Exploring nurses' and patients' perspectives of limit setting in a forensic mental health setting

Abstract

Limit setting is an intervention that is frequently used by mental health nurses. However, limit setting is poorly conceptualized, its purpose is unclear, and there are few evidence-based guidelines to assist nurses to set limits in a safe and effective manner. What is known is that the manner in which nurses set limits influences patients' perceptions of the interactions and their emotional and behavioural responses. In this qualitative study, 12 nurses and 12 patients participated in personal, semistructured interviews that aimed to explore limit setting and to propose principles to guide practice. The findings suggested that: (i) limit setting is important to safety in mental health hospitals; (ii) engaging patients in an empathic manner is necessary when setting limits (when nurses engage in an empathic manner, the therapeutic relationship is more likely to be preserved and the risk of aggressive responses is reduced); and (iii) an authoritative (fair, respectful, consistent, and knowledgeable), rather than authoritarian (controlling and indifferent), limit-setting style enhances positive outcomes with regards to adherence, reduced likelihood of aggression, and preservation of the therapeutic relationship. In conclusion, a limit-setting style characterized by empathic responding and an authoritative, rather than authoritarian interpersonal, style is recommended. Elucidating the components of this style is critical for effective training and best practice of mental health nurses, and to reduce aggressive responses from limit setting.

Risk assessment and subsequent nursing interventions in a forensic mental health inpatient setting: Associations and impact on aggressive behaviour

“…Inpatient, aggression may in part be associated with the quality of the interaction between staff and patients (Lancee et al., ), and in particular, limit setting has been linked with aggressive responses from patients, which may in part be due to the manner in which limits have been set. For example, a more authoritarian style of limit setting may engender a hostile response from patients, whereas limit setting using an authoritative approach may enhance positive outcomes (Maguire et al., ). Patients may also view limit setting as an intervention that is more restrictive in nature; as such, this intervention should be reserved for when the level of risk has escalated and is imminent rather than when the person is presenting in the low‐ and moderate‐risk bands.…”

Getting to know the person behind the illness – the significance of interacting with patients hospitalised in forensic psychiatric settings

“…If nurses fail to separate the individual and the crime, they risk creating a distance between patients and staff as patients are likely to perceive staff as guards rather than people that they can establish helpful and trusting relationships with (Hörberg , Maguire et al . ). Rather than fulfilling the intentions of the guidelines, such cultures tend to be fostering rather than caring, as nurses become emotionally distant from forensic patients.…”

“…Another study addressed the positive outcomes of interacting with patients in psychiatric forensic settings in an empathetic manner; the therapeutic relationships were more likely to be preserved by patients in comparison to an authoritarian approach (Maguire et al . ). Just as Maguire et al .…”

‘I know what I need to recover’: Patients’ experiences and perceptions of forensic psychiatric inpatient care

“…Patients may experience that coercive measures are used in their best interest, to prevent them from doing things they would regret (Holmes et al 2015;Tingleff et al 2019). Staff setting limits in an empathic, authoritative manner can be perceived as positive (Maguire et al 2014).…”