Mental health nurses’ attitudes, behaviour, experience and knowledge regarding adults with a diagnosis of borderline personality disorder: systematic, integrative literature review

Aims and objectives To establish whether mental health nurses responses to people with borderline personality disorder are problematic and, if so, to inform solutions to support change. Background There is some evidence that people diagnosed with borderline personality disorder are unpopular among mental health nurses who respond to them in ways which could be counter-therapeutic. Interventions to improve nurses’ attitudes have had limited success. Design Systematic, integrative literature review. Methods Computerised databases were searched from inception to April 2015 for papers describing primary research focused on mental health nurses’ attitudes, behaviour, experience, and knowledge regarding adults diagnosed with borderline personality disorder. Analysis of qualitative studies employed metasynthesis; analysis of quantitative studies was informed by the theory of planned behaviour. Results Forty studies were included. Only one used direct observation of clinical practice. Nurses’ knowledge and experiences vary widely. They find the group very challenging to work with, report having many training needs, and, objectively, their attitudes are poorer than other professionals’ and poorer than towards other diagnostic groups. Nurses say they need a coherent therapeutic framework to guide their practice, and their experience of caregiving seems improved where this exists. Conclusions Mental health nurses’ responses to people with borderline personality disorder are sometimes counter-therapeutic. As interventions to change them have had limited success there is a need for fresh thinking. Observational research to better understand the link between attitudes and clinical practice is required. Evidence-based education about borderline personality disorder is necessary, but developing nurses to lead in the design, implementation and teaching of coherent therapeutic frameworks may have greater benefits. Relevance to clinical practice There should be greater focus on development and implementation of a team-wide approach, with nurses as equal partners, when working with patients with borderline personality disorder.

Care planning for aggression management in a specialist secure mental health service: user involvement

This paper describes an audit of prevention and management of violence and aggression care plans and incident reporting forms which aimed to: (i) report the compliance rate of completion of care plans; (ii) identify the extent to which patients contribute to and agree with their care plan; (iii) describe de-escalation methods documented in care plans; and (iv) ascertain the extent to which the de-escalation methods described in the care plan are recorded as having been attempted in the event of an incident. Care plans and incident report forms were examined for all patients in men's and women's mental health care pathways who were involved in aggressive incidents between May and October 2012. In total, 539 incidents were examined, involving 147 patients and 121 care plans. There was no care plan in place at the time of 151 incidents giving a compliance rate of 72%. It was documented that 40% of patients had contributed to their care plans. Thematic analysis of de-escalation methods documented in the care plans revealed five de-escalation themes: staff interventions, interactions, space/quiet, activities and patient strategies/skills. A sixth category, coercive strategies, was also documented. Evidence of adherence to de-escalation elements of the care plan was documented in 58% of incidents. The reasons for the low compliance rate and very low documentation of patient involvement need further investigation. The inclusion of coercive strategies within de-escalation documentation suggests that some staff fundamentally misunderstand de-escalation.

Vocational training and knowledge development: a deeper understanding

Construction management research literature has identified the importance of understanding the practical realities of skills and training provision and the role of reflective practice in the development of knowledge. This paper examines vocational training of experienced site staff in the development of their knowledge through SVQ training to investigate the primary factors for successful learning in site-based construction staff with a supervisory/management role. Using semi-structured interviews the impact of vocational training on individual candidates and other sitebased staff are investigated. The paper explores, through the reflections of 26 SVQ candidates (20 SVQ3 and 6 SVQ4), a deeper understanding of how site supervisors and site managers learn through the SVQ process and develop tacit knowledge through formal reflection. Reflective practice develops practical wisdom (Phronesis). The investigation explains aspects of practical wisdom and how knowledge, practice and skills are developed through vocational training. There is a clear perception by those completing the qualification that it has enabled them to perform their job better identifying numerous examples relating to problem solving, critical thinking, making decisions and leadership. It has been found that Phronesis is evident on a day-to-day basis on site activities developed through reflective practice in personal development. The reflective practice in developing knowledge also builds, within individuals, a better understanding of themselves and their capabilities through the learning achieved in the SVQ. Future work is identified around analysing the role of the assessor in facilitating Phronesis in the SVQ context.