1. ‘They’re really PD today’ Environmental Influences
Emma Jones
‘They’re really PD today’
An exploration of mental health nursing students’ perceptions of developing a therapeutic relationship with service users with a diagnosis of antisocial personality disorder
Background
The therapeutic relationship, as highlighted in NICE guidelines (2009), is considered the ’cornerstone of nursing’ (Welch, 2006, 161) and of particular importance when working with service users with a personality disorder (Bolton et al., 2014; Livesley, 2007; NICE, 2009a/ 2009b). Attitudes relating to borderline personality disorder, and their influence on this relationship, have received some focus in the literature (Wright & Jones, 2012). However, a lack of prior studies have explored therapeutic relationships with student populations in relation to antisocial personality disorder.
Previous studies (Happell & Gough, 2009; Martin & Happell, 2001; Nolan & Chung, 1999) have discussed the positive effect of clinical placements on student nurses’ practice. NIMHE & DH (2003) suggest that pre-qualifying education for mental health professionals should both facilitate understanding and enhance knowledge and skills for working with individuals with personality disorder. Additionally, this may assist in modifying attitudes towards working with service users with personality disorder (Krawitz, 2004; Shanks et al., 2011) and ultimately positively influence the development of therapeutic relationships.
Policy-
NICE guidelines (2009) antisocial personality disorder, other government documents; no longer a diagnosis of exclusion (NIMHE & DH, 2003)
Practice relevance-
Prevalence of personality disorder in mental health services, students’ placements, learning, the therapeutic relationship
Research-
Previous studies completed on attitudes of borderline personality disorder, importance of the therapeutic relationship and students’ learning and experiences
Aims
To explore mental health nursing students’ thoughts of developing a therapeutic relationship with a service user with a diagnosis of antisocial personality disorder
To compare the thoughts of students who had experience in secure services and those that had not
Ethical considerations
University of Central Lancashire School of Health Ethical Approval, action plans were in place
Sample
Recruitment- the university through various media outlets
Consent- consent forms, information leaflet
2nd year mental health nursing students
Two groups- those that had experience in secure services and those that had not
Methods
Focus groups were used.
This encouraged the participants to feel comfortable and more data could be attained. It promoted conversation and reduced the risk of hierarchical influences.
A case example and topic guide were used.
The aim was to explore the thoughts of students and focus groups allowed for this.
There were four participants in the first group, with experience.
In the second group, without experience, there were seven participants.
Analysis
Thematic analysis was used to analyse the data (Braun & Clarke, 2006).
Limitations
A limitation of this study was the small sample size of students from one University, which reduces the ability to generalise the findings (Sim, 1998). Also, as the participants in the study volunteered to attend, they may have been more open-minded towards the service user population than others.
The researcher kept a reflexivity log to prevent personal assumptions or biases influencing the research project (Lacey & Luff, 2007).
Findings
Diagnosis
Safety
‘…the terminology of it has got like a negative… sort of impact… hasn’t it?’
‘… it wouldn’t change how you like viewed them or that, because you have to view them on an individual basis’
‘… like don’t get too bogged down with the actual diagnosis’
‘…you’d just want to be careful that you’re not crossing boundaries’
‘…everyone always talks about boundaries but boundaries for them and boundaries for us’
Engagement
Environmental Influences
‘ … people don’t want to chat about what’s going on with them all the time. People just want a normal conversation’
‘You’ve got to be approachable for them to want to engage with you’
‘…there’s already a negative attitude with staff. So that does rub off on you’
‘…I think it can cloud someone’s judgement’
‘…you go out with that wall up and you can’t engage with anyone anyway can you?’
Discussion
Despite concerns about service users’ criminal histories and questions around the terminology of the diagnosis, both groups in this study stated the importance of seeing beyond this and seeing the individual. This is also identified as being vital in the evidence base (Bolton et al., 2014; NICE, 2009a; Wright & Jones, 2012). A key difference identified in this study as compared to the evidence base was the influence of clinical placements on students’ attitudes. Previous studies have shown a positive effect of clinical placements on students’ attitudes towards service users (Happell, 2008; Happell & Gough 2009; Henderson et al., 2007; O’Brien et al., 2008). Contrastingly, this study found that placement experiences elicited negative effects on students' perceptions of engaging with service users with a diagnosis of antisocial personality disorder.
References
Bolton, W., Lovell, K., Morgan, L., & Wood, H. (2014). Meeting the challenge, making a difference: Working effectively to support people with personality disorder in the community. London, United Kingdom: Department of Health.
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3,
Happell, B., & Gough, K. (2009). Nursing students’ attitudes to mental health nursing: Psychometric Properties of a self-report scale. Archives of Psychiatric Nursing, 23(5),
Henderson, S., Happell, B., & Martin, T. (2007). So what is good about clinical experience? A mental health nursing perspective. Nursing Education in Practice, 7,
Horberg, U., Brunt, D., & Axelsson, A. (2004). Clients' perceptions of client-nurse relationships in local authority psychiatric services: A qualitative study. International Journal of Mental Health Nursing, 13(1), 9-17.
Krawitz, R. (2004). Borderline personality disorder: Attitudinal change following training. Australian and New Zealand Journal of Psychiatry, 38,
Lacey, A., & Luff, D. (2007). Qualitative data analysis. Retrieved from
Livesley, W. J. (2007). An integrated approach to the treatment of personality disorder. Journal of Mental Health, 16(1),
Martin, T., & Happell, B. (2001). Undergraguate nursing students’ views of mental health nursing in the forensic environment. Australian and New Zealand Journal of Mental Health Nursing, 10,
National Institute for Health and Clinical Excellence (NICE). (2009a). Antisocial personality disorder: Treatment, management and prevention. London, United Kingdom: National Institute for Health and Clinical Excellence.
National Institute for Health and Clinical Excellence (NICE). (2009b). Borderline personality disorder: Treatment and management. London, United Kingdom: National Institute for Health and Clinical Excellence.
National Institute for Mental Health in England (NIMHE). & Department of Health (DH). (2003). Personality disorder: No longer a diagnosis of exclusion. Leeds, United Kingdom: National Institute for Mental Health in England.
Nolan, P. W., & Chung, M. C. (1999). Nursing students’ perceptions of their first mental health placement. Nurse Education Today, 19,
O’Brien, A. J., Buxton, M., & Gillies, D. (2008). Improving the undergraduate clinical placement experience in mental health nursing. Issues in Mental Health Nursing, 29,
Shanks, C., Pfohl, B., Blum, N., & Black, D. W. (2011). Can negative attitudes toward patients with borderline personality disorder be changed? The effect of attending a STEPPS workshop. Journal of Personality Disorders, 25(6),
Sim, J. (1998). Collecting and analysing qualitative data: Issues raised by the focus group. Journal of Advanced Nursing, 28(2),
Welch, M. (2005). Pivotal moments in the therapeutic relationship. International Journal of Mental Health Nursing, 14,
Wright, K., & Jones, F. (2012). Therapeutic alliances in people with borderline personality disorder. Mental Health Practice, 16(2),
Recommendations
As the first study on this specific area, further exploration is needed
Particularly further exploration of the impact of staff influences on student nurses during clinical placements
There has been limited research into service users’ perceptions of the therapeutic relationship with student nurses (Horberg et al., 2004) and no known research completed exploring the perceptions of service users with antisocial personality disorder of developing a therapeutic relationship with students. Therefore, although this study adds to the current body of knowledge, further exploration is needed.
Conclusion
The participants were open, questioning and reflective
All the participants commented on seeing past the diagnosis and seeing the person
So, what happens from qualifying?
The influence of placement staff can have a negative impact on student nurses’ perceptions of developing a therapeutic relationship with service users with antisocial personality disorder