Nursing in secure environments: preparation, practice and expectations

Abstract

This study examines complex areas of nursing practice in secure mental health care, offering historical and contextual analyses of these highly politicised services. A survey design is used to consider educational preparation of nurses working in these settings; and to define competencies required by those working at varying levels of security.
Data from focus groups (N=19) and interviews (N'24) with key service and educational personnel were content-analysed to yield a theory of nursing in secure environments comprising of an overarching definition incorporating eleven key themes supported by forty-five-statements of competency. The theory was translated into a questionnaire and distributed to national
samples of nursing staff working in high, medium and low security environments (N852) for testing. Respondents (N=276) stated whether individual competencies were part of their current practice or supervisory involvement; and the degree of importance they accorded to each competency.
Findings suggest that the theory proposed is strongly supported by nurses working within all levels of secure mental health services in the UK. This study also suggests that the preparation of nurses to work in secure mental health care is deficient at pre-registration, induction and postregistration levels. Students attending pre-registration placements were poorly prepared by educational staff who generally knew little of the specialty. In many instances, these placements also failed to make explicit the intended learning outcomes. Induction and post-registration training tended to be ad hoc; was frequently deficient in basic safety standards; and seldom skills-based.
The competence framework received widespread support from nurses at all levels of security in relation to their level of importance. Perceptions of specific competencies in relation to role perfonnance varied with level of security regarding nurses' involvement with the patient's family; patient's preparation for transfer and support following discharge; and involvement with patient's local community. Results identified issues in relation to security and how procedures in parts of the system - notably in high security - militate against therapeutic care. Noticeable differences emerged between respondents working in high and medium secure environments.
Issues of concern common to all levels of security included teamwork; balancing security and therapy; boundaries of professional practice; and clinical supervision.
Conclusions suggest that the proposed competence framework provides an appropriate infrastructure for development of nursing in secure mental health care. It has clear implications for educational preparation of nurses, providing a suggested curriculum at pre-registration, induction and post-registration levels. It also encourages service planners to utilise competencybased job descriptions and focus staff development within their services more precisely.