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The Roles of Forensic Nursing in Caring for Indivi ...
Presentation and Q&A
Presentation and Q&A
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Hello and welcome. I'm Dr. Donna Roland, I'm the director of the Psychiatric Mental Health Nurse Practitioner Program at UT Austin School of Nursing and also the clinical nursing expert or SMI advisor. I'm so pleased that you're joining us today for our SMI advisor webinar, the roles of forensic nursing and caring for individuals with serious mental illness. Next, SMI advisor is also known as the clinical support system for serious mental illness and it's an APA and SAMHSA funded initiative devoted to helping clinicians implement evidence based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers that you need to care for your patients. Today's webinar has been designated for one AMA PRA category one credit for physicians and one nursing continuing professional development contact hour. Data for participating in today's webinar will be available through March 20th. Slides from the presentation today are available in the handouts area found in the lower portion of your control panel. Select the link to download the PDF. Please feel free to submit your questions throughout the presentation by typing them into the question area found in the lower portion of your control panel. We'll reserve 10 to 15 minutes at the end of the presentation for Q&A. And now I'd like to introduce you to the faculty for today's webinar, Dr. Debra Pinals and Jennifer Black. Dr. Debra Pinals is an adjunct clinical professor of psychiatry at the University of Michigan Law School. She also serves as the director of the program in psychiatry law and ethics and as a clinical professor of psychiatry at the University of Michigan Medical School. Dr. Pinals is also the medical director of the behavioral health and forensic programs for the Michigan Department of Health and Human Services. She's board certified in psychiatry and forensic psychiatry and is also a diplomat of the American Board of Addiction Medicine. Jenny Black is a sexual assault nurse examiner for adults and adolescents. She's the director of forensic nursing at Safe Alliance in Austin, Texas. Ms. Black co-founded Austin's community-based forensic nursing program. She was principal investigator in the University of North Carolina's Women's Health Study, the first national study to research the recovery process after sexual assault. Ms. Black served in leadership at the Travis County Sexual Assault Response and Resource Team and as a member of the Texas Office of the Governor's Sexual Assault Survivors Task Force. And again, I'm Donna Roland and my ties to forensic nursing began with time spent working in the Philadelphia prison system and as well as an inpatient forensic psychiatry unit at North Philadelphia Health System that cared for individuals on early parole release who had a serious mental illness along with a substance use disorder. Additionally, I'm currently involved in forensic research in my role as the nursing co-director of UT Austin's Institute on Domestic Violence and Sexual Assault. I recently co-presented some of our findings in the UK related to a large study of university campus sexual assault and longitudinal mental health outcomes and another study on optimal care provision for survivors of human trafficking based on a local medical home model that we established. Thank you again, Debra and Jenny, for leading today's webinar. Our disclosures are listed here. Dr. Pinal serves on the Board of Representatives for the National Commission on Correctional Health on behalf of the APA. And our learning objectives include looking at the prevalence of individuals with SMI in criminal settings, discussing roles of nursing and treatment of such individuals, and applying information about forensic nursing to contexts where these individuals may receive care and treatment. I will turn it over to Deb to start talking about statistics on mental illness for those with justice system involvement. Hello, thank you very much. I'm really excited to be here and work with my colleagues. Let me just give us some background so we can do some level setting on statistics on mental illness for those involved in the criminal legal system, focusing primarily on adults. Next slide. So unfortunately, the statistics are fairly daunting and sobering. Mental health indicators in US jails and prisons say that about two in five people who are incarcerated today have a history of mental illness. It's very, depending on how you define mental illness, the broader definition studies show that almost 40% are housed in state and federal prisons and even more, a higher percentage of individuals are held in local jails. This is really, again, something that we are really, many of us are working on hard to try and turn the tides. But when we look closely at these populations, we understand that we have an over-representation of people with mental illness and particularly people with serious mental illness in the criminal justice system. Next slide. When we look at this compared to the general population, this is another set of studies that was amalgamated from 2012 and the findings are not any better now, that compared to the general population, when we look specifically at serious mental illness, again, narrowing that definition, we see that if the general population has about 5.4% of all broadly defined serious mental illnesses, the state prison population and the jail population are at least four times higher. We also know that people on probation and parole are at high risk of having serious mental illness. Remember, most people who are incarcerated are going to be released and oftentimes they will be released on conditions of probation or parole. Substance use disorders are also highly prevalent in the population with about half to 70% of the population between prisons and jails having a history of substance use disorders. When we look at co-occurring disorders, again, compared to the general population of people with mental illness, 25% will have a co-occurring disorder and about 60% of those in state prisons and 72% of those in jails and about 50% of those on probation or parole. Now, again, when you look at the studies, they will vary. The percentages vary depending on how studies define serious mental illness, define substance use, but we know there's a high overlap in that population. So people working with individuals that have been criminal legal involved should be looking at the individuals with serious mental illness potentially as having a co-occurring substance use disorder. Next slide. When we look at the statistics from the lens of the public mental health system, which is a different way of rather than counting heads in jails and prisons and looking at prevalence rates there, it's really looking at those that receive public mental health services. There's a couple of interesting studies. One looked at data in Massachusetts. One looked at data in Connecticut. And again, these are somewhat older studies, but I think they're very telling. People in the public behavioral health system who tend to have more serious mental illnesses like schizophrenia and bipolar disorder have high arrest histories and have been involved in the criminal justice system. About a quarter of the population of those served will say that they were involved in the criminal system within the last two years. Next slide. And therefore, when we look at the work that we have to do and we're working in the criminal justice system, we really have to pay attention to these co-occurring disorders. These are individuals often with trauma histories. Excuse me just one minute. Sorry about that. They're often people with trauma histories, as we'll hear about later, as well as high proportions of people with social determinants of health as factors like poverty and education levels that contribute to these intersectionality issues of the individuals involved in the criminal legal system. Next slide. It's important to realize that the symptoms themselves of mental illness are usually not the driving factors of criminal conduct. In some rare percentage of cases, we may see this where, for example, a symptom of mania or symptom of psychosis directly leads to the criminal behavior. But more often than not, what we're seeing is, again, these social determinants of health and criminogenic factors that are driving criminal behavior for people with mental illness, just like for people without mental illness. So things like antisocial personality disorder, co-occurring substance use that leads to criminalization of substance use disorders that we see are often going to be the drivers of criminal behavior. So we know that decreasing symptoms of mental illness alone will not fully change the criminal justice system. In other words, if we cured mental illness, we would still have crime. But that doesn't mean we don't want to make every effort to address symptoms of mental illness. There are many factors for people with mental illness struggling in the criminal legal system. But it is not a direct correlation between mental illness and crime. And so therefore, we want to really think about how treatments can be maximized and help people achieve the best outcomes. Next slide. So the settings where clinicians provide care to individuals with serious mental illness that are considered forensic can vary. Next slide. For example, people may have preconceived notions of what we mean by a, quote, forensic population. But what we know is that individuals who are justice-involved will receive care across a number of different settings. This can include jails, prisons, state hospitals, community mental health, as I said, in the data looking at public mental health recipients. Emergency rooms. I frequently see individuals with justice involvement in the emergency department. And the emerging crisis stabilization units. People who are justice-involved will appear in any number of places in any of the places that we see patients in general. Next slide. Therefore, we really want to think about helping educate the provider network about what mental health care looks like within jails and prisons. And we have other SMI advisor webinars that go into this in more detail. But in general, depending on your community, mental health services can vary significantly across jails and prisons. And so it's important for you working with the population of people with serious mental illness who may have been justice-involved to have an understanding of what is happening in your own jurisdiction. Care is required to be commensurate with community standards. But for a variety of reasons, jails and prisons are not the same in terms of their structure and focus on security. And therefore, there's many avenues to work towards uplifting the care that people are receiving within jails and prisons. They are complex environments, and the interplay between security and treatment needs can sometimes be at odds with each other. In general, a prison which is usually run by the state system will have more levels of mental health care, broadly speaking, like inpatient, outpatient, and residential. People with serious mental illness may be transferred from one prison to another to receive the different levels of care. Whereas within a jail, you're going to be in a local jail that's potentially going to have some specialty units, but more often than not, the care will be received in a more general way with the mental health staff serving the population across the jail, depending on the size of the jail. Persons with serious mental illness might therefore be more at risk for different kinds of things that happen within jails and prisons. For example, behavior that doesn't follow some of the rules might lead to disciplinary infractions, and that can impact housing decisions both within jails and within prisons. And very often we see, and all too often we see, people with serious mental illness that are housed in jails in more confined settings because their behavior isn't able to follow some of the same rules, or they might be at risk of victimization. And so as a protective factor, they may be housed in more restrictive settings. That is, again, something within the jail and prison world that is being addressed and looked at more rigorously over time, but nonetheless, this is often the place where people with serious mental illness may receive their care. Next slide. Mental health services and correctional settings require screening, assessment, referral, and evaluation. The screening would be done on admission and reception, and the goal is to help people receive timely access to services. Usually there's going to be a systematic screening at reception by a qualified mental health professional, by even a layperson, and then a further screening by a qualified mental health professional that would be done within 14 days. A comprehensive mental health evaluation would be done if the screening indicated a more comprehensive evaluation was necessary. Referrals to mental health can take place at any point in the incarceration, and inmates must have a means of making their needs known to medical staff that's usually done through some kind of note that they write saying that they want to be seen. And generally speaking, there should be opportunities for them to avail themselves of crisis services. Again, how those are staffed may vary in your local jails or prison setting, and it's helpful to know how that is working if you're seeing patients that are coming in and out of the jail. A record keeping is done. There are health records within a jail system and mental health records, and those are required to be accurate, complete, and confidential. Next slide. Antiretropic medications are also supposed to be available for people within criminal justice settings, just like they are in the community. However, this can also be tricky. This requires appropriate screening and referral. It's difficult at times to get continuity from the community. There needs to be a medication reconciliation. This is where forensic nursing can really be helpful to make sure that medications are aligned from what people are receiving in the community. There does have to be access to prescribers, and with workforce challenges, that can be difficult. There can be formulary distinctions across settings that can make access to medications from one setting to another difficult. Provisions for medication over-objection for people who are declining medication with people with serious mental illness who are declining medication is also a complicated topic. Within jails, prisons usually have remedies for this and procedures for this, but within jails, there may not be as readily available remedies, and therefore, there may be people who are declining medication for long periods of time where it's very important for the healthcare professionals, including the nurses and all hands on deck, to recognize if somebody is declining medication and what kind of further assessments or treatments they may need. Treatment strategies can also be challenging if there's not proper attention to those issues, and the more we look at people with serious mental illness in the justice system, the more we're reminded, once again, about therapeutic alliances and the importance of engaging people in the care that they can benefit from. Next slide. Clinicians can be involved through criminal court processes, civil court processes through civil commitment, in mental health courts. They may be involved even as testimony and expert witnesses, and so we see clinicians working in a variety of contexts related to the justice-involved populations, and anyone listening to this webinar may have different roles that they wear at different times in terms of their own involvement. Next slide. Another place where we see a multidisciplinary approach to justice-involved individuals is in forensic assertive community treatment. This is a model of care that is based on the ACT assertive community treatment model, but with an added component recognizing that the individuals being served have cycled through criminal systems as well as the mental health system, often the substance use system, and so the model is designed to support individuals with serious mental illness who are criminal justice-involved, and it focuses on preventing incarceration rather than just focusing on preventing hospitalization, although that's part of the model as well. Generally, the supports, again, involve a wraparound multidisciplinary team that continues to work with that person over time with different elements of care provided, like a hospital without walls, as needed over time, over the course of somebody's life trajectory. Next slide. SAMHSA has promoted some of the work around forensic assertive community treatment with key components that show that when working with individuals in the community, focusing on areas that address criminogenic risk, those kinds of factors and features that lead people to be more engaged in criminal behavior are going to be an important component, and that often means being adept at working with people with antisocial personality traits and styles and peers. Client eligibility should be based on sets of well-defined criteria, including multiple incarcerations because, again, the goal is to try and eliminate the cycle of incarceration. Client access to round-the-clock individualized psychiatric treatment and social services are a part of the model. Service delivery, again, is through a multidisciplinary team and a cross-system mental health and criminal justice team training so that people understand both the criminal system as well as the mental health system, and fidelity to the ACT model with quality control can be utilized as well, and this often requires flexible funding and implementation support for individuals that are involved in forensic assertive community treatment. Now, in addition to working in these models, we also are engaged in care for individuals who are victims and survivors of crime, and that's really important to realize that people with serious mental illness are much more at risk for victimization than they are at perpetration of violence and crime, and so with that, I'm going to turn this over to Dr. Rowland. Thank you very much. Next slide. So care provided by forensic nurses as well as the interdisciplinary team related to victims and survivors of crime includes interpersonal violence, sexual assault, and human trafficking. Interpersonal violence and sexual assault have much overlap, and interpersonal violence includes relationship abuse, stalking, coercion, and control. Strangulation represents a real escalation of interpersonal violence, including physical consequences and as you can imagine, psychological terror. And when strangulation is occurring, mortality is high. Most experience also multiple strangulation episodes, and there are higher rates of this with ongoing interpersonal violence. Sexual assault includes harassment, unwanted sexual contact, and sexual assault itself. And human trafficking includes both sex trafficking and labor trafficking, or working under involuntary conditions. Next slide. So those who've been victimized are, of course, much more likely to experience PTSD, alcohol misuse, drug misuse, depression, as well as things like academic or employment disengagement, and experiencing, of course, stress and less resiliency over time. Individuals that have serious mental illness are, as Deb said earlier, vulnerable to crime, also vulnerable to interpersonal violence and sexual assault. And intersectionality here with this overlap really compounds the gaps in system responses and resources. So all three, the interpersonal violence, sexual assault, and human trafficking are not mutually exclusive phenomena, and they often overlap. And victims of these things require really thoughtful care for their complex situations, keeping safety and mental health in mind. Next slide. So this is an infographic that I really like from a study conducted by UT's Institute on Domestic Violence and Sexual Assault, and it illustrates some facts as well as the financial costs incurred as a result of sexual assault in this one state. Some of the more striking notes that I think I'd like to relay is that about a third of all residents of this state have experienced a sexual assault. That's huge. And nearly two-thirds of these victims report having multiple assaults. The costs are about $43 million a year annually, sorry, annually, I said, for victim services. And lastly, I think I'll point out that only 9% of sexual assaults are reported to law enforcement and even fewer are prosecuted. Next slide. Now I will turn it over to Jenny to talk about sexual assault nurse examiners. So sexual assault nurse examiners are one type of forensic nurse. Forensic nurses care for people who are victims of any sort of interpersonal violence. Sexual assault nurse examiners obviously look after folks who've experienced a recent sexual assault. So our primary focus is the health and well-being of our patients, and again, these are people who've experienced sexual assault usually within the last five days to 10 days. That timeframe for getting to see a specialized healthcare provider like one of us varies from state to state and is based on reimbursement legislation. We offer patients a menu of offerings when they come in to see us. We do consultations about their options. We provide medical care for people who would like to have that. We also offer evidence collection and support, whatever that might look like. It could include referrals to civil legal services like protective orders. It could look like referrals for any kind of healthcare that they might be needing and also emergency shelter, because sometimes people are fleeing situations that they can't go back to. We also do evidence collection for use in the criminal legal system. It's not uncommon that we are the first healthcare providers that our patients have seen in a long time, so we come to our encounters in a comprehensive manner. We listen for whatever needs that may be present, and we address them as we can. That might look like making appointments with a primary care provider for somebody to be seen for whatever thing they walked in with. We get folks connected with dental care. We connect people with counseling services and with shelter, like I mentioned earlier. Civil legal services are a great boon to the work that we do because people often need that kind of support as well or have questions about their particular situations, especially when there are children involved and they're trying to keep them safe. We address folks' physical and mental healthcare needs, like I said. Sometimes healthcare is the only thing that our patients want from us. What that looks like in general is emergency contraception to prevent an unwanted pregnancy, sexually transmitted infection prevention, and then also HIV prevention when that's indicated. We also support and advocate for survivors within law enforcement agencies and with prosecutors as well, as cases sometimes move through the criminal legal system. So, our colleagues who work in emergency departments, which is where most of this particular nursing service is located across the country, they specialize in identifying and advocating for victims of abuse and neglect and have tools to be able to help identify folks. They should also be connected with community agencies that provide shelter, that provide safety, and that provide follow-up counseling. Now, we'll shift back to Deb to talk about care for individuals with serious mental illness who are issued involuntary treatments. Great. Thank you so much. We can go to the next slide. So, involuntary treatment is a really complicated topic, and of course, I want to emphasize the point that what we always want to do is prioritize voluntary treatment first and recognize that the more we can engage patients in positive thoughts about their treatment and less coercive and less perceived coercion, the better the likely outcomes. And that said, within the criminal processes, there are mechanisms for courts to order individuals to comply with treatments, and I use the word comply because that is usually the word that would be used with a court order, whereas in treatment settings, we usually think about adherence to treatment. One of the complicated issues is that even with a court order, even though the court orders the person to take the treatment or to comply with treatment, it doesn't authorize the clinician to involuntarily medicate the individual. So, there is this distinction between that, and sometimes there's a disconnect in understanding about how that can work. Also, we have treatments, for example, medications like clozapine that do not come in injectable forms, and so having somebody needs to be willing to swallow the pill, so to speak, and take the medication. So, again, another reason why engagement is so important is that we do, even though we have a tremendous array of long-acting injectables, which are really remarkable and help with adherence, not every medication that we offer for psychiatric illness is something that can be administered involuntarily. So, a couple things just to think about. For patients that are involved in mental health courts, they may be mandated to take their treatment. For patients that are assigned to competency restoration, there may be a court order that they comply with treatment. Same with conditions of release or probation conditions or parole conditions or when people are in the forensic hospital. Where somebody is authorized to have medication over objection, there are complex legal processes and rights-related issues that need to be considered very carefully before one gets to that route. Nonetheless, it is important that if you're working with somebody with serious mental illness, and especially hearing what Dr. Rolland just said about victimization, is that we really think carefully about being trauma-informed and helping patients and people that we're serving really understand what the ramifications are if they're not compliant with court orders and really helping them feel that they're being treated fairly, even when the court has ordered them to comply. Next slide. In civil processes, there are also orders that can be written by judges for patients to take medications. This happens very commonly in psychiatric inpatient hospitals. It can happen in acute settings, in state hospitals. And there's also community-assisted outpatient treatment, and there's a lot of information on SMI Advisor about AOT. And that also comes with a civil court order for treatment. Again, what this means is that in these settings, there are going to be processes where sometimes the court order will authorize the clinician to administer medications over objection, but sometimes they won't. For example, typically with assisted outpatient treatment, even though the person subject to the order has been ordered to comply with medications, it doesn't necessarily authorize the clinician to administer medications over objection in a non-emergency situation. And emergency situations are going to be distinct from court orders. And so, again, it's very important when you're working with individuals who may have challenges with adherence that we do everything we can to be trauma-informed and maximize adherence, recognizing that many of these individuals may have been victims themselves and have trauma histories, but nonetheless may also need treatment and we need to work within the legal structures and operate under the law and with rights in mind as we proceed. Next slide. There's a real important need to think about the role of interdisciplinary teams and multidisciplinary teams in working with the criminal justice populations. That's why I was particularly excited to be working with two wonderful forensic nurses to think about this. There's no work that I could do as a psychiatrist that wouldn't be supported by nurses and nurses with expertise working with the criminal legal population can be really helpful because they can use their talent and support to help foster that engagement, help educate patients, and we can work collaboratively to achieve better outcomes for people with serious mental illness. Next slide. So the interdisciplinary team process and the FACT team was highlighted as one example of using real interdisciplinary teamwork to help individuals both reduce their chance of returning to the criminal system and maximizing their positive engagement in community systems. There's also the role of peers, people with lived experience with mental illness that can also be helpful, and this includes, as we work together, training hospital staff together, training the staff within a jail or a prison together so that we're not siloed between nurses and psychiatrists, between peers and the physicians or peers and others. What we really want to do is think as an interdisciplinary team that are all working together to help the patient achieve the best outcome. This can create, this is not easy. There's challenges in the systems of care that are constantly being dealt with, and the more we can understand the input across disciplines about what's going on with the patients and the people that we're serving, the better we can do in achieving positive outcomes. Again, remembering that it's common for individuals with serious mental illness in the criminal system to have comorbidities, and this can include substance use disorders and trauma histories. Getting that input across multiple disciplines for how people are doing and what might achieve the best success can be very helpful. We know that people with serious mental illness, as we heard, with their victimization are often not taken as seriously by some in terms of their reporting of what's happening, and we need to take all of those reports extremely seriously and pursue investigations where that seems to be appropriate if there's suspicion that somebody has been victimized that they're reporting. Next slide. Forensic nurses really have to work in each of these aforementioned settings and roles, and here's where I'm going to turn this back over to my friend Donna to pick up where I left off and really talk about what the advantages are and the importance of pulling in forensic nurses and working together. Thanks, Deb. Again, the forensic nurses are such an important part of the interdisciplinary team in caring for these individuals and work in all of these roles that we've been talking about. I want to give a shout out to Dr. Ann Burgess, who is a forensic nurse and the founder of the field of victimology, very exciting things. So about two decades ago when I was in my master's program at Penn, I was fortunate enough to attend some of her seminars when this was a brand new thing people were talking about. She's currently on faculty at Boston College School of Nursing and recognized as an international pioneer in this area. And incidentally, her work based on treating survivors of sexual trauma and abuse is said to be the inspiration behind the Netflix series Mindhunter, if anyone has seen that, which highlighted early work by the FBI in profiling violent offenders. Next slide. And again, forensic nurses play a pivotal role in caring for individuals who are justice involved or victims or survivors of crime. Next slide. And we'll talk a few minutes about ACEs or adverse childhood events. And these are things that occurred before the age of 18 in childhood. This was the seminal longitudinal work was started by Folletti and colleagues at Kaiser Permanente in California and is ongoing. So adverse childhood experiences are particularly traumatic events that occur in childhood. And they're all listed here, the list that they use. For example, experiencing violence, abuse, or neglect, witnessing violence in the home or in the community, having a family member attempt or die by suicide, and also included are aspects of the child's environment that can undermine sense of safety, stability, things like growing up in a household with substance use problems, mental health problems, instability due to parental separation or household member being incarcerated. And ACEs increase the many, many risks in adulthood exponentially. So the more ACEs that occurred in one's childhood, the higher likelihood of the associated risks throughout adulthood. Next slide. Excuse me. ACEs and other associated social determinants of health, such as living in unresourced or racially segregated neighborhoods, frequently moving, food insecurity, all of these things can cause toxic stress. And this can negatively impact brain development, immune systems, stress response systems, and physical health, ultimately. So ACEs are linked to chronic health problems, including mental illness, substance use issues in adolescence and into adulthood, as well as physical health issues. So you can see kind of the building of the pyramid here, you have the ACEs at the bottom, and then you have social, emotional, and cognitive impairment, and perhaps adoption of health risk behaviors that can lead to disease, disability, and social problems in adulthood, and even premature mortality. ACEs also can have a tremendous impact on future violence, victimization, and lifelong health and opportunities, of course. Next slide. So we bring up this topic of trauma and ACEs because individuals involved in the criminal justice system almost certainly have experienced trauma. There are high levels of trauma experienced by youth involved in the criminal justice system, individuals receiving care in various psychiatric settings that Deb had talked about earlier, and of course, incarcerated individuals. And she also mentioned that substance misuse is common as well. And we know that earlier and chronic trauma experiences disrupt development and physical health. Next slide. So again, being involved in institutions and the criminal justice system in and of itself is traumatizing. This includes circumstances before and during arrest, as well as some other issues, such as disruption of networks and loss of control, exposure by close contact to others in situations that might be also traumatizing, as well as public exposure. And forensic nurses and others on the healthcare team really must employ trauma-informed care throughout their work with these individuals. Next slide. And I will turn it back over to Jenny to talk about some of these nursing roles. Here we go. So trauma-informed care, oops, I don't think my camera came back on. Let me grab that. There we go. Trauma-informed care in our environment looks like offering a lot of choices and providing informed consent and declination when people come in to see us. We employ a four-step consent process. When we offer our services, we explain everything that is involved in it and let people pick and choose any part of it or the entirety of it or stop and start as they would like as we move through our encounter. Our four-step process includes explaining what we'd like to do next and explaining how that will go and asking if that is something that somebody would like to do and then moving forward with it. It might look like in our field asking, what I'd like to do next is comb through your hair. The reason why we do that is because sometimes people get debris, other people's hair, fibers caught up in their hair during these things and we'd like to come through there to collect anything that might be found. I have like a little white paper towel and a generic black comb, I'd like to drape the paper towel over your shoulders and comb over the top of that to catch anything that might be there. Is that all right if we do that next? So every procedure that we go through has that little informed consent section before we move into it. This allows our patients to make a decision about whether or not they would like to engage in what it is we're offering, and when people decline our services or decline a part of our procedure, then we can also have a conversation about what are the consequences of possibly declining. It's looking like our slides might be popping ahead. Are we okay? There we go. We do a lot of education with our patients and with our staff and with our community partners in law enforcement and prosecution and hospital administration and community-based advocacy about the neurobiology of trauma and how trauma can affect the patients that we see in the immediate term, why people might be acting in a way that is difficult to understand to other first responders, and also about how trauma may look for them as they are moving through their next days and weeks and months. We work to support the well-being of our staff as well by providing debriefs, you know, immediately after encounter or at any time that somebody would like one. We do a lot of chart reviews with our staff that are non-punitive. We provide 24-7 availability to our staff to problem-solve and deal with whatever unexpected circumstances may come up because this field has a lot of unexpected circumstances. We're also a member of the Better Tomorrow Network, which we mentioned earlier, which is the nation's first clinical network of sexual assault response sites. It's really marvelous to get to participate in the research projects that are coming out of there because we're contributing to the advancement of our field and the understanding of how people recover after a sexual assault. We do a lot of advocacy and navigation for the people that we provide care for within both health care and legal systems. We talked a little bit ago about what that might look like in health care. It's making appointments for people when our encounters are during business hours. It's getting people connected with other services that they might need to take care of their health, and not necessarily as a result of this victimization, but for anything that they might need. Navigating the legal system is also very important to us and can sometimes be challenging. We fiercely advocate for our patients' rights, particularly the right to have evidence collected. We work with other response colleagues who may or may not have the same understanding of legislation that guides the work that we do, or what best practices are, or what evidence collection time frames may look like. We do a lot of education with our community partners as well. For those of you who are interested in forensic nursing, here's a little bit of information about it. We have a professional organization called the International Association of Forensic Nurses, and they are really great. I'm very happy to be a member. Their benefits are marvelous. There is certification available by board exam for forensic nurses that is internationally recognized. There's a conference every year in September moves around the world, and it's delightful to go to that. There are lots and lots of educational offerings, including the requirements to certify in this field. It's very basic. There's a 40-hour didactic course. There are clinical requirements. There are courtroom observation requirements, and of course, you have to learn how to use a speculum, so there are clinical requirements for that as well. It is an intensely interesting field. It's also intensely difficult because of the trauma exposure. We'll talk a little bit more about that in a second, but it's also quite rewarding. It's a wonderful thing to see people come into our care not doing okay, and then leave our care in better shape than when they came in. That's the part of it that's really great. So challenges in forensic nursing, like mentioned a minute ago, the secondary trauma exposure can be quite intense. Hearing the story of the worst thing that happened to somebody on a daily basis can be quite difficult to deal with, so we always encourage our folks to have their own supports, family, friends, therapists, all of the things that might be resources for them. When we are doing advocacy within the criminal legal system, that can be difficult also. On the one side, we have really severe, sometimes trauma histories, and on the other side, we have systems that don't function as well as we would like them to, and being in between those two places can be challenging. There's a lot of turnover in this field, which is understandable. We find that, like I mentioned a second ago, one of the most rewarding parts of what we do is being able to connect with patients and shepherd them along from a place of not doing so great to feeling at least a little bit better, and that's quite difficult to do with patients who are experiencing active psychosis or other acute mental illness. We still provide excellent care, but it's a little bit different on both ends. There's less give and take there. We, just like most other folks in health care, deal with resource scarcity and funding inadequacy. Forensic nursing, or at least sexual assault nursing, is a relatively new field, and it's going through some growing pains right now as we are seeking recognition on a federal level and funding sources on federal, state, and local levels to provide the care that we do. So, one of the ways that we address and mitigate some of the difficulties that we encounter in this work is by focusing on the relationships that we have with each other and the relationships that we have with our patients. One of my favorite nursing theorists is Joanne Duffy. I wanted to include this here. Her eight caring factors are things that we work very hard to incorporate into our encounters, not just with our patients, but with our staff and with our community partners as well. If you're unfamiliar with her work, it's great stuff. Go take a look at it. And then, lastly, thank you for coming. Wonderful, and those were our references, which are available in references that you download. Thank you all for being part of such an interesting presentation. Before we shift into Q&A, I want to take a moment and let you know that SMI Advisor is accessible from a mobile device. Use the SMI Advisor app to access resources, education, and upcoming events, complete mental health rating scales, and even submit questions directly to our team of SMI experts. Download the app at smiadvisor.org app. And now we'll take questions. If you haven't already, enter some questions into the section in the bottom of the GoToWebinar control panel. We probably only have time for a few. I will start with one that is for Deb. Do you have any thoughts on why individuals with SMI are more over-represented in jails over prisons? Well, yeah, that's a really interesting question. Probably because jails represent really just this very acute population. You know, jails are places where mostly people are held pretrial and on low-level offenses, and we know that people with mental illness are more likely to be arrested for lower-level offenses than for serious offenses, whereas prisons are going to be places where people serve at least a year or more, so that means that they've been arrested on more serious offenses, and so that's probably one of the reasons. Thank you. Okay, and this next is for Jenny, and it's kind of two parts. So you mentioned rewards of being a sexual assault nurse examiner, so what is the most rewarding part of that, and are you able to, I guess, follow any of the patients that you encounter over time? Those are great questions. The first one, at least for me, the most rewarding part of this work is being able to connect with people when they are vulnerable and really need support. We create a soft place for people to land after a really terrible thing, and that is very, very gratifying to be able to help people. That's kind of cliche, but that's really where it is for me, and the second question, again, was about, give me one more time. Are you able to follow any patients or individuals over time that you see? Some practices do have that capacity. The place that I work does not, and it's really just a function of funding and staffing. It's really wonderful to be able to reconnect with people and do an additional assessment for injuries. How are things healing? How are people doing? What else do we have that we might be able to connect you with that might be helpful? There are programs across the country that do do that, but unfortunately, ours is not one of them. Okay, let's see. While she's looking for the question, I just want to jump in and say I loved your answer, Jennifer, and also just really think about settings where I've worked where people report being victimized on units, and having somebody who can really do that soft landing isn't always there, and so I think that's just, I think that's really something for us to think about as a need. Absolutely. Okay, so this next one is for Deb. Do you think that formularies in jails and prisons will improve, and do these tend to differ from formularies at state hospitals and community mental health centers, and so what are the barriers with these formularies? Yeah, I mean, unfortunately, cost is one of the barriers, and generally speaking, correctional formularies are more restrictive than what we see in state hospitals or in Medicaid in terms of access to medications and community settings. It's not that cost doesn't matter. You know, it matters for me as somebody who might need medications. You know, cost matters, but that is one of the barriers. We may start seeing more things shift as we look at, you know, potentially seeing some cost offsets. If, for example, if we see Medicaid expand to be able to cover services for people coming back into communities through some demonstration waivers and things like that, we may see medications coming into that. There's also been funding for medications for opioid use disorder that has supported some of the access to those medications in jails and prisons, and we've seen different medications, like medications for hepatitis C, have become more and more available within jails and prisons, so I think there's opportunities to really look at that so that we achieve continuity of care and really look at systems approaches to care as opposed to just siloed approaches to care, but there's work to be done to advance that. Thank you. Okay, and one more for Jenny. Can you elaborate or provide any pearls for using trauma informed care in forensic nursing settings? Yes. For me, I think the first, one of the first principles is self-awareness. You have to understand how your own nervous system is doing. If you are going to walk in and provide care for somebody with a dysregulated nervous system, you have to understand where your triggers are, when things start to escalate for you so that you can maintain your own self, because if you walk in and you have a calm nervous system, everyone will co-regulate with you. If you walk in and what you're hearing becomes difficult, it's a fine thing to excuse yourself and collect yourself and then come back and get back to the work that you're there to attend to. I think taking care of yourself and being aware of what your capacity is, what your tools are, what you need when you are low on capacity and how to manage all that stuff is critically important to longevity in this work. A great question. Thank you for asking it. Thank you. That's great advice for that. I think that will be all the questions we will be... Oh, there's one more. Well, we'll slip in one more. This is for Deb. So, what additional elements or adaptations are common for the FACT teams that differ from the ACT teams? You mentioned the focus being prevention of recidivism, but how is this really done that's different? Yeah, one way is that there's usually a staff person that's kind of more expert in how the criminal legal system works that helps contribute to the multidisciplinary team. There's also more partnership with probation or parole depending on who the community supervisor is for that individual. And so there's more work being done at that level where the treatment team and the criminal justice supervisor are kind of working hand-in-hand to help support that individual. And then there's cross-training really to understand what the issues are that put that person at risk and how systems can best approach reducing recidivism. Great. Thank you. Okay, so next slide. Whoever's got control. Maggie Violet. Thank you. So, if there are any topics that were covered in this webinar that you would like to discuss with colleagues in the mental health field, you can post a question or comment on SMI Advisors webinar roundtable topics discussion board. This is an easy way to network and share ideas with other clinicians who participate in this webinar. If you have questions about this webinar or any other topic related to evidence-based care for SMI, you can get an answer within one business day from one of SMI Advisors national experts on serious mental illness. This service is available to all mental health clinicians, peer support specialists, administrators, and anyone else in the mental health field who works with individuals who have SMI. It is a completely free and confidential service. Next. SMI Advisor is one of many SAMHSA initiatives that are designed to help clinicians implement evidence-based care. We'd encourage you to explore the resources available on the Mental Health Addiction and Prevention TTCs as well as the National Center of Excellence for Eating Disorders and the Suicide Prevention Resource Center. These initiatives cover a broad range of topics from school-based mental health through the opioid epidemic. To claim credit for participating in today's webinar, you'll need to have met the requisite attendance threshold for your profession. Verification of attendance may take up to five minutes. You'll then be able to select next to advance and complete the program evaluation before claiming your credit. And lastly, please join us next week on January 27th as Dr. Megan Arrett and Dr. Tawny Smith present Psychotropic Medications in Pregnancy. Again, this free webinar will be on January 27th at 12 p.m. Eastern. Thank you for joining us and until next time, take good care. Thank you for participating in today's free course from SMI Advisor. We know that you may have additional questions on this topic and SMI Advisor is here to help. Education is only one of the free resources that SMI Advisor offers. Let's briefly review all SMI Advisor has to offer on this topic and many others. We'll start at the SMI Advisor website and show you how you can use our free and evidence-based resources. SMI Advisor's mission is to advance the use of a person-centered approach to care that ensures people who have serious mental illness find the treatment and support they need. We offer several services specifically for clinicians. This includes access to education, consultations, and more. These services help you make evidence-based treatment decisions. Click on consult request and submit questions to our national experts on bipolar disorder, major depression, and schizophrenia. Receive guidance within one business day. It only takes two minutes to submit a question and it is completely confidential and free to use. This service is available to all mental health clinicians, peer specialists, and mental health administrators. Ask us about psychopharmacology, recovery supports, patient and family engagement, comorbidities, and more. You can visit our online knowledge base to find hundreds of evidence-based answers and resources on serious mental illness. All content in our knowledge base is reviewed by our team of national experts from the American Psychiatric Association, Harvard, Emory, NAMI, University of Texas at Austin, and more. Browse by key topics or search for a specific keyword in the search bar. Access our free education catalog to find more than a hundred free courses on topics related to serious mental illness. You can search the education catalog by topic, format, or credit type to find courses that fit your needs. SMI Advisor also offers live webinars each month that let you learn about evidence-based practices and participate in live Q&A with faculty. Check out our education catalog often to find new courses and earn continuing education credits. For individuals, families, friends, people who have questions, or people who care for someone with serious mental illness, SMI Advisor offers access to resources and answers from our national network of experts. The individuals and families section of our website contains an array of evidence-based resources on a variety of topics. This is a great place to refer individuals in your care for information about their conditions. They can choose from a list of important questions that individuals who have SMI typically ask. SMI Advisor worked with experts from the National Alliance on Mental Illness to develop these important questions and many of the resources in this section. Watch videos on important topics around SMI, such as what to know about a new diagnosis. They can also find dozens of fact sheets, infographics, and links to other important resources. To access even more evidence-based resources for individuals and families, visit our online knowledge base. All content in our knowledge base is reviewed by our team of national experts from the American Psychiatric Association, Mental Health America, National Alliance on Mental Illness, and more. Browse by key topics and select view all to uncover a list of resources on each topic. SMI Advisor offers a smartphone app that lets you access all of the same features on our website in an easy-to-use, mobile-friendly format. You can download the app for both Apple and Android devices, submit questions, browse courses, and access clinical rating scales that you can use in your practice with individuals who have SMI. SMI Advisor also created My Mental Health Crisis Plan, a smartphone app that helps individuals in your care to create a crisis plan. The app is available on both Apple and Android devices. It helps people prepare in case of a mental health crisis. They can make their treatment preferences known and specify who should be contacted and who should make decisions on their behalf. The app even guides individuals through the process to turn their crisis plan into a psychiatric advance directive. Thank you for your interest in SMI Advisor. Access our free education, consultations, and more on smiadvisor.org at any time.
Video Summary
In this video, Dr. Donna Roland, the director of the Psychiatric Mental Health Nurse Practitioner Program at UT Austin School of Nursing, discusses the roles of forensic nursing in caring for individuals with serious mental illness (SMI). The video aims to provide information and resources for clinicians working with individuals with SMI in a forensic setting. Dr. Roland introduces the SMI Advisor, an initiative funded by APA and SAMHSA that helps clinicians implement evidence-based care for those with SMI. She explains that SMI advisor is focused on providing clinicians with the answers they need to care for their patients, and the webinar has been approved for AMA PRA credits and nursing continuing professional development contact hours. Dr. Roland then introduces the faculty for the webinar, Dr. Deborah Pinals and Jennifer Black, who both have expertise in forensic nursing. Dr. Pinals discusses the prevalence of individuals with SMI in criminal settings and the challenges of providing care in these settings. She highlights the need for trauma-informed care and the complexity of involuntary treatment. Jennifer Black then discusses the role of sexual assault nurse examiners in caring for victims and survivors of crime, including sexual assault and human trafficking. She describes the various roles and responsibilities of forensic nurses and emphasizes the importance of trauma-informed care in their work. The video concludes with information on how to access additional resources and support through SMI Advisor.
Keywords
forensic nursing
serious mental illness
SMI
SMI Advisor
evidence-based care
trauma-informed care
involuntary treatment
sexual assault nurse examiners
victims and survivors of crime
additional resources
Funding for SMI Adviser was made possible by Grant No. SM080818 from SAMHSA of the U.S. Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, SAMHSA/HHS or the U.S. Government.
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