What Is Borderline Personality Disorder Nursing Essay

Published Date: 23 Mar 2015

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 assistant 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 evaluation 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 recall bias. This bias was not investigated and shows some weakness in the research validity. Respondents may have created explanations for attitudinal change based on other external factors.

Bowers L and Allan T / 2006

To assess the components of attitude to personality disorder and a factor analysis of feelings generated within nursing staff by PD

Specifically designed questionnaire comprising of 37 items set on a 6 point Likert scale.

N=904, over three sets, from various occupational levels and settings.

The largest influences on staff attitudes towards personality disorder are organisational and suggest that training, supervision and staff support structures promote positive attitudinal changes better than simply employing positive staff.

Good psychometric study comprising of the measurement of knowledge, abilities, staff attitudes & personality and educational input.

Good participant numbers (N=904) using recognised diagnostic tools for analysis.

Overrepresentation of nonregistered staff who were non responders which may skew results from this staff group as uninformed response to the behavioural aspects of PD may be liable to overly judgemental and negative attitudes.

Author / Date

Aim of Study / Paper

Type of Study / Information

Main Findings / Conclusion

Strengths / Limitations

James P D and Cowman S / 2007

Aims to describe nurses knowledge, skills and attitudes towards BPD to provide guidance toward development of services and education.

A descriptive survey questionnaire consisting of five sections of demographics, frequency of contact, understanding of diagnosis and treatment, confidence and role understanding.

N=157 of mental health nurses

BPD is regularly encountered by mental health nurses and are considered to be difficult to manage. Services need to develop in line with best practice. Nurses need to be provided with appropriate education in meeting the needs of this client group.

Use of previously established and recognised questionnaire. A small pilot study was used to assess content and validity (n=15). Inclusion of recognised rating scale (Likert) and multiple choice as opposed to true false questions to allow for more depth of answer.

Small study participant group (n=157) with a 41.4% response rate (n=65). All respondents worked in the same geographical location, as such caution needs to be used when attempting to generalise to other services and staff groups.

Single use methodology used to collect data. A more in-depth analysis could have been achieved by used of multiple collection methods; this may have been achievable considering the small participant numbers.

Commons-Treloar A J and Lewis A J / 2008a

To assess the attitudes of mental health and medical emergency medicine clinicians towards patient with BPD

A purpose designed and established questionnaire and assessment tool to quantify attitudinal levels and demographic information between two differing groups of staff.

Significant differences were found between mental health and emergency medical staff when looking at the attitudes, with emergency medical staff having poorer attitudes. However both groups showed a moderate improvement in attitude when provided with training on the disorder

N=140 participants across three health services covering both general and mental health care. Purpose designed demographic questionnaire coupled with a standardised and established questionnaire on attitudes towards self harm (ADSHQ) adapted (with permission) to be only used with patients with a diagnosis of BPD. Good response rate mean of 90.8% (n=127) (community 89.4% & inpatient 92.3%).

Non-representation of unqualified staff within the study disregards a large portion of the workforce.

Author / Date

Aim of Study / Paper

Type of Study / Information

Main Findings / Conclusion

Strengths / Limitations

Commons-Treloar A J and Lewis A J / 2008b

To assess the impact of attended targeted education on BPD on the attitudes of staff towards the diagnosis.

A RCT using purpose designed and established questionnaires and assessment tool to quantify attitudinal levels and demographic information in staff dealing with patients who self harm and have a diagnosis of BPD.

Statistically significant improvement in staff attitudes were found within both staff groups following the targeted educational program. This shows a necessity to provide regular access to the targeted clinical education of staff working with patients with a diagnosis of BPD.

Both pre and post education scores rigorously analysed to obtain data using a recognised analytical tool (ANCOVA) to compare pre and post educational attitudes within the ADSHQ adapted (with permission) to be only used with patients with a diagnosis of BPD.

Non-representation of unqualified staff within the study disregards a large portion of the workforce.

Woollaston K and Hixenbaugh P / 2008

To explore nurses relationships with BPD patients from their own perspective.

Semi-structured interviews and thematic analysis of results of staff attitudes and beliefs surrounding the diagnosis and how to best provide care.

The data contained within this article appears to suggest that negative attitudes are borne out of staffs feelings of helplessness. The need to provide nurses with appropriate training in managing this groups is paramount.

Good clear methodology and explanation. Clear explanation of the thematic analysis process providing clarity and validity to the study.

Small participation number (n= 6) and researcher had previously worked with 66% of participants (n=4) which could have affected their inclination to express themselves freely and candidly.

Author / Date

Aim of Study / Paper

Type of Study / Information

Main Findings / Conclusion

Strengths / Limitations

Purves D and Sands N / 2008

To investigate staff attitudes of psychiatric staff towards BPD with a view to looking at how education and supervision can produce attitudinal change.

35 item Questionnaire to assess global attitudes towards personality disorders using close ended and fixed response questions.

Overall negative attitudes were reported within the questionnaires. A positive relationship between education and attitudinal response is recorded within the literature. Negative attitudes directly relate to inequality of care.

Recognised and validated questionnaire used (APDQ) using Likert scaling. Information analysis using recognised and validated software programme (SPSS).

Good participation size (n= 110) with a return rate of 54% (n=61).

No indication of pilot of questionnaire prior to use. Based on a single geographical study and no data from non responders recorded.

Commons-Treloar A J / 2009

To examine the impact of two educational programs on clinical attitudes towards BPD.

Both a purpose designed and established questionnaire and assessment tool with a six month follow-up.

Significant improvements in attitude were noted immediately after both educational programmes. However, this improvement was not maintained in the group who attended cognitive-behavioural program where as the psychoanalytical; group participant maintained a significantly improved attitudinal change towards the diagnosis of BPD.

Recognised and validated questionnaire used (ADSHQ) using Likert scaling.

Use of both qualified and non qualified staff.

Good use of follow-up questionnaire to validate continued attitudinal changes.

Although a validated questionnaire, the ADSHQ only allows for the respondent to reply positively or negatively. Having no neutral response applies some restrictions to the results.

Participation size (n=140) with a 18% dropout rate (n=118) is relatively small for this type of study and would need to be replicated on a larger scale to improve its validity.

Author / Date

Aim of Study / Paper

Type of Study / Information

Main Findings / Conclusion

Strengths / Limitations

Maltman L and Hamilton L / 2011

A preliminary evaluation of the effects of workshop training in changing attitudes towards personality disorder in prison staff

A recognised and validated 37 item, self-report questionnaire using Likert scale administered pre-training and after a two month interval

Workshop training showed little improvement in attitudinal change. However, significant differences were noted on the security vs vulnerability scale with participants reporting feeling less fearful ,anxious and manipulated by PD offenders.

The ADPQ questionnaire is known to provide a robust structure, good psychometric properties and validation.

Missing data was evaluated to ensure the evaluation sample represented the entire trainee group using a t-test.

Given the sample size of this research (n= 67) the reader will need to be careful when applying this to global attitudes towards PD. Entrenched negative attitudes went untested within the studay and post training data was difficult to collect, indicating some potential self-selection bias within the group.

Brief interviews of participants would have helped to determine prior understanding of PD to help complete the ADPQ as it asks for previous emotional reactions to PD.

McGrath B and Dowling M / 2012

A qualitative study of psychiatric nurses attitudes towards working with BPD patients.

In-depth interviews incorporating thematic analysis of open ended questions.

Participants perceived BPD patients in a negative light and reported providing minimal care and distancing themselves from patients with BPD. By understanding the origins of BPD, produces a higher level of empathy. Improved education and workshops were discussed as a way of improving this understanding

Multiple data collection method used (semi-structured interview & staff-patient interaction response scale (SPIRS)) to collect qualitative data. Allowing for more indepth participant narratives. verbatim quotes from the interviews allowed insight into the main issues that have been identified in the analysis.

Only one mental health unit used within the study which limits it validity for global attitudes. Self-selecting sample produced only those whose interest was working with BPD. The views of those who did not participate may have given differing results.

SO FAR 6069 WORDS.

CHAPTER ONE. PERSONALITY DISORDER

INTRODUCTION

MAIN

CONCLUSION

CHAPTER TWO. STAFF ATTITUDES

INTRODUCTION

MAIN

CONCLUSION

CHAPTER THREE. THE PROVISION OF EDUCATION IN PERSONALITY DISORDER.

INTRODUCTION

MAIN

CONCLUSION

DISCUSSION.

CONCLUSION.

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BIBLIOGRAPHY.

APPENDICES.

Appendix 1. DSM-IV-TR classification of personality disorder (APA 2000).

Cluster

Type

Description

Cluster A

Suspicious

Paranoid

Suspicious of other people, sensitive to rejection and holds grudges.

Schizoid

Prefers own company to that of others, has a rich fantasy world.

Schizotypal

Has odd ideas and difficulty with thinking 'eccentric'

Cluster B

Emotional and Impulsive

Anitsocial

The commonly held view of the 'psychopath'

Doesn't care about the feelings of others or feel guilty, impulsive, finds it hard to have close relationships, often involved in crime.

Borderline

Finds it hard to control emotions, feels bad about self, often self harms, forms relationships quickly but easily looses them.

Histrionic

Overly dramatic and self centred, worries about appearance, craves excitement.

Narcissistic

Feels important and dreams of success, power and status; craves attention; tendency to exploit others.

Cluster C

Anxious

Anankastic (Obsessive-compulsive)

Perfectionist; cautious; difficulties in decision making; sensitive to criticism.

Avoidant

Anxious and tense; worries a lot; insecure and inferior feelings; need to be liked; sensitive to criticism.

Dependent

Relies on others to make decisions; feelings of incompetency; difficulty in coping with daily tasks; feels abandoned by others easily.

Pryjmachuk 2011.

Appendix 2. Critical analysis of papers.

Paper 1.

Cleary M, Siegfried N and Walter G (2002) Experience, knowledge and attitudes of mental health staff regarding clients with borderline personality disorder. International Journal of Mental Health Nursing. 11, 186-191.

Data for this study was collected using a 23 item questionnaire that was posted to both community and hospital based mental health staff. As I could not find CASP guidelines that covered quantative questionnaires', this article is critiqued using Greenhalgh (2010). "ten questions to ask about a paper describing a questionnaire study" (Greenhalgh 2010:178).

Question 1. What was the research question, and was the questionnaire appropriate to answer it.

The aim of this paper was two fold. Firstly it aim was to provide baseline data of mental health staff's experience, knowledge and attitudes towards the management of patients with a diagnosis of borderline personality disorder (BPD). Secondly the paper aim was then to provide direction for education and training for mental health nurses in the area of management of patients with a diagnosis of borderline personality disorder.

In this case a questionnaire was an appropriate tool for the collection of information as it allowed the researchers to reach a wider group of mental health practitioners (n=516) than would have been possible by use of interviews. However the paper could have been strengthened by the use of semi-structured interviews or focus groups to allow for a deeper exploration of the question (Greenhalgh 2010).

Question 2. Was the questionnaire used in the study valid and reliable?

The definition of a valid questionnaire is one that measures what it claims to measure. The authors don't discuss the validity of their questionnaire and don't discuss any inter-rater reliability figures, however the questionnaire was valid in that it provided a standardised approach that allowed for the questions to be asked in an "identical format and responses recorded in a uniform manner" (Greenhalgh 2010:180).

Question 3. What did the questionnaire look like, and was this appropriate to the target population?

Although the questionnaire was not included within the article, a clear explanation of the questions was included within the text. The questionnaire in this study was comprised of three parts. Firstly it looked at participant demographics such as age, sex, professional designation, main working environment and number of years in mental health services.

The second part of the questionnaire was then objectively assessed by the use of seven content questions to which respondents' had to either agree or disagree with a set statement.

Lastly the respondents' were asked to assess current service provision and their views about additional resources, attitudes and opinions about BPD and their commitment to further education.

The first and second parts of the questionnaire used tick boxes which allowed for a standardised approach to data collection, where as the third section allowed for the subjective opinion of the respondent. This appears to be an appropriate method of data collection for the targeted population.

Question 4. Were the instructions clear?

The researchers provided full instructions in a handout that was included with the questionnaire. This allowed clear instruction to the participant prior to commencing the questionnaire. The tables that have been included within the article clearly show examples of the questions. These show that the language used was neither confusing nor ambiguous in nature.

Question 5. was the questionnaire adequately piloted?

The authors do not discuss any piloting of the questionnaire. This may show a weakness within the paper that I will need to consider when discussing the paper in my dissertation. Walliman and Appleton (2009) explain that it is important to pre-test questionnaires on a small group of participants prior to use within a main study as this allows testing of the questions and irons out any issues that may arise.

Question 6. What was the sample?

Random sampling was used in this study. Random sampling is where a targeted group (in this case mental health worker) is identified then a random selection of people within the group is invited to participate in the study. Within this study the sample group comprised of 516 mental health service workers of varying grades and within various settings.

Question 7. How was the questionnaire administered, and was the response rate adequate?

The questionnaire was administered via post and required self-completion on the part of the participant. The response rate for the questionnaire was discussed fully within the article. The authors explain that the overall response rate was 44%, with response rates between settings being between 415 and 46%. They also state that there was no method of follow up due to ethical restraints. This ethical restraint is not named within the paper but lack of follow up could have contributed to the low response rate. Another aspect that is discussed is the target group having been extensively surveyed in the past, which could have resulted in survey burn-out (Walter et al 1999) causing a negative reaction and non response rates. However as the response rates were proportionately distributed the questionnaire could be considered to show a reasonable representation of the study population.

Question 8. How was the data analysed?

Data from the questionnaire was analysed by use of the already established IBM statistical software programme known as SPSS Statistics (Statistical Product and Service Solutions) (SPSS Inc: 1998). The data was then presented as observed rates and simple frequencies which produced emerging themes.

Question 9. What were the main results?

The paper shows that 79% of participants considered themselves to be knowledgeable in the identification, assessment and management of BPD, however only 32% of participants report having previous training in the management of BPD via courses, workshops and supervision. 80% of staff acknowledge people with BPD are difficult to effectively manage compared to other mental health disorders. 76% of respondents reported that further training would be helpful with 95% stating that they would readily participate in further training were it available.

Question 10. What are the key conclusions?

The results of the paper report that despite staff believing that they had a good knowledge base and were confident in managing people with a diagnosis of BPD, they acknowledge the difficulties in the managing of patients with the diagnosis.

The paper endorses the need for further development in the management of BPD by use of appropriate continued staff education and support in order to provide the best possible care for this difficult patient group.

References.

Greenhalgh P (2010) How to read a paper: The basics of evidence based medicine (4th edition). Oxford, Wiley & Sons.

Walliman N & Appleton J (2009) Your Undergraduate Dissertation in Health and Social Care. London, Sage Publications.

Walter G, Cleary M & Rey J M (1999) Want to know how to conduct a survey but too afraid to ask: a step by step guide. Australian Psychiatry. 7, 258-261.

Paper 2.

Krawitz R (2004) Borderline personality disorder; attitudinal change following training. Australian and new Zealand Journal of Psychiatry. 38, 554-559.

Data for this study was collected using a survey questionnaire that was applied pre and post workshop and at six month follow-up of healthcare professionals who attended a two day training workshop on borderline personality disorder (BPD) aimed at a variety of mental health professionals from various settings. As I could not find CASP guidelines that covered quantative questionnaires', this article is critiqued using Greenhalgh (2010). "ten questions to ask about a paper describing a questionnaire study" (Greenhalgh 2010:178).

.

Question 1. What was the research question, and was the questionnaire appropriate to answer it.

The aim of this articles research was to assess the effectiveness of providing a two-day workshop on clinical attitudes towards working with patients with a diagnosis of BPD.

By use of pre and post questionnaires, the authors could look at changes in attitude within a significantly short period of time. By the use of a systematic approach such as a survey questionnaire the authors are ensuring that the data they collect is appropriate to the aim of the paper and can answer the research question being hypothesised.

As in the first paper a questionnaire was an appropriate tool for the collection of information as it allowed the researchers to research a wide group of mental health practitioners all who attended the training (n=910). Due to the large sample size, interviews would have been both time and resource heavy (Greenhalgh 2010).

Question 2. Was the questionnaire used in the study valid and reliable?

The questionnaire used in the study had not been tested for both reliability and validity, which places some doubt on the strength of the study. However, the response rate for this study is high (n=418) and the use of ANOVA analysis of variance, indicates validity of results. The standardised approach within the questionnaire administered pre, post and 6 month follow-up indicates an increase in the reliability of the study as differences in the results from the three time periods originate from differences in attitude and not from inconsistencies in three questionnaires.

Question 3. What did the questionnaire look like, and was this appropriate to the target population?

The authors do not give an example of the questionnaire. However an explanation of the questions and rating scale used is clear withi