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International Journal of Culture and Mental Health

ISSN: 1754-2863 (Print) 1754-2871 (Online) Journal homepage: http://www.tandfonline.com/loi/rccm20

The culture of fear: expanding the concept of risk


in forensic psychiatric nursing

J.D. Jacob & D. Holmes

To cite this article: J.D. Jacob & D. Holmes (2011) The culture of fear: expanding the concept
of risk in forensic psychiatric nursing, International Journal of Culture and Mental Health, 4:2,
106-115, DOI: 10.1080/17542863.2010.519123

To link to this article: http://dx.doi.org/10.1080/17542863.2010.519123

Published online: 09 Sep 2011.

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International Journal of Culture and Mental Health
Vol. 4, No. 2, 2011, 106115

The culture of fear: expanding the concept of risk in forensic psychiatric


nursing
J.D. Jacob* and D. Holmes

School of Nursing, Faculty of Health Sciences, Ontario, Canada

The purpose of this article is to present, in part, the results of a nursing research
that aimed at describing how fear influences nurse-patient interactions in a
forensic psychiatric setting. Guided by an inductive research design (grounded
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theory), the analysis of data revealed that nurses incorporate a risk discourse into
their practice. As a result, our data show that cultural narratives of risk affect the
experience of nursing care and nurses day-to-day management of potential
threats embodied by the patients. Furthermore, we assert that risk management is
enmeshed in a cultural script that justifies the deployment of precautionary
actions.
Keywords: culture; fear; forensic psychiatry; nursing; risk

Introduction
Currently, the use of the term risk has become increasingly prevalent in the
healthcare literature (OByrne, 2008). While publications on this topic proliferate,
other concepts upon which it relies, such as fear, remain relatively unexplored and
undertheorized (Furedi, 2006). In effect, despite the expanding literature on risk, the
concept of fear remains relatively invisible and exists only in an underdeveloped form
(Furedi, 2006). Such an observation represents a theoretical gap as the concept of
risk has no objective meaning by itself; everything depends on the shared values of
the threatened group. They are what gives the risk its effective existence (Ewald,
1993, p. 225). Choosing whether something or someone is at risk (or not) is a process
defined by the internalization of a perceived threat at the individual and collective
levels. Therefore, risk cannot be explored without investigating its threatening
origins. Fear then becomes an important sociological concept that needs to be
explored in relation to the concept of risk.
According to Furedi (2006), fear is situational and is to some extent the product
of social construction. It is constituted through the agency of the self in interaction
with others. It is also internalized through a cultural script that instructs people as to
how to respond to threats to their security (Furedi, 2006, p. 20). That is, the
conversion of a response to specific circumstances is mediated through cultural
norms that inform people about what is expected of them when confronted with a
threat and how they should respond and feel (p. 20). As a cultural artefact,
responses to perceived threats are, therefore, enmeshed in a specific set of values and
beliefs that are often shared within a group and enacted through specific procedures

*Corresponding author. Email: jeandaniel.jacob@uottawa.ca

ISSN 1754-2863 print/ISSN 1754-2871 online


# 2011 Taylor & Francis
http://dx.doi.org/10.1080/17542863.2010.519123
http://www.tandfonline.com
International Journal of Culture and Mental Health 107

and practices (Schein, 2004). At the individual level, the fearful experience remains
the product of perceptions and appraisals, which varies from one person to another
(Lazarus & Folkman, 1984). However, what should be feared and how the feared
object should be dealt with is also part of a cultural construct that gives meaning to
the notion of risk and the rationalization supporting ritualized risk-aversive practices
in specific settings.
In psychiatry (including forensic psychiatry) the study and understanding of fear
has largely been overthrown by the practice of assessing and managing risk (Castel,
1991). That is, fear has been described as an unspoken topic in the field despite
significant professional socialization to the risks of violence (and its avoidance)
embodied by forensic psychiatric patients (Holmes & Federman, 2003; Mason, 2002;
Morrison, 1990). As recent research demonstrates, working under threat compels
nurses to redefine their interactions and choice of interventions with patients (Arnetz
& Arnetz, 2001; Duxbury & Whittington, 2005; Foster, Bowers, & Nijman, 2007;
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Kindy, Petersen, & Pakhurst, 2005; Morrison, 1990; Needham, 2006). Because of the
perceived risk of violence that patients embody, the need for self-preservation on the
part of nurses becomes a perceptible variable that influences nurse-patient interac-
tions (Arnetz & Arnetz, 2001; Duxbury & Whittington, 2005; Foster, Bowers, &
Nijman, 2007; Kindy, Petersen, & Pakhurst, 2005; Morrison, 1990; Needham, 2006;
Whittington & Balsamo, 1998). The negative effects of fear (one of the most reported
effects of violence) on patient care have been described by various authors (Farrell,
Bobrowski, & Bobrowski, 2006; Foster, Bowers, & Nijman, 2007; Hellzen
et al., 2004; Holmes, Perron, & OByrne, 2006; Kindy, Petersen, & Pakhurst, 2005;
Needham, 2006). The apprehension about being victimized may lead fearful
healthcare staff to adopt more controlling and less responsive services (Foster,
Bowers, & Nijman, 2007), to dissociate themselves from patients (Farrell, Bobrowski,
& Bobrowski, 2006; Hellzen et al., 2004; Holmes, Perron, & OByrne, 2006; Kindy,
Petersen, & Pakhurst, 2005) and to become passive carers. Other authors have
suggested that further investigation should be conducted on the dark side of care,
when those who pose a risk to the staffs integrity are more likely to be treated with
less trust and less commitment, or neglected altogether (Hellzen et al., 2004). In this
case, fear as a principal emotion in response to a perceived threat plays an important
role that considerably affects how nurses view patients and interact with them
(Farrell, Bobrowski, & Bobrowski, 2006; Hellzen et al., 2004; Holmes, Perron, &
OByrne, 2006; Kindy, Petersen, & Pakhurst, 2005). Under cultural discourses of
risk, a better understanding of fear in the forensic nursing domain could provide a
supplementary tool to understand nurse-patient interactions in this setting. More
importantly, recognizing how at risk individuals are managed will, hopefully, help
us develop ethically sound forensic nursing practice.
Consequently, the overall objective of this article is to present, in part, the results
of a nursing research that aimed at describing how fear influences nurse-patient
interactions in a Canadian forensic psychiatric setting. For the purpose of this paper,
we will concentrate on the researchs emergent concept of Fear, as it constitutes the
main object of analysis in relation to the concept of risk. By exploring this
association, we hope to explore the effects associated with the incorporation of a risk
discourse on nursing practice.
108 J.D. Jacob and D. Holmes

Research methodology
Given the state of the literature on the subject of fear in forensic psychiatry,
a qualitative methodology enabling a descriptive and comprehensive analysis was
required. Data analysis followed the basic principles of grounded theory (Strauss
& Corbin, 1998) as adapted and displayed in a sequential fashion by Paille (1994)
(codification, categorization, integration, conceptualization and theorization). As
such, the data collection and data analysis were conducted simultaneously (constant
comparison) in order to build a theory that remained empirically grounded in the
participants narratives.

Research process and sampling


From July to September 2008, 18 semi-structured interviews with nurses
(14 Registered Nurses and 4 Registered Practical Nurses) were conducted and
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used as the primary source of data for analysis. Direct observation, mute evidence
(institutional documents), memos and a field work journal were also used to help
grasp the complexity of fearful representations in this particular setting. In keeping
with grounded theorys inductive principles, participants continued to be recruited
for the study as long as new data emerged from each of the interviews. This process,
which included the codification of interviews and gradual categorization and
integration of emergent concepts, produced four mutually exclusive categories:
(1) Context, (2) Nursing Care, (3) Fear and (4) Othering. For this paper, we will
concentrate on the third category, Fear, as it constitutes the main object of analysis
in relation to. As such, we will explore how forensic psychiatric nurses incorporate
the risk discourse into their practice, expand on the effects of this integration on their
perception of safety and, finally, describe the strategies developed by nurses to avoid
victimization.

Revisiting the total institution: incorporating the risk discourse


As the participants of the study explained, nursing care in forensic psychiatry
revolves around the incorporation of risk as an element in defining the patient
population as threatening. As such, the incorporation of a risk discourse into nursing
practice enables us to draw parallels between forensic psychiatric hospitals and total
institutions (Goffman, 1990). Characterized by their internal modes of functioning
and normalizing attributes, total institutions can be defined as sites where
a mortification of the self takes place. Those who become captives of these
institutions will be submitted to a process that seeks to reconfigure behaviours,
thoughts and motivations according to a predetermined set of institutional agenda.
If this process has originally been attributed to the experiential progression of
mentally-ill individuals in asylums, Holmes (2005) suggests that processes of
mortification also affect nursing staff working in forensic psychiatric environments,
a finding corroborated by the results of this research.
According to Goffman (1990), each individual enters a total institution with an
imported or domestic culture, one that is shaped by life experiences and social
structures. For nurses, this may represent a professional culture resulting from
academic training and hospital based practice. At any point in time, this culture is
what constitutes the frame of reference that consolidates the individuals identity
International Journal of Culture and Mental Health 109

(Goffman, 1990). However, even with the best intentions (therapeutic rationale), the
total institution will not substitute its own culture with each individuals presenting
culture. The total institution suppresses previously consolidated external identity and
imposes its own internal frame of reference. Therefore, previously defined social
representations of the self are stripped upon entrance into the total institution and
are replaced by this internal culture. As the research results suggest, once nurses enter
forensic psychiatric environments, they are immersed in a culture of risk (Holmes,
2001, 2005; Homes & Federman, 2003; Mason, 2002; Perron, 2008). Over time,
nurses developed a new clinical scheme of reference that is rooted in suspicion and a
subsequent heightened sense of awareness. This new clinical scheme of reference
essentially accounts for a distancing from original conceptions of nursing care
(domestic culture) to a scheme of reference that is coloured with safety and security
rationales. Nurses are constantly reminded of the risks involved in working with
mentally-ill offenders. As such, nurses assimilate a culture of risk and incorporate
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this notion into their practice. The following quotes attest of this incorporation:

This is a forensic unit. There is a potential situation going on here that you need to be
aware of. . . . When I talk to student I always try to take just a few minutes and make
them keenly aware of what can happen when you let your guard down . . . when you stop
being diligent . . . (Informant 5)

Being nave can get you a long way. However, there only needs to be one bad incident . . .
I know one woman who worked here for years without a single major incident, and then
she was not paying attention to her patient downtown, and he assaulted a little
girl. . . . and this lady was extremely nave. . . . it was not a problem for her for twenty
years, but there is that one incident and that is all it takes. (Informant 6)

. . . and you know, we have got a pellet gun brought onto the ward by a really offender
kind of guy and held someone hostage. There have been very serious things over the
years. (Informant 15)

According to Ewald (1993), once a population is identified as at risk, everything


within it tends to become  necessarily becomes  just that (p. 221). In this sense,
defining the patient population as being at risk is a static element that nurses are
socialized to incorporate into their care. The assessment of risk that implies
continuous day-to-day evaluations (mental status exam) comes to be tainted by an
overriding need to see patients as always potentially dangerous. This situation is
partially explained by the collective history of adverse events (what has happened in
the past), which becomes a source of information and apprehension that fosters a
group conception of risk and how it should be avoided. As Sunstein (2005) argues,
when people use the availability of heuristics, they assess the magnitude of risks by
whether examples can readily come to mind. If people can easily think of such
examples, they are far more likely to be frightened than if they cannot (p. 36).
The verbal history, as well as the prolonged work experience in forensic
psychiatry, creates the effect of familiarity that affects the availability of these
examples and the deployment of precautionary strategies. As Sunstein (2005) warns,
heuristics can lead to serious errors in assessments, in terms of both excessive fear
and neglect. However, one cannot remain blind to experience. Such is the dilemma
portrayed in this study: nurses build a repertoire of experiences that will inevitably
affect the precautions deployed with patients, while nurses who have not yet seen
110 J.D. Jacob and D. Holmes

or experienced these events may not feel the need for the same guarded approach
to patients:

Maybe it is because I am new and I have not had an awful lot of experience in this field.
Not to put myself down but . . . I have seen a lot, but at the same time I have not seen a
lot. So maybe because I have not seen as much as I will see over the years to
come . . . maybe that is why . . . like, do not get me wrong . . . I always have my guard up.
But I guess . . . there are other people that have their guards up more than what I do, and
I am just not there yet. So . . . like I said, maybe it is because I am new . . . there is more to
come for me to see. That maybe I will . . . have my guard up even more than what I do
now. (Informant 14)

The literature on the process of carceralisation (Chauvenet, Rostaing, & Orlic,


2008) may shed insight into this reality. Secure structures, such as forensic psychiatric
institutions, tend to create a paranoid state of mind. The constant surveillance and
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rigid frameworks that they evoke force individuals (both patients and staff) to
re-interpret the meaning of social interactions (Chauvenet, Rostaing, & Orlic, 2008).
Over time, representations of the patient (or prisoner) become polarized and the
secure structure then becomes an environment where discourses of danger are
omnipresent (Chauvenet, Rostaing, & Orlic, 2008). Much like the results of this
study, it is these polarized discourses of danger that come to limit therapeutic
opportunities:

I think it causes conflict internally within peoples minds, and differing opinions in
terms of approaches to treatment plans and things. I think the conflict inside is that you
can become a little preoccupied with the security and the legalistic aspects of it. And
that has an impact on the care and treatment you can provide as well. So reconciling
those two is difficult. (Informant 3)

The architecture of fear


Defining forensic psychiatric patients as an at risk population has repercussions on
methods of hospitalization. As the research results suggest, managing an at risk
population involves the incorporation of technologies and architecture to (and for)
the provision of nursing care. In effect, the secure environment that exists in forensic
psychiatry often involves the use of surveillance technologies to enable complete
visibility and control of the captive population. It is the need for complete visibility
and control described by participants in this study that enabled us to expand on new
dynamics between architecture, (in)visibility, risk and fear.
This research setting proved to be interesting regarding the incorporation of
technology to nursing care as the use of cameras had recently been removed from the
work environment. The use of technology was part of an ongoing philosophical
debate within the hospital where participants expressed conflicting views regarding
the positive and negative effects of cameras on the units. This conflict primarily
revolved around the effects of technology on nursing care. As the history of the
research setting attests, cameras had been used because of their safety inducing
features. Nurses could observe dangerous/unstable patients from a distance without
having their personal integrity threatened. In time, the use cameras took on other
therapeutic functions to the detriment of nurse patient interactions. As this next
participant explains, cameras created a distance between nurses and patients:
International Journal of Culture and Mental Health 111

Except for in the seclusion room, [cameras] were the biggest mistake they ever made on
forensics, because it took nurses out of the ward and into a bubble. And over here, the
nurses are still in the bubble. So at any given time, you can walk up to the office, and
there is usually three or four people sitting there. . . . cameras did not tell you what was
going on in the rooms. . . . You could not tell a mental status looking through a
camera. . . . Cameras, I think they really allow people to not use their skills in
observation and assessment. (Informant 2)

However, the removal of surveillance technologies roughly fifteen years after their
introduction produced feelings of division, exclusion and (in)visibility by partici-
pants. As a result, the location of nurses on the wards was always defined in relation
to others (both patients and staff) and was qualified in terms of relative safety. Not
being visible on the units affected both the functioning of the units and the general
perception of safety:
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I felt safer on our old unit. . . . Because of the monitoring that we were able to do. The
camera system that we had in place. . . . You could see so much more, and you were
aware of what was going on. . . . You knew that when you are in the main hallway, staff
could see you. You knew that if you went into one of the patients dorms, or even went
into the bathroom, staff saw you going in there. They knew where you were on the ward
at all times. (Informant 7)

Plus not having the monitors, like the cameras that we can use. And you just felt that
when that was there and your own co-workers were watching, they had your back. Here,
without that, it feels like you do not know if anybody has your back or not. (Informant 1)

The forensic psychiatric institution as a space of fear (where patients threaten


individual and collective integrity) seems to be an environment where the effects of
visibility have been internalized by nurses. Under the gaze of others (notably through
the use of cameras on their old unit), nurses described a sense of unity despite
physical separation from the group. This unity, described as knowing that they have
your back or the consciousness of each others visibility, was considered important
for nurses because of the potentially dangerous patients with whom they were
working. Visibility then fulfilled an important role in securing boundaries between
individuals, as well as providing a sense of safety. The real-time, visual connection
between the nurse who is observed and the nurse who is the observer creates a
comfort that surpasses other security devices (i.e. personal alarm systems).

The productive effects of fear


Working in an environment that is defined by the potentiality of dangers has an
effect on the way nurses conduct themselves in practice. The perceived risk of
violence that participants described in this study created continuous negotiations
between physical safety and the ways nurses managed their behaviour on the wards:
In this way, the perceived risk of violence exerts a subtle governing influence over
those who directly experience it, and those who believe they might (Mason, 1999,
p. 122). In this sense, the negotiation between physical safety and management of the
self was described in a way that justified and created interventions to counter
possible victimization. The threat of violence that patients embodied forced
participants to produce interventions to contain and control this threat. Fear then
becomes an emotion through which certain aspects of life are administered (Bourke,
112 J.D. Jacob and D. Holmes

2006). When an individual experiences fear, that experience justifies cautionary or


pre-emptive action.
In this research, most nurses found that the security provided by the psychiatric
institution (staffing, locked doors, rules etc.) enabled them to interact with patients.
However, as some of the participants explained, there may be a certain type of
conditioning that takes place over time that reorganizes the nurses cognitive and
behavioural scheme of reference. Forensic environments impose a certain way of
seeing patients, interpreting and responding to their behaviours. These responses,
which are not necessarily conscious, become internalized and become part of this
new scheme of reference that is specific to the forensic environments (and possibly
others):

Now I had a hard time when I first came over there, if you are talking about
fear. . . . because, in forensics if you were getting rushed by seven or eight people, you are
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in serious trouble. . . . It took a long time for me to get down from that. So I guess that
there were a lot of things that went on that I had just kind of internalized and just did.
(Informant 5)

I think that there is more fear than the people acknowledge. I think that people become
conditioned to working in these environments. I think, especially when you get people
that are acutely ill, and you understand their history and potentials, and people say,
Well I worked there anyways . . . it does not bother me . . . I do not know if that is true.
I think there is a degree of anxiety in everyone working in these environments. I think
that that is a good thing, in that it makes them think of the safety needs of everyone
around in the environment and dealing with people that have potential. (Informant 9)

In other words, it may be difficult to access the fear-motivated rationale behind


certain practices, especially in an environment where discourses of risk justify
(in clinical terms) restrictive measures to create a safe environment. Many of the
participants described an anxiety or nervousness that some patients provoked in
them. However, the capacity to define the source of this anxiety (making the
subjective objective) serves a distinct function and represents a particular process,
wherein making a threat tangible enables the fearful/threatened individual to control
the disruptive object by various means (neutralizing the threat) (Bourke, 2006).
In response to the fear of violence, psychiatric nurses have always instituted
rituals of protection such as removing personal articles and ward searches (Goffman,
1990; Morrison, 1990). By thinking in terms of prevention, nurses then limit chances
of violence, but also act on situations that have not yet happened. In this research,
nurses defined three ways in which the threatening situation could be controlled:

(1) Interventions directed at the self: gathering information about the patient
and/or situation and, subsequently, taking action to minimize victimization
(talking in open spaces, doing rounds two-by-two, evaluating patients from
a distance etc.).
(2) Interventions directed at the patient: forms of control that are aimed at the
patient (and his body), such as verbal de-escalation, PRN medication, using
physical force, developing a privilege system etc.
(3) Interventions directed at the environment: forms of control that seek to
rearrange the environment to avoid victimization, such as the use of cameras,
controlling what is allowed on the units, staffing etc.
International Journal of Culture and Mental Health 113

These interventions will depend, however, on the nurses appraisal of possible


outcomes and his/her capacity to manage the situation (Lazarus & Folkman, 1984).
In this process, nurses will also evaluate the consequences of using certain strategies
over others, which will vary depending on the relationship between the individual,
the context and the available resources (Lazarus & Folkman, 1984). This research
shows that nurses are highly influenced by the context in which they practice. In
effect, nurses will deploy interventions directed at the self and at the environment to
the extent that they evaluate the situation as manageable within the cultural script of
the institution. Once a patient or a situation escalates (or considered of significant
risk), nurses need to control the disruptive object (patient) in order to neutralize the
threat. This is done on a continuum of restrictive interventions (de-escalation to
physical force). However, the dangerousness associated with some patients force
nurses to take precautionary repressive measures to ensure the overall safety of
the units (including their own safety). In such cases, risk management strategies are,
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once again, enmeshed in a cultural script that justifies some precautionary actions
over others. Much like Holmes, Perron and Guimond (2007), the results from this
study would indicate that the way risk is dealt with is a process that is often
influenced by peers and the culture of the institution:

I am having a conversation with a client and he is saying, I would like the door open for
an hour. Okay, you want me to stay in here for an hour before I come out . . . well, you
are going to unlock the door . . . well, I want the door open. And well: No. I can open it
a crack, but we are not leaving the door right open; that is too much stimulation. And
then you will have somebody in the background piping, No we do not leave the doors
open under any circumstances. Well okay. I guess . . . we will have to take a different
plan. (Informant 6)

The underlying message conveyed through this research is that nurses are
encouraged to engage in a reflexive exercise regarding the restrictive measures
deployed in their work environment. Collective understandings of how at risk
individuals should be dealt with must be unearthed if we wish to develop ethically
sound forensic nursing practice. If practices that seek to create a safe environment are
not discussed openly, then nurses may develop ways of practicing that further
distance themselves from idealistic conceptions of care. The narratives that
participants shared regarding the use of preventive seclusion or even open quiet
rooms in this research attest to this contextual consideration. Nurses who evolve in
an institution become accustom to its cultural script and do not necessarily question
the possibility of other ways of doing in any given situation. More importantly,
defining the patient population as being at risk must not become an overriding
practice that justifies the deployment of any and all restrictive measures.

Final remarks
The objective of this article was to present, in part, the results of a nursing research
that aimed at describing how fear influences nurse-patient interactions in a forensic
psychiatric setting. Throughout the paper, we concentrated on the researchs
emergent concept of Fear, as it constitutes the main object of analysis in relation
to the concept of risk. By exploring the concepts of fear and risk in forensic
psychiatry, it is evident that contextual considerations (such as organizational
culture) must not be overlooked when analysing nursing interventions. As this
114 J.D. Jacob and D. Holmes

research indicates, nurses working in forensic psychiatry are socialized to discourses


of risk, which, in turn, guides the way their practice is constructed. The danger
associated with such a reality is when fear, or at least security rationales, goes
unrecognized and is blindly integrated to nursing routines; that is, the interpersonal
contact and nursing process espoused by the profession are themselves at risk of
being replace by overriding rules of security. Nurses must not undermine the possible
effects that the forensic psychiatric environment may have on the way they envision
their practice and especially how clinical nurse-patient interventions and interactions
might be the result of a defensive process sanitised by cultural narratives of risk.

Acknowledgement
J.D. Jacob and D. Holmes involved like to thank the Social Science and Humanities Research
Council for work support.
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Notes on contributors
Jean Daniel Jacob is Assistant Professor at the school of Nursing, Faculty of Health Sciences,
University of Ottawa. His research latest are situated with the field of psychiatry/forensic
psychiatry and include topics such as violence, risk, ethics and the sociopolitical aspects of
nursing practice.

Dave Holmes is full professor and Vice-Dean (Academic) at the University of Ottawas Faculty
of Health Sciences. He is also University Research Chairs in Forensic Nursing (20092014)
and Nurse-Researcher at the University of Ottawa, Institute of Mental Health Research
(Forensic Psychiatry Program). Most of his work, comments, essays, analyses and research are
based on the poststructuralist works of Deleuze Guattari and Michel Foucault. He is co-editor
of Critical Interventions in the Ethics of Health Care (Ashgate, 2009) and Abjectly Boundless:
Boundaries, Bodies and Health Care (Ashgate, 2010). He is also Editor-in-Chief for APORIA 
The Nursing Journal.

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