A Meta-Ethnographic Review of Forensic Psychiatry Inpatient Care. Nursing Staff Experiences of the Nurse-Patient Encounter

Abstract Aim The aim of this review was to synthesise qualitative research into how nurses perceive and experience encountering patients in forensic inpatient care. Review method This review followed the steps of meta-ethnography developed by Noblit and Hare. Data sources Twelve studies, published from 2011 to 2021, were identified through a search of relevant databases in December 2021. Findings The synthesis revealed three third-order and 10 second-order constructs during the translation of concepts in the studies. These are: Adopting the patient’s perspective (liberation, comprehension and resistance), Action (security, trust, flexibility and predictability) and Activation (afraid or safe, involved or indifferent and boundaries). Further, a line of argument was developed which indicates that in forensic psychiatry inpatient care, nurses experience having to deal with internal and external resistance that affects their freedom of choice in the creation of a caring relationship. Conclusion The encounter is experienced as a continuous process in which the foundation is laid for the encounter (approach), the encounter unfolds and develops (action) and the nurse experiences the encounter (activation). The process is intertwined with and takes place in a context where care is influenced by the duality of the task (task), the culture of care (context), the patient’s expression (patient) and the nurse’s own impression of the patient’s expression (oneself). Implications Professional communities should support initiatives that can strengthen nurses’ self-awareness and provide opportunities for reflection on practice, which will both benefit the resilience of the nursing staff and the quality of care for patients in this setting.


Introduction
This article reports findings of a meta-ethnography of published qualitative research into nurses' experiences of nurse-patient encounters in forensic psychiatry settings.'Encounters' within a care setting can be perceived as the convergence of two individuals (Carlsson, 2010), where the caregiver must ensure that the encounter is rooted in trust and promotes the patient's health journey (Dahlberg & Segesten, 2010).One of the challenges in conducting research on nurse-patient encounters is the lack of conceptual consensus of the term (Holopainen et al., 2019).Travelbee (1971) states that encounters precede nursing care and develops through various stages.Martinsen (1989) describe the encounter as an abstract space among individuals with an explicit demand on the carer.Despite the lack of consensus on terms, there has been a growing discussion about whether modern health care lacks compassion for patients and fails to provide individualised care, and this is relevant to forensic psychiatric care (Nilsson et al., 2019).Patients receiving forensic psychiatric care are mainly people who have committed severe crimes and, in connection with a conviction, have been assessed as suffering from a severe mental disorder.According to Gutheil (2004) forensic psychiatry is the sub-speciality that deals with topics appearing within the border area between psychiatry and law.The principles and aim of forensic care can be seen as universal, despite the fact that laws and regulations governing the delivery of care differ greatly from country to country (Edworthy et al., 2016;Sampson et al., 2016).
Forensic psychiatry is deemed to be synonymous with a focus on safety and security, i.e. that the care must benefit the individuals while maintaining a high level of safety (Arboleda-Flórez, 2006).This regulation reflects a balance between, on the one hand, respect for the individual's freedom and autonomy and, on the other hand, society's obligation to protect those who lack the ability to protect their own good or whose freedom needs to be limited in order to protect other people's lives and health.Considerations that become tangible in connection with the termination of forensic psychiatric care.Forensic psychiatry's dual role in medicine and law means that, in parallel with coercive legislation, the fundamental rights of the Health and Medical Care Act also apply.Consequently, rehabilitation within inpatient forensic psychiatric care is time-consuming as the goal is to increase patients' level of functioning and well-being and also reduce the risk of recidivism (e.g.Thomson & Rees, 2023).Rehabilitation is made more difficult by the fact that the environment in which forensic psychiatric care is conducted is drastically different from what it is like to live as a citizen in society.Among other things, the patient has very limited freedom of action, which limits the risk of the violence recurring as long as the care is ongoing.This means that nursing staff, in their profession, are constantly faced with the duality of either being fostering or caring.In other words, they deal with heightened emotions and the risk of becoming emotionally blunted when providing care in a high-security hospital (Middleton & Jordan, 2017).
In order to promote meaningful interactions in which the patient is seen as a person and not as an object (Nicholson et al., 2010), nurses need to manage the interaction so that it does not inhibit their encounters with the patient (Tingleff et al., 2019).Dealing with one's own emotions is essential in psychiatric care, a process that is similar to what Hochschild (2003) called emotional labour.Gross (1998) suggests that a strategy which he called emotional regulation (Gross, 2002) can be used early in this process of emotional labour.Emotional regulation can be understood as a strategy to manage and minimise problematic patient behaviours and conflicts (McDonnell, 2010), which according to Hammarström et al. (2022) is strongly correlated with how healthcare staff treat the forensic psychiatric patient.
It is of great importance that nursing staff have the ability to see the patient as a person in order to facilitate the nurse-patient interaction (Syrén, 2014).A humanistic view is essential to create a caring nurse-patient relationship (Zugai et al., 2015), as it entails an openness that may promote participation and the opportunity for the patient to experience self-determination (Selvin et al., 2016).In a caring relationship, the patient can express their own needs and experiences; this requires that the nurse is both knowledgeable and experienced, and actively wants to participate in the patient's lifeworld (Hörberg, 2018).However, nurses in forensic psychiatry and in somatic care have expressed that they feel limited and powerless due to rules and regulations, safety aspects, lack of time and heavy workload, which affects patient participation (Hörberg, 2008;Tobiano et al., 2015).
Therefore, understanding nurses' experiences when engaging with patients is crucial for supporting caring in forensic psychiatry (Söderberg et al., 2020).This is particularly important in forensic psychiatric inpatient care where patients' behaviours risk reducing the contact time between nurses and patients (Hammarström et al., 2022).There is an increasing number of qualitative studies that are relevant to this subject, but they are usually based on case studies and small samples.Systematic overviews regarding this subject are sparse, so it is difficult to draw any conclusions.This article uses the meta-ethnographic review and synthesis method to integrate results from qualitative research studies (Noblit & Hare, 1988;Britten et al., 2002) and focuses on nurses' experiences of the nurse-patient encounter in forensic psychiatric inpatient care.

Aim
This meta-ethnography aims to provide insight into nurse-patient relationships in forensic psychiatry inpatient care by synthesising research that explores the experiences of nurses in these relationships.The research question was: • How do nurses perceive and experience encountering patients in forensic inpatient care?

Design
Following the structure of Barken et al. (2019) a synthesis was conducted using the meta-ethnographic method developed and described by Noblit and Hare (1988) and adapted for health research by Britten et al. (2002).Qualitative papers on how carers in forensic psychiatry inpatient care experience the carer-patient relationship was collected and integrated in this study.Meta-ethnography is a inductive synthesis method where the results of different papers are integrated and interpreted, forming a new whole in relation to theoretical concepts.According to Noblit and Hare (1988) the method aims to gain a new understanding by interpreting instead of describing a phenomenon within a specific context.Which is achieved by systematically gathering qualitative research (Campbell et al., 2011).Following Noblit and Hare (1988), the method consist of seven steps: Step 1defining the object of interest (aim), Step 2 -search methods and outcomes and quality appraisal, Steps 3-6 -data abstraction and synthesis and Step 7 -writing the results.ENTREQ (Tong et al., 2012) and eMERGe guidelines (France et al., 2019) were used to improve transparency and quality of this study.The systematic gathering of research was guided by mesh terms [Medical Subject Headings] and keywords, forming two major terms "forensic psychiatry nursing" and "nurse-patient relation".The search strategy was devised in collaboration with a specialist librarian (OE).

Search methods
Following step 2 in Noblit and Hare's approach (1988) Also hand searches of reference lists of papers were retrieved.Medical subject headings and free-text searches related to nursing staff, forensic psychiatry inpatient care, nurse-patient relationship, experience and qualitative research were used.Different databases were used to cover research on nurse-patient encounters in forensic psychiatry in-patient care (cf.Booth et al., 2016).A non-systematic search for grey literature was performed in Google Scholar, ProQuest, Web of Science and The Cochrane Library, but did not retrieve any relevant articles.
We utilised the search term 'nurse' because it is an internationally recognised term encompassing various categories of nursing staff, including 'enrolled nurses, ' 'auxiliary nurses, ' and 'care aides, ' not solely limited to registered nurses holding a bachelor's degree in nursing.Within different segments of the healthcare system, individuals with varying levels of education are engaged, yet they all possess experience pertaining to the phenomenon under investigation in this review.

Search outcome
The systematic review initially resulted in 160 studies, with 88 studies remaining after duplicates were removed.All authors contributed by individually screening titles and abstracts in relation to the inclusion and exclusion criteria, presented in Table 1.
According to Malpass et al. (2009), the systematic search procedure was used to guarantee that the final sample is detailed and rich to be used to contribute to the final synthesis.For the purposes of this synthesis, items were included that were related to inpatient units/wards that provide forensic psychiatric care and/or to adult patients with a goal of recovery and discharge.After review of titles and abstracts, 53 papers were retrieved for more detailed evaluation The full text of all 53 retrieved papers was read and the inclusion and exclusion criteria were applied (Table 1).A sample of 53 papers was thus obtained for quality appraisal which resulted in the final inclusion of 12 papers.The selection process is shown in the flow chart below (Figure 1).

Quality appraisal
The review team independently assessed the quality of the included paper using the CASP tool (Critical Appraisal Skills Programme, 2018).Papers were evaluated to appraise the degree to which they provided a rich account of participants' experiences of the nurse-patient relationship (Harden & Thomas, 2008).To avoid any conflict of interest in connection with the quality assessment, the study by Hammarström et al. (2019) was quality assessed by two professors who were not part of the original study.The included articles were assessed to maintain a quality that was above average, with 10 of the articles receiving a high score and two slightly lower because they lacked descriptions of the authors' prior knowledge and relationship to the participants.All the articles had findings that provided rich insight into the personal lived experiences of nursing staff in the nurse-patient relationship.

Data abstraction and synthesis
A non-linear process was used in step 3-6, were the analytic and synthesising procedure is reported.The alternation between the different steps increased the authors' conception of each study.While the synthesis was carried out by the first author, each step was thoroughly discussed with the co-authors.
Step 3: The 12 papers were read repeatedly, and the details of the primary studies were extracted (Table 2).The studies encompassed 156 nursing staff with experience in forensic psychiatry inpatient care.The studies were conducted in Canada (1), Denmark (2), Finland (1), South Africa (1), Sweden (5) and the UK (2).
Step 4: In order to decide how the found empirical studies related to each other, there results were sorted into a chart, where relevant, common recurring themes/categories were listed and arranged into first-order constructs (participants' quotes) and second-order constructs (authors' interpretations) (Britten et al., 2002).
Step 5: Vincze et al. (2015) was selected as an index study due to its quality and richness.The key themes from the index study were compared with those of the second study and the synthesis of these two studies was compared with the third study, and so on.When comparing all studies, key concepts were interpreted using a constant comparison method (Britten et al., 2002).During this comparison, comparable descriptions and notions were managed together based on its similarities, re-ordering, re-linking and reassembling (clustering) the metaphors until a shared comparison was identified (Campbell et al., 2011).
Step 6: From the previous step, themes and categories emerged that were further analysed and abstracted to form a third-order conceptual framework connecting both the first-order and second-order constructs (Britten et al., 2002).In order to create new relationships between the concepts, the authors had to read the findings with "new eyes" to establish a third-order interpretation developed through a  line-of-argument synthesis (Britten et al., 2002).An example of the synthesis process is presented in Table 3.

Findings
The synthesis revealed three third-order and seven second-order constructs during the translation of the concepts in the papers.These are: Adopting the patient's perspective (liberation, comprehension and resistance), Action (security, trust, flexibility and predictability) and Activation (afraid or safe, involved or indifferent and boundaries) see Table 4.A line of argument was established which indicates that in forensic psychiatry inpatient care, nurses experience having to deal with internal and external resistance that affects their freedom of choice in the creation of a caring relationship.The line of argument is based on the three third-order constructs, through which a conceptual model has been developed that illustrates the inter-relationship between the conditions of the nurse-patient encounters in forensic psychiatry inpatient care (Figure 2).The included articles are referred to by number as indicated in Table 4.

Approach (third-order construct)
The synthesis is a compilation of how nurses approach and lay the foundation for their dealings with patients in forensic care.Their approach is intentional and involves mental liberation from possible prejudice and an attempt to zero themselves in order to open up to the complexity of the patient's situation, context and history.The approach includes preparing for the patient's expression of resistance or for their own reactions to encountering resistance.

Liberation (second-order construct)
Liberation was found as a construct in the nurses' approach to the patients in nine of the studies included.Liberation was targeted at prejudices, objectification and customary attitudes both in advance of and during relations with the patients.Prejudice against patients in the context of forensic care was particularly prominent in newly qualified nurses or nurses who lacked experience with the patient group (6).The nurses said that over time they had become aware of their own or society's perception that such patients are dangerous, malicious and inhumane (6, 7).Prejudice was considered an obstacle to seeing and respecting the person behind the crime (3) and could instil a "them-and-us" attitude that was not beneficial to any of the parties in the interaction (9).The nurses also strove to free themselves from allowing diagnoses to define people and treat the patients primarily as individuals rather than statistics (6).
Breaking with previous attitudes and patterns was seen as redemptive both in the service in general ( 8) and in dealing with the individual patient as the nurses realised that patient expressions were not always what the patients pretended (1, 2, 12), which often required creativity and reorientation from the nurse (10).

Comprehension (second-order construct)
In 10 of the studies included, the nurses emphasised that a comprehensive understanding is important in dealings with patients.Comprehension meant entering the patient's lifeworld and trying to understand the patient's thoughts, feelings and reactions in light of their life history, both in terms of past and present events (1, 2, 5, 6, 10).This often meant that the nurses needed to compile information that they sensed or observed when they met the patient, like piecing together a puzzle (12).It also required cultural insight on the part of the nurses about different sub-cultures or environments to which the patients belonged (8).The studies showed that achieving an overall picture was as much a process of reasoning and mapping of events, situations and people involved, as it was an emotional attitude, which required time and getting to know the patient (3,6,11).Expecting the unexpected or understanding the patient's changing expressions as part of the nature of their illness was also crucial in forming an overall impression (4).

Resistance (second-order construct)
Resistance was a consistent feature in the nurses' approach to the patients.It could either be experienced as an internal resistance by the nurse or an expected resistance from the patient, and was found as a construct in all the studies included.Inner resistance could be experienced as an instinctive reluctance to approach a person who could potentially be threatening or dangerous (4,5,11).It could also consist of feelings of frustration and hopelessness when trying to approach patients who blocked relational contact (5, 10).In such situations, the nurses described taking on an active approach to counteract their own destructive attitudes (6, 7, 9) practicing patience and perseverance in waiting for the patient (9, 10) or challenging the patient's perception of reality (1, 3, 8, 12).

Action (third-order construct)
Action serves as a basic prerequisite for the nurse-patient interaction in forensic psychiatric inpatient care.Action represents a clinical openness that is based on increased awareness and insight into the patient's daily life on the ward, and a quest for dialogue with the patient.Action promotes the understanding of the patient's development and management of everyday life on the ward, enabling the caregiver to make ethical considerations regarding the patient.To act and assess and prevent possible risks, the nurse needs to have the freedom to act individually in dealing with the patient, which requires active commitment and participation on the part of the nurse.

Security (second-order construct)
Nurses in 10 studies (Table 4) felt that interactions and their own attitude in these interactions with the patient were based on the security that routines and rules provided (1-3, 6, 7, 9, 10, 12).A sense of security also came from the knowledge and availability of present and reliable colleagues (1, 4-6, 9, 10) and was influenced by their own feelings (1, 2, 5).

Trust (second-order construct)
The nurse-patient interaction enabled the patient to be treated with a caring attitude aimed at creating a caring relationship.Despite the distance caused by the asymmetry, which naturally exists in the relationship between the nurse and the forensic psychiatry patient, the importance of the relationship is emphasised (1,2,4,5,8,10).In 10 studies, the nurses experienced a sense of trust when dealing with patients (Table 4).The experience of trust was described as a feeling of being close to the patient, which provided safety (2).Relational closeness was further strengthened when nursing skills were prioritised in the patient encounter (1-4, 6-8, 10, 11), a fact that and compensated for technical solutions (6).Moreover, relationships and being close to the patient reduced uncertainty and brought the nurse peace of mind in dealing with the patient (2).
Responsiveness and availability increased the possibility for the patient to become involved in the care (2, 8, 10).The nurse's freedom to act individually in patient dealings created security and trust in the relationship with the patient, which increased the nurse's ethical sensitivity (8, 9) and thus prevented authoritative and coercive care (2,4,5,11).
Having freedom in interactions with the patient enables the nurse to proceed with a caring attitude (2, 4, 8-10) which counteracts the nurse's feelings of uncertainty and fear (5).

Predictability (second-order construct)
An important aspect of the nurse-patient encounter is an understanding of its inherent asymmetry.It is always asymmetrical and contains power on the part of the nurse that is not repressive, but is intended to create compliance on the part of the patient (1,5,8,9,11,12).In interactions with the patient, the nurse has the power to interpret and thus try to predict the patient's behaviours (2,(8)(9)(10).Ten studies (Table 4) indicate that the nurses experienced the encounters and the relationship with the patient as significantly important for them to be able to predict the patient's behaviours (1,2,4,5,(8)(9)(10)(11)(12).Despite the distance and the asymmetry that naturally exist between the nurse and the patient in forensic psychiatric inpatient care, the existence of rules gives the nurses an important sense of freedom (4) as rules limit the resistance that the patient shows in the encounters (4, 9, 12).The freedom to act enables the nurse to use the knowledge that has emerged from the relationship with the patient during interactions (2, 4).

Activation (third-order construct)
The synthesis presented an overview of how nurses experience nurse-patient encounters within a forensic setting.Being a nurse in a forensic clinic entails devoting oneself to patients' well-being and abiding by rules and regulations.This creates a dilemma and a constant inner dialogue which is intertwined with and stems from being touched by the patient's expression of suffering.Such expressions stir up emotions that may be difficult to handle as they are intertwined with constantly dealing with their own power and perceived resistance from the patients from themselves.

Involved or indifferent (second-order construct)
In eleven of the studies that make up this review, nurses experienced that the nurse-patient encounters and relation affected them in the long run.Dealing with expressions of suffering over extended periods could lead to nurses feeling either involved with or indifferent to the patient (2,(4)(5)(6)(7)(8)(9)(10)(11)(12).
Caring in a forensic setting sometimes meant not seeing any results, which gave rise to a sense of discouragement for the nurses and made it difficult to empathise with the patient (5-7, 12).It was difficult to retain a sense of compassion, not become resigned, and instead encourage participation from both parties in the encounter (1, 5, 7, 10-12), despite facing negativity in the form of nagging, threats and violence (5,7,12).

Boundaries (second-order construct)
In 10 of the studies nurses depicted interactions with patients as being ethically challenging since they involved dealing not only with the duality of caring and guarding, but also with their own emotions and inner dialogue, reflecting upon oneself as a nurse (1, 2, 5-12).Consequently, being a nurse in forensic psychiatry meant dealing with personal insecurities and finding one's own personal boundary between personal and private (5,10,12).The different studies vary in their descriptions of what the nurses experienced as personal and what affects nurses' vulnerability (5).However, nurses are unanimous in emphasising that nurse-patient interactions force them to look inward and discover their own personal boundaries through self-reflection (1, 2, 5-12).

Line of argument
A line of argument was formulated which suggests that in encounters with patients in forensic care, nurses experience having to deal with internal and external resistance that affects their freedom of choice in the creation of a caring relationship.The line of argument is illustrated through a conceptual model in Figure 2. The experience of the everyday encounters between nurse and patient in forensic psychiatric inpatient care is rooted in the basic prerequisite for the care.In other words, the purpose of the assignment is to improve patients' mental health and reduce the risk of recidivism.Interactions are experienced as a continuous process in which the foundation is laid for the encounter (approach), the encounter unfolds and develops (action) and the nurse experiences the interaction (activation).The process is intertwined with and takes place in a context where care is influenced by the duality of the task (task), the culture of care (context), the patient's expression (patient) and the nurse's own impression of the patient's expression (oneself).The nurse's actions are deliberate and involve releasing prejudices to be able to open up to the patient's complex situation and history, as well as readiness for the patient's expression of resistance and for their own reactions to encountering resistance.The starting point of the encounters is awareness of and insight into the patient's daily life, and a quest for dialogue with the patient.An understanding of the patient's development and management of everyday life is promoted by the nurse, which enables ethical considerations in relation to the patient.The nurse's actions pre-suppose individual freedom in dealings with the patient, which do not only involve a focus on care but also compliance with rules and regulations.This duality creates an inner dialogue that is intertwined with the patient's expression of suffering.Such expressions concern the nurse and can be difficult to deal with as they are related to handling perceived resistance from the patient and themselves.

Discussion
A line of argument has been developed which indicates that in encounters with forensic psychiatric patients, nurses experience having to deal with internal and external resistance that affects their freedom of choice in the creation of a caring relationship.Dealing with power and resistance and the tension in-between, makes the nurse aware of their own thoughts and actions (Hammarström et al., 2022;Martinsen, 2009).
This meta-ethnography has unveiled three basic prerequisites for the nurse: approach, action and activation, which together influence the nurse-patient encounters.Liberation, comprehension and resistance are the key elements of the approach process.The process can be understood as the link between power, resistance and freedom.Being on the caring side of a relationship means being in a position of power, acknowledging that there is an asymmetry (e.g.Holmes, 2005;Markham, 2021).This also means that nurses must inevitably deal with the obligation and responsibility of the encounter being based on the patient's needs (Rydenlund et al., 2019).Ricoeur (1992) argues that we should use ethics as a compass to understand this responsibility and the moral dilemmas we face.That we always have the choice in the encounter with the other to choose, to either lift or lower the other with our deeds.Often, our moral action precedes us without having insight into our own ethical reasoning about our actions.Therein is a responsibility linked to our choices, a responsibility that requires us to use ethics and for an ethical discussion within ourselves so that the encounter will fulfil its true purpose, and become something we share, something mutual.In other words, nurses have the freedom and responsibility to reshape themselves in the asymmetric power relationship (Ricoeur, 1992).Without freedom, there is no room for the nurse to change in their interactions with the patient (Martinsen, 2007).
Managing this responsibility in encounters means understanding the patient, which is only possible if encounters involve a process of self-reflection around the nurse's own pre-conceived ideas.It can be considered a requirement for the nurse to understand the patient's expression of suffering and thus truly see the patient's true self.In practice this means being able to problematise one's own personal attitudes and put them aside to create a relationship and promote participation (cf.Markham, 2021;Söderberg et al., 2020).The feelings that the patient and their crime give rise to result in the nurse becoming cautious and vigilant instead of being inviting without being intrusive.In such situations, self-reflection can support the nurse to adopt a caring attitude in dealing with the patient rather than focusing on being careful and adopting a guarding role (Hörberg, 2018).Allowing the patient's expression to make an impression means feeling some kind of shared vulnerability, which enables the nurse to alleviate suffering by making decisions based on compassion and the patient's needs (Hammarström et al., 2022).
According to Foucault (2001), the nurse-patient encounter in forensic psychiatric inpatient care takes place in a closed and locked room where time stands still.It is a context created for deviant people, where the culture is characterised by disciplinary framework control, i.e. by rules, structure, routines and goals.The forensic psychiatric context is also part of a bigger open context in the healthcare system, where people can come and go.The healthcare context is part of our society, a context with a high-speed culture (Rosa, 2015) that crosses borders, dissolves structures and is characterised by care.Safety, trust, flexibility and predictability are all key elements of the forensic psychiatric context and serve as basic prerequisites to the nurse-patient interactions within forensic psychiatric inpatient care.
In the forensic psychiatric context, where encounters take place and develop, the nurse represents a clinical openness that is based on increased awareness and insight into the patient's everyday life on the ward, and a striving for dialogue with the patient (Hörberg, 2008).This requires the nurse to have the freedom to act individually in interactions with the patient, which in turn requires active commitment and participation on the part of the nurse (Söderberg et al., 2020).This not only means having a responsibility to encourage patient participation, but it is also an important aspect for high-quality care (Tobiano et al., 2015;Livingston et al., 2012).
Finally, the content of the studies that compile this meta-ethnographic review indicates that facing patients, dealing with an asymmetric relationship and the balance of power and resistance activate an inner dialogue within the nurse.This leads to nurses needing to confront themselves in the form of addressing shortcomings and dealing inevitably with their own vulnerability.Facing vulnerability in the workplace often meant overstepping one's personal boundaries, which nurses described as problematic (Ricoeur, 1992;Angel et al., 2020).Vulnerability must therefore be protected; it is something we all share, and it binds us together, there is reciprocity between us as humans.Alleviating another person's suffering should not thus be misunderstood as being the same thing as removing vulnerability, instead it should be seen as an issue to address (Ricoeur, 1992).
When trying to get close to the patient, encounters are often used as a platform to establish a relationship based on openness (Rydenlund et al., 2019).However, interacting also meant facing fear, not only the patients' fear, but also the nurses' own fear (Jacob & Holmes, 2011).Dealing with one's fear meant reflecting partly on oneself and partly on the patient's expression of suffering, a process that could be perceived as arduous or difficult to understand, because when suffering is difficult to understand, nurses risk becoming indifferent (Hammarström et al., 2020).When opening up to others, nurses also put themselves at risk of harm (Rytterström et al., 2021).However, allowing expressions to make an impression could mean seeing beyond those expressions and what they stand for, thereby also seeing the patient for the person they are.This could enable the nurse to act out of compassion and according to their inner desire to do good (Hammarström et al., 2022).
Due to its clinical importance, this study offers a model that can help nurses, researchers, teachers and students to understand the nurse's interactions with the forensic patient.Future research is needed to increase the understanding of how nurses address their own emotions in these encounters, as this is an evident part of creating a caring relationship.Professional communities should support initiatives that can strengthen nurses' self-awareness and provide opportunities for reflection on practice, which will both benefit the resilience of the nursing staff and the quality of care for patients in this setting.

Conclusion
This meta-ethnography provides an overall understanding of nurses' experiences of nurse-patient encounters in a forensic setting.A figure is presented (Figure 2) that illustrates the composition of such encounters.In dealing with patients, nurses have to handle internal and external resistance that affects their freedom to choose between a caring or guarding approach in their relationship with the patient.Future research is needed to increase the understanding of how nurses navigate their own emotions during these interactions, as this constitutes a fundamental aspect of employing agency to create a caring relationship.

Strengths and limitation
By following the seven steps of Noblit and Hare (1988), a rigorous methodological approach was applied to achieve credibility and trustworthiness.After OE had identified potentially relevant studies, the review team (OH, LH, and SAD) independently screened studies and assessed the relevance and quality of the research included.The authors had different backgrounds and prior knowledge, and some were not familiar with a forensic setting, which was deemed as an asset in the numerous discussions that guided the analysis and writing of this study.Additionally, two of the authors were familiar with the studied context, which gave the research team a unique ability to unravel and truly understand the meaning of the findings in the research included.
The studies that were included varied in design, methods, data collection, analysis and participants' socio-demographic factors.Overall this gave nuance to the illuminated phenomenon, which leads to a deeper understanding of the nurse-patient interaction in forensic psychiatry care as the generality of the findings is reliant on the variations of the depicted phenomenon (Dahlberg et al., 2008).Although the included studies were conducted in various countries, more than half were conducted in the Nordic region.The transferability of the findings to other countries and health environments must therefore be assessed with caution.While international rules and laws that govern forensic inpatient care differ, within the forensic context, the importance of nurse-patient relationships and interactions is consistent.
Despite conducting both systematic and unsystematic searches, the results yielded relatively few hits.This may be attributed to the limited extent to which the phenomenon has been investigated, as well as its treatment and reference with ambiguous or varied terminology.A fundamental requirement for attaining a deeper understanding of the phenomenon within the domain of forensic psychiatry is the analysis and consensus-building regarding its conceptual framework and scope.

Figure 1 .
Figure 1.Inclusion of studies by systematic literature research.

Figure 2 .
Figure 2. nurses in forensic inpatient care and their experience of the nursepatient encounter.

Table 2 .
Characteristics of the studies included.

Table 3 .
an example of the synthesis process-from first-order construct to a line-of-argument.itjustsort of came as time went by, [. ..] and I think I started seeing them as human beings and not just a statistic on a chart with, you know two counts of murder or two counts of rape...and yes, you have to be able to, or you cannot work.We analysed the patient's history.We made a kind of time-line of his past, all his relationships, how his life was… the reasons he ended up in niuvanniemi Hospital.ComprehensionIf you have a bit of a 'them and us' attitude, especially when you want things done, they're not going to be as cooperative as they will be if you've had some kind of relationship with them.resistance

Table 4 .
Included articles categorised into third-order and second-order constructs.