) and “Broeset Violence Checklist” (Almvik & Woods,
1998; both cited in Woods & Kettles, 2009). Nurses have
used risk assessment tools to predict and record violence
(Gunenc et al., 2015), determine intervals between mea-
sures of risk (Dickens & O'Shea, 2015), and validate mea-
▪ Implications for FMH Nursing Practice
sures (Bjørkly, Eidhammer, & Selmer, 2014).
Empiricists might argue that valid, reliable risk assess-
ment tools provide unproblematic evidence of risk, with im-
plications for FMH nurses' risk management (Woods &
Kettles, 2009). However, a possible problem with some risk
assessments is that persons who are Black are more likely to
be judged to be high risk and are overrepresented in secure
hospitals, indicating the need for culturally competent as-
sessments (Rutherford & Duggan, 2007; Saunders, Browne,
& Durcan, 2013). In addition, the extent that risk assessment
is seen as providing “evidence” of individuals' risk depends
on how that evidence is interpreted and the methodological
approach adopted. In modernist approaches to risk assess-
ment, scientific approaches and the collection of “objective”
evidence are seen as a “dominant discourse” (Foucault, 1980;
Rolfe, 2001), held by people in positions of power, with
service users' views about risk seen as less objective
(Coffey, 2012) or less valid (Rolfe, 2001).
In contrast, some researchers using qualitative method-
ologies argue that there is no single “truth,” such as science,
which can explain all aspects of reality, including risk, but
many “truths” to be interpreted (Goding & Edwards,
2002). These methodologies, including ethnomethodology
(Coffey, 2012), “Foucault's theory of governmentality”
(Dixon, 2012), and grounded theory (Chiringa, Robinson,
& Clancy, 2014; Reynolds, Jones, Davies, Freeth, &
Heyman, 2013), have been used to understand forensic ser-
viceusers' perspectives, meanings, and lived experiences and
to enhance understanding of the nature of risk and risk as-
sessment. Studies (admittedly, of only a few services) have
found that forensic service users sometimes experience risk
management as very intrusive, with excessive scrutiny,
sometimes with staff assessment of safe behaviors as “risky”
(Coffey, 2012; Reynolds et al., 2013), redolent of Goffman's
(1968) “Asylums.” As an example, in one study, patients felt
compelled to hide assertive anger and comply with assess-
ments and interventions with which they disagreed, in order
to be discharged. There was a lack of service user involve-
ment in risk assessments (Reynolds et al., 2013). However,
in another secure hospital, Dixon (2012) found that forensic
patients felt that they could express their views about risk.
Risk management measures in the community have
been found to have iatrogenic effects, with forensic service
users feeling stigmatized because neighbors noticed many
professionals visiting their home (Coffey, 2012), and re-
quirements to live in hostels of long distances from their
families (Chiringa et al., 2014). Limited accommodation
and community services, relevant to individuals' welfare
4 www.journalforensicnursing.com
Copyright © 2018 International Association of Forensic Nurses. Unauthorized reproduction of this article is prohibited.
and managing risk, have also been noted (Fisher &
Drake, 2007).
The extent that FMH nursing is considered to be evidence
based depends on the meaning of “evidence.” FMH nursing
interventions can involve both direct application of findings
(e.g., from RCTs) to nursing practice and indirect influence
through a knowledge of research findings, as illustrated by
a substance misuse group facilitated by a nurse and other
professionals.
The type of evidence appropriate for service users de-
pends on their needs and on specific assessments and inter-
ventions. Risk assessment and risk management are likely
to be based on both valid and reliable tools and on FMH
nurses' clinical expertise and knowledge of service users.
The latter sources of evidence, and service users' views and
experiences, are also relevant to other aspects of assessment
and care. Evidence from studies, including RCTs, conducted
by academics and other professionals also inform some as-
pects of FMH nursing practice. RCTs appear to be a prom-
ising source of evidence for the effectiveness of antipsychotics,
psychoeducation, and more recent cognitive–behavioral
therapies and related FMH nursing interventions in high
secure hospitals. However, RCT findings do not necessar-
ily indicate that they are generalizable across settings with
differing levels of security or that any particular interven-
tion is appropriate for an individual service user. The evi-
dence base for some interventions is based on small-scale
qualitative studies. Judgment is needed to decide whether re-
search findings with limited generalizability yield evidence
that can be applied to the FMH nurse's area of practice.
The importance of the therapeutic relationship in FMH
nursing has been emphasized in several studies. Other evi-
dence includes findings that aspects of secure wards' social
climates, including therapeutic communication, a safe envi-
ronment, and service users' mutual support, are of benefit,
and explore the need for self-awareness on the part of
FMH nurses to ensure that interventions are not affected
by negative attitudes. Research on attachment and reenact-
ment of trauma can inform FMH nurses' reflective practice,
and, facilitation of ward environments, which avoid
retraumatization, with efforts to minimize physical restraint
and other potentially traumatizing interventions. Therapeu-
tic environments canalso include interventions to ensure ser-
vice users' good physical health, based on research findings
of their needs related to diet, exercise, and smoking cessation
programs.
Establishing an evidence base also involves identifying
areas of FMH nursing practice for which there are limited
research findings and undertaking relevant research. Ex-
amples include forensic service users' psychosexual needs,
culturally competent care of asylum seekers, and further
RCTs and other studies of cognitive–behavioral therapies,
Volume 00 • Number 0 • Month 2018

psychoeducation, and other interventions used by FMH
nurses.
It is recommended that relevant undergraduate and post-
graduate education include examples of nursing interventions
involving direct application of evidence and ways that
practice can be indirectly influenced by research findings.
More research is needed to establish the extent that
FMH nurses use EBP, both directly and indirectly. Collab-
oration between practicing nurses and academics is also
recommended, particularly in projects enabling practice
development based on evidence.
▪
Conclusions
In considering evidence and its application to practice, FMH
nurses need to be aware of the complex nature of research
findings. This complexity is illustrated by contrasting
FMH nursing research on the production of valid and reli-
able risk assessment tools and qualitative research on iat-
rogenic effects of staff assessment of safe behaviors as
“risky” and intrusive risk management. These findings can
enable FMH nurses to reflect on their practice and ensure
that risk assessment and management limit adverse conse-
quences, and that they are culturally competent. Research
in this area indicates the importance, in FMH nursing, of
considering service users' views and enabling their participa-
tion in risk assessment and management, and of the need for
research on the best ways to enable this.
▪
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