Attitudes and perceptions of mental health nurses towards borderline personality disorder clients in acute mental health settings: a review of the literature.

This study aims to synthesize published research on registered mental health nurses’ (RMNs) attitudes towards clients with a diagnosis of borderline personality disorder (BPD) in acute mental health inpatient settings. BPD has been categorized as a diagnostic type of personality disorder in both the DSM IV (American Psychiatric Association 2000), which suggests a key feature of BPD is a ‘pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts’ and the ICD-10 (World Health Organization 1992), which uses an alternative definition and terminology of this disorder which makes reference to an Emotionally Unstable Personality Disorder. In relation to the DSM-IV (American Psychiatric Association 2000) BPD is described as a cluster B personality disorder that is labelled as ‘emotional or erratic types’, and as suggested by Moran (2002) this cluster tends to attract the most attention through behaviours such as poor impulse control and deliberate self-harm. BPD clients in particular have been described as acting impulsively, without consideration of the consequences and displaying symptoms such as poor self-image, chronic feelings of emptiness, participating in intense and unstable interpersonal relationships and taking part in self-destructive behaviour (ICD 10, 1992). The literature suggests that BPD is the most prevalent of all personality disorders (Moran 2002) with research estimating 2–3% of the population meeting the diagnostic criteria (Stuart & Laraia 2005). Within acute inpatient health services it is thought that approximately 15% of clients fulfil these criteria (Winston 2000). Many professionals find these clients difficult to interact with and treat, perhaps because BPD may aversely affect interpersonal relationships, including relationships with nursing staff (Stuart & Laraia 2005). The difficulties experienced by nurses when caring for this client group combined with the general pressures on acute inpatient mental health services, such as, the promotion of a therapeutic environment which is not dangerous or chaotic, dealing with issues surrounding a staffing crisis, a lack of leadership and problems arising due to bed management systems, something that Lelliott et al. (2006) suggest continue to persist, can create circumstances in which staff are reluctant to admit clients with BPD. Nevertheless, literature suggests that a brief admission may in fact benefit some clients in crisis (Moran 2002). In addition to this, as stated by the National Institute for Health and Clinical Excellence guidelines (2009), clients with BPD should not be excluded from any health or social care service because of their diagnosis or because they have self-harmed. This means that clients with BPD should not be refused from acute mental health inpatient settings due to their diagnosis and the problems and behaviours associated with it. There have been previous literature reviews into RMNs attitudes towards clients with BPD in acute mental health inpatient settings (Eastwick & Grant 2005, Filer 2005). Filer (2005) suggests that optimism for change, attributions of control and beliefs surrounding dangerousness all play a role in shaping RMNs negative attitudes in regards to BPD clients. Eastwick & Grant (2005) suggested RMNs, through negative labelling of these clients may reinforce many thoughts and behaviours associated with this illness such as; self-mutilation, perceptions and fears of rejection and abandonment. However, as these reviews failed to describe adequately how they searched and carried out their reviews, their usefulness is limited and their results should be viewed with caution. Journal of Psychiatric and Mental Health Nursing, 2010, 17, 657–662