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Personality disorders are described as conditions that have some deviation from the considered normal personality state and is characteristically associated with a “range of psychiatric symptoms and aberrant behaviours” (Sansone & Sansone 2009:17). Personality disorder traits (Appendix 1) can be seen to be exaggerated normal human traits (APA 2000) which is a criticism of the concept of personality disorder in that a normal human behaviour can be labelled as deviant when it does not adapt into a particular situation or environment (Baker et al 2011). However it is the use of maladaptive coping strategies means that people with this diagnosis are disproportionately represented within the criminal justice and mental health systems (McVey & Murphy 2010) with studies indicating between 45.7% and 47.4% of prisoners in the UK having a diagnosis of borderline personality disorder (Fazel 2002, Sansone & Sansone 2009).
Borderline Personality disorder is a condition that can generate a large amount of distress not only for the people who have the disorder but also those who nurse them. Serious psychological distress is experienced by people with this disorder, which is usually managed by the use of dysfunctional coping mechanisms such as drug addiction, risky sexual encounters, violence, self harm and suicide (McVey & Murphy 2010). The diagnosis of personality disorders remains controversial, as does the questions whether the condition is treatable or not (McVey & Murphy 2010) and whether the person qualifies for a diagnosis of disorder or simple personality trait.
Diagnostic criteria.
Personality disorder is classified within the World Health Organisations International Statistical Classification of Diseases and Related Health Problems (ICD-10) (WHO 2010) as being characterised by a tendency towards impulsivity without considering the possible consequences for their actions. It also explains that mood may be unpredictable and liable to aggressive emotional outbursts which can lead to conflict with others. Borderline type also has the characteristics of disturbance in self-image, chronic feelings of emptiness abandonment and rejection, unstable interpersonal relationships, an impairment of psychosocial functioning and by a tendency towards self-destructive behaviour, including self-harm and suicide (National Institute for Health and Clinical Excellence (NICE) 2009, WHO 2010).
The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders: 4th edition: Text Revision (DSM-IV-TR) (APA 2000) criteria for personality disorder defines borderline personality disorder as instability of interpersonal relationships, frantic efforts to avoid abandonment, a disturbance of self image, transient paranoid ideation and mood instability with a marked impulsivity that begins in early adulthood (APA 2000). Both the ICD-10 and DSM-IV-TR are “well reasoned and scientifically researched nomenclatures” (Widiger 2001: 60) that are used to describe the current understanding of disorders of personality. However, differences within the diagnosis criteria are prominent. In the ICD-10 there is no specific category for borderline personality disorder, instead it is classified as subtype under emotionally unstable personality disorder, which is comparable to the DSM-IV-TR personality disorder criteria. The inclusion of quasi-psychotic features is another difference within both diagnostic criteria with the ICD-10 not classing this as a symptom of borderline personality disorder (National Collaborating Centre for Mental Health (NCCMH) 2009) and the DSM-IV-TR stating it as one of nine diagnostic criteria (APA 2000). NICE, in collaboration with The British Psychological Society and The Royal College of Psychiatrists, endorses the DSM-IV-TR diagnosis of Borderline Personality Disorder (NCCMH 2009) and in keeping with UK guidelines, any reference to diagnosis in this dissertation shall follow suit.
Perceptions amongst staff.
There is a paucity of studies that have specifically focussed on staff attitudes towards borderline personality disorder; instead researchers prefer studying this issue from the broader term of personality disorder (James & Cowman 2007). However, research indicates that approximately two percent of the current population would meet the diagnostic criteria for borderline personality disorder, with a quarter of those presenting with the severest symptoms and already be known to the mental health services (Krawitz & Watson 2003) which, as previously mentioned, is significantly increased when looking at the custody services,
The results of the literature, in the area of staff attitudes towards patients with a diagnosis of borderline personality disorder, tend to point towards the focus of care being predominantly managed by nursing staff; however it is true to state that all mental health disciplines find working with personality disordered patients to be challenging (Bland et al 2003, Bowers 2002, Cleary et al 2002, James & Cowman 2007, McVey & Murphy 2010). As such staff can hold negative views towards patients with a diagnosis of borderline personality disorder due to the negative stereotypes that are portrayed.
Patients with borderline personality disorder have frequently been excluded from services simply due to their diagnosis, which NICE state could be due to lack of confidence and skills within the healthcare workforce (NICE 2009). Health care policy in the UK has advocated for mental health services to become more responsive to the needs of patients with personality disorders (NIHME/DH 2003) in an attempt to end the marginalisation of services towards people with a personality disorder diagnosis. Lack of and inadequate training is often cited within literature as an issue for nursing staff managing this difficult patient group (McVey & Murphy 2010). Themes from the literature indicates that nursing staff do not feel that the current level of training is adequate in preparing them for the role of managing and treating personality disorder with only a small percentage of nurses receiving training on personality disorder outside of their undergraduate training (Cleary et al 2002, Deans & Meocevic 2006, James & Cowman 2007,Krawitz 2004). Commons-Treloar & Lewis (2008) discusses the lack of training on personality disorder in the nursing population, explaining that nurses negative attitudes improved when provided with specified training in the area of personality disorder.
Due to the entrenched nature of Borderline Personality traits, working with patients who have this diagnosis is both slow and labour intensive. Murphy & McVey (2010) estimate that, in some settings, a twelve month period of therapeutic relationship building may be needed in order for the patient to feel safe enough to engage in any meaningful work. Therefore lack of post qualifying education is a failure to provide nurses the opportunity to develop the skills, knowledge and attitude for working with this specific patient group.
Negative and pessimistic attitudes towards patients with borderline personality disorder can result in patients feeling dismissed by nursing staff and health care professionals in general, which in turn can increase the duration and severity of the condition (Commons-Treloar & Lewis 2008, NCCMH 2004).
2. RESEARCH METHOD.
2.1 The author’s previous experience
This dissertation originates from previous experience when working with borderline personality disordered women whilst at a female forensic low enhanced secure unit as a nursing Helpant prior to undertaking training. I noted that some staff hold negative attitudes towards patients with this diagnosis and would tend to prefer to work with patients suffering from psychotic illnesses whereas other staff appeared to work well with personality disordered patients.
People with a borderline personality disorder diagnosis give rise to the notion of the unpopular patient (Pilgrim 2001, Wright et al 2007) which can evoke powerful negative emotional and attitudinal responses from healthcare staff (McVey & Murphy 2010). This negative response has in the past led challenges in the nursing of personality disordered patients and personality disordered patients being denied services on the grounds of non treatability or not receiving the adequate care (James & Coleman 2007).
In my experience, these negative attitudes have led to people with personality disorder being stigmatised with labels such as attention seekers, manipulative, difficult, disrespectful and unappreciative, which has led me to consider whether education surrounding personality disorder would help to alleviate some of the negative attitudes displayed and thus improve the levels of care provided.
2.2 Rationale.
The research issue is based around clients with borderline personality disorder and the effects they can have on the nursing population that manage their care. The study is based around the hypothesis that education on borderline personality disorder (or personality disorder in general) can have a positive effect on the attitudes of nurses working with this very difficult client group. This study will identify the issues this patient group can present to the nursing team and highlight specific areas that could be improved by the use of both formal and in-house educational interventions.
In order to establish what is already understood about staff attitudes towards borderline personality disordered patients, the author undertook an initial opinion based search of the relevant literature. This initial exploration within current UK Journals and books displayed that there are still underlying issues of negativity around the diagnosis of borderline personality disorder which posed the initial question of ‘Would staff attitudes improve with more education surrounding personality disorders ?’
2.3 The literature review.
As such it was decided to conduct a full literature review of the subject to provide an overall view of how education can provide a more positive caring environment for people with borderline personality disorder. A literature review is defined as a comprehensive study, critical in-depth analysis of pre-existing research literature upon a particular topic (Walliman & Appleton 2009, Aveyard 2010) which provides a summary and synopsis of a particular research subject.
The decision to undertake a literature review as opposed to any other research method was decided on the basis that to answer the research question could be managed by the use of following specific steps as defined by Aveyard (2010) ;
Identify a research topic that is relevant to the programme you are studying for and arises from an issue you have concerns over.
Identify what is already known about the subject.
Identify a research question that is neither too wide nor too narrow.
Complete a comprehensive systematic search of the literature.
Review the strength and weaknesses of the research methods used in your chosen papers. Deciding on the importance of the research to your particular question.
Synthesise the findings and sum up the literature.
Suggest appropriate implications for practice and suggest possible future research
2.4 Search Strategy.
From the initial literature review a proposed research question was developed. The initial research question was to ask ‘What is the effectiveness of education aimed at improving staff attitudes towards self-harming behaviour in patients with a diagnosis of personality disorder’, as a lot of emphasis within mental health nursing (and nursing in general) is based upon the ideal that staff build and maintain effective positive therapeutic relationships (Department of Health (DH) 2006, Barker & Barker 2009), challenge inequality, stigma and promote recovery (DH 2004).
Both thesaurus and ‘Mesh’ term searches were incorporated into the search strategy in order to exhaustively identify all of the relevant search terms available. Systematic literature searches were carried out using truncation (star symbol *) to allow for different word endings, for example the truncation NURS* finds NURSE, NURSING, NURSES etc (Walliman & Appleton 2009), and the Boolean logic operator ‘OR’ to relate key terms, followed by combinations of the key terms using ‘AND’ in order to provide focus to the search (Table one).
Table one: Initial search terms.
Search Term
Combined with
“Education OR Training”
“Staff”
OR
“Nurs*”
OR
“Healthcare worker”
Or
“Mental health Nurs*”
“Self Harm” OR “Self Injury” OR “Self Mutilation”
“Personality Disorder” OR “pd” OR “Borderline Personality Disorder”
“Attitudes” OR “Perceptions” Or “Views”
PsycInfo, CINAHL, BNI,ASSIA, Cocrane Library and the Pubmed data bases were systematically used using the search terms. To ensure a systematic search which would not be affected by spelling mistakes or misplaced truncation the terms in table 1 were copied and pasted into each database.
The keywords listed in table one were used to identify trials and reviews relevant to the study aim, however very little literature was found that was relevant specifically to staff attitudes to self harm and borderline personality disorder due to being too specific. Following a discussion with the authors designated dissertation supervisor, library staff and healthcare colleagues, it was concluded that the key terms being search were narrowing the question too much. This allowed the author to rethink the research question in terms of its key words. The author surmised that using both self harm and personality disorder as key words complicated the search strategy and produced too few articles of research due to the question being unfocused by trying to incorporate too many factors. Aveyard (2010) addresses this by explaining that the research question that addresses one question only is more realistic at undergraduate level study.
This required a second data base search using the same keywords with the exception of “Self Harm” OR “Self Injury” OR “Self Mutilation”. This was decided upon as borderline personality and self harm are, in many cases are inexorably linked as a way of emotional regulation or as an external expression of internal pain (Kleindienst et al 2008) and would help to broaden the search.
Therefore the author redefined the research question in light the above points and settled on the more manageable question of What role does education play in improving staff attitudes to patients with a diagnosis of Borderline personality disorder?. Self harm will still be discussed within this dissertation however the primary focus will remain on attitudinal changes towards the diagnosis of borderline personality disorder as opposed to symptomatology.
The revised keyword search (Table Two) was systematically applied using identical data bases as the initial search (Table Three). NHS Evidence and Google scholar were additionally searched as a means of accessing full text articles that were not available within other databases.
Table Two: Revised search terms.
Search Term
Combined with
“Education OR Training”
“Staff”
OR
“Nurs*”
OR
“Healthcare worker”
Or
“Mental health Nurs*”
“Personality Disorder” OR “pd” OR “Borderline Personality Disorder”
“Attitudes” OR “Perceptions” Or “Views”
Table Three: Electronic Databases.
PsycINFO
CINAHL (Cumulative Index to Nursing and Allied Health Index)
BNI (British Nursing Index)
ASSIA (Applied Social Sciences Index and Abstracts)
COCRANE LIBRARY
PUBMED
NHS Evidence (accessed as a means of full text access not available in other databases)
Google Scholar (accessed as a means of full text access not available in other databases)
The systematic searching of the databases produced the following results (Table Four).
2.5 Inclusion and exclusion criteria.
Inclusion and exclusion criteria were then applied to the systematic literature search to allow for further refinement of the literature search (Tables Five and Six). This ensured that I did not get sidetracked with non relevant data and remained focused on my research topic question (Aveyard 2010). Further articles were also found both by hand searching relevant journal hard copies and the use of scrutinising the article and journal reference details. Aveyard (2010:89) advocates this technique by stating “it is useful to scrutinise the reference list of those key articles for further references that may be useful”. However some of these papers were excluded as not meeting the inclusion criteria for the literature review. This snowball sampling technique is considered to be effective in achieving a comprehensive literature search (Aveyard 2010, Walliman & Appleton 2009).
Table Four: Database Results.
Search keywords and synonyms
Results
PsycINFO
Results CINAHL
Results
BNI
Results
ASSIA
Results
COCHRANE
Results
UK PUBMED CENTRAL
Results
NHS
Evidence
#1
Education OR Training
583,122
369,437
31,281
92,262
41,569
996,036
1,633,922
#2
Personality Disorder OR pd OR Borderline Personality Disorder
44,508
5932
387
560
17,314
5,080,743
61,044
#3
Attitudes OR Perceptions OR Views
747,215
110,171
21,803
3310
26,387
672,551
761,621
#4
Staff OR Nurs* OR Healthcare Worker Or Mental Health Nurs*
139,109
573,663
197,278
70,406
26,350
909,553
430,790
#1 and #2
2978
612
43
361
860
86,668
2721
#2 and #3
4308
221
70
451
658
73,628
1968
#1 and #2 and #3
405
46
12
40
99
10,018
207
#2 and #3 and #4
214
71
70
47
56
8272
94
#1 and #2 and #3 and #4
51
23
12
11
24
3216
24
Table Five: Inclusion Criteria
Inclusion Criteria
Rationale
Articles published between 2002 and present only.
This allowed for a 10 year study period of relevant literature.
English language publications only.
Due to being an English speaker only I felt it pertinent to only allow English language only article to be included. Due to time and resource constraints it would not have been feasible to translate non English articles. This is noted as a limitation of the study later.
Primary research directly related to the chosen topic.
Primary research papers are undertaken according to an accepted scientific method (Aveyard 2010) and contain a full account surrounding definition of the subject question, the methodology used, a presentation of results and a discussion (Walliman & Appleton 2009).
Use of European, Australian and American Articles.
Due to the paucity of literature covering my research topic from the United Kingdom, I decided to add in countries in an endeavour to search as comprehensively as possible as most of the key discussions originated from non United Kingdom sources.
Duplicate articles.
Any articles that come up in various databases ensure that the search strategy is systematic and comprehensive, well focused and relevant (Aveyard 2010). Therefore, as long as they met the other inclusion criteria they were included.
Key terms in title and abstract.
In searching for the Keywords within both title and abstract allows for a more comprehensive search and avoids missing articles if you search for keywords within the title alone (Aveyard 2010, Walliman & Appleton 2009). This was systematically done throughout each database.
Table Six: Exclusion Criteria.
Exclusion Criteria
Rationale
Articles published pre 2002
Any research that is older than 10 years was not considered for this dissertation.
Unpublished (Grey) literature
Searching for unpublished (Grey) literature is normally beyond the scope of an undergraduate researcher due to both time and resource restraint
Full text documents available as purchase only.
Due to monetary constraints, it was not possible to include any non free articles. However this is seen as a limitation to the research process and is acknowledged as such within this dissertation.
Primary research whose focus was self harm.
Although there is a distinct link between Borderline personality disorder and self-harm, it is not exclusive. Although self-harm will still be discussed within this dissertation the primary focus will remain on the effects of education on attitudinal changes towards the diagnosis of borderline personality disorder as opposed to symptomatology.
Secondary research (added after discussion with dissertation supervisor).
Primary research should be the primary focus of a dissertation of this nature. Aveyard (2010) explains that a secondary source is one step removed from the ideas referred to within the literature and should be avoided whenever possible to avoid the possibility of misreporting of primary research within them.
From the original forty six papers identified within the literature search, twenty one did not meet the above inclusion criteria. Of the remaining twenty five papers, and after clarification with my dissertation supervisor, thirteen were identified as either secondary research papers (9) or primary research that was not directly related to attitudinal changes post education(4) and as such were excluded from the list. This left a total of twelve papers that would be critiqued and themed to provide the information to complete this dissertation (Table Seven)
2.6 A quick note on secondary sources.
It was decided to exclude secondary sources of literature upon the advice of both Aveyard (2010) and my dissertation supervisor. Although this does not limit the research for the dissertation it was important to recognise that secondary resources often make reference to primary research (Aveyard 2010). Therefore it was used as part of the snowballing search method. As some of the literature did not report on research findings, it can still be of use in setting both the context and aid in reflecting on the findings within this dissertation. As such secondary papers that will be used to inform the discussion components, offer supporting discussion points on the efficacy of education in changing attitudes towards the diagnosis of borderline personality disorder.
Within a previous module on research awareness and critical appraisal, the hierarchy of evidence devised by Sackett et al (1996) was discussed. This hierarchy of evidence places both expert and anecdotal opinion below all others. Therefore it is important for me to make a comprehensive assessment of the quality of the information provided within all secondary sources before they are included within the discussion aspects of this dissertation (Walliman & Appleton 2009) By comparing it to different sources I will be able to identify any bias, inaccuracies and pure imagination on the part of the author prior to inclusion.
2.7 Limitations.
At this point it should be acknowledge the limitations of the literature review. Being a novice researcher in health and social care has resulted in the literature review being less than perfect. Due to both time and monetary restraints, some articles that would have aided in this dissertation could not be accessed. The literature was also limited to English language articles due to me only speaking this language. Again due to time restraints there was no guarantee that the papers would have been correctly translated to allow for inclusion. Although this limitation is not uncommon (Aveyard 2010) it should be noted that non-English papers were available which may have contributed to a better understanding of the issues discussed within this dissertation but which could not be translated within the timeframe of this dissertation project.
Research Results.
3.1 Critical appraisal of evidence.
An important step in the review process is the critical Assessment of the research literature to be included (Walliman & Appleton 2009) as it helps in determining the quality of the evidence. Katrak (2004) identified a large number of critical appraisal tools available. Critical appraisal is defined by Aveyard 2010 as:
A structured process of examining a piece of research in order to determine its strengths and limitations, and therefore the weight it should have in your literature review.
Aveyard 2010:93.
Woolliams et al (2009) also provide an appraisal tool that allows the novice researcher to appraise articles. They suggest the use of six strategic questions of what exactly is being said, who was the author, why have they written the paper, how was the research carried out, when was it carried out or written and where did the researchers gain their information. This method allows for the assessment of quality of research articles with the questions being adaptable to the research being looked at. However I felt that this approach did not allow for an in-depth analysis of the papers in this dissertation, as such I decided to use the Critical Appraisal Skills Programme (CASP) (CASP 2010a,b,c) as advised by Aveyard (2010) for qualitative and quantative papers and, for questionnaire papers, Greenhalgh’s “ten questions to ask about a paper describing a questionnaire study” (Greenhalgh 2010:178). CASP tools are useful to the novice researcher as they provide “a consistent approach to the critique of research” (Aveyard 2010:99) and help to enable practitioners to develop the skills to source and make sense of current research (Casp 2010a).
Fenton (2009) explains that research generally comes in either qualitative or quantative research methodologies. However questionnaires can be either qualitative or quantative dependent on the questions asked (McLeod 2008). Therefore, all research articles included within this dissertation were critiqued using these two recognised critiquing tools.
3.2 Synthesis of article findings.
Aveyard (2010) provides guidelines for synthesising the findings from the articles for the novice researcher (table seven). As such, after the appraisal of the papers to provide a summary of the information (appendix 2), they were then compared by the use of thematic analysis to assign codes to the findings. Themes were then developed and compared to aid in the discussion within the following chapters.
Table Seven: Summary of Information: Papers selected for full text retrieval (after Aveyard 2010: 128).
Author / Date
Aim of Study / Paper
Type of Study / Information
Main Findings / Conclusion
Strengths / Limitations
Cleary M, Siegfried N and
Walter G / 2002
To obtain baseline data to provide direction for developing and planning education and to determine staff engagement is education
A 23 item questionnaire and statistical analysis/
N=516 from various occupational levels and settings. Measurements of knowledge, attitudes, experience and willingness to attend training in BPD.
Patients with a personality disorder are challenging and 76% of nursing staff support the need for continued staff education and support. 76% of respondents would find further training helpful with 95% stating that they would readily participate in further training.
Standardised approach to data collection using an established collection programme covering different settings and professions.
Noted missing data and poor response rate of 44% (n=229). Could have been more effective if combined with another research method such as semi structured interview to provide more in-depth answers. No indication of pilot of questionnaire prior to use.
Krawitz R / 2004
To assess the effect of training workshop on clinical attitudes towards working with BPD. The main goal being the achievement of positive change in attitudes of clinicians.
A survey questionnaire administered pre and post workshop training. N=910 (before exclusion) from public mental health and substance abuse services who attended workshop training over an 18 month period.
Workshop training was effective in achieving positive attitudinal change in clinicians working with patients with a diagnosis of BPD. This showed the achievability of attitudinal change through training towards positivity of working with BPD patients.
Large sample size and good response rate of 62% (n= 418) and the exclusion of participants who attended other training on BPD to avoid confounding variables to attitudinal change (n=241). Good longitudinal follow up of 18 months (6 monthly follow up).
Survey questions not tested for validity and reliability. Sample biased towards only those who wanted to attend the workshops AND filled out all three interval follow-ups. No indication of pilot of questionnaire prior to use.
Author / Date
Aim of Study / Paper
Type of Study / Information
Main Findings / Conclusion
Strengths / Limitations
Bowers L, Carr-Walker P, Paton J, Nijman H, Callahan P, Allan T and Alexander J / 2005
To identify what events and experiences influence the attitudes and beliefs of prison staff working on a dangerous and severe personality disorder (DSPD) unit.
Semi-Structured interviews using open questions focused on changes of attitude.
N=66 from mixed gender prison officers working across an assessment and treatment unit.
Positive factors on staff attitudes included a greater understanding of the PD, improvement in prisoner behaviour, education, and staff support, whereas negative attitudes were influenced by delays in establishing treatment programmes, some inmate behaviours and negative portrayal of the profession by media press. To maintain positive attitudes DSPD units need to adopt timely implementation of treatment programmes, a clear philosophy and regime, invest in staff training and clinical supervision.
A longitudinal study with semi-structured interview at baseline, eight and sixteen months. Transcribed tapes and recognised software used for analysis of qualitative data (NUD*IST 6).
Fair participant number (n=66) which produced (after dropout) a total of 96 interviews for analysis.
Semi-structured interview with open ended questions allowing staff to describe their experiences and give examples. This allows for more in depth understanding of attitudinal change and precipitating factors.
Open ended questions in the semi structured interviews, which reflected on the previous eight month period, allowed for some
