Addressing attitudes of pre registration mental health nurses

towards people with Personality disorder (PD): evaluation

of an educational programmeLynda Smithies

Professional Lead School of Nursing and Midwifery ,

Keele UniversityUK

Introduction • Negativity surrounding ‘personality disorder’• NIHME (2003) ‘PD No Longer a Diagnosis of

Exclusion’• NIHME(2003a) ‘The Personality Disorder

Capabilities Framework -Breaking the Cycle of Rejection’

• 2007 DH/Ministry Justice commissioned the ‘Knowledge and Understanding Framework’ (KUF)

Goal of K.U.F.

• To improve service user experience through developing the capabilities, skills and knowledge of the workforce in health, social care and criminal justice settings .

• Develop a realistic culture of hope and respect • 3 levels

KUF (level 1)

• 3 facilitated study days • Facilitated jointly by practitioner and service

user

• High quality on line learning materials

Setting

• The study took place in a School of Nursing and Midwifery in a University the UK in 2013/2014

Aim

• To examine the understanding ,attitudes and capabilities of 3 cohorts of mental health pre registration student nurses towards people with PD ,immediately before and after a three day programme (KUF).

Sample

• Nursing students (BSc(Hons) and DipHe) were in their second year of a three year programme leading to registration.

• All students in three consecutive cohorts consented to take part in the study(n=54) .

• Students who did not complete all three days were excluded from the study (n=10)

Data collection

• Data was collected by pre and post training questionnaires using PD-KASQ (Bolton et al 2010).

*Knowledge and understanding • *Attitudes • *Capabilities

• Also captured were students’ anonymous comments about the perceived benefits of the programme.

Results :Qualitative

1. “What is the one thing that you have learned that will influence your daily work”

Hope, optimism and recovery

Challenging stigma

Developing skills to work with this client group

Hope ,Optimism & Recovery

“we should encourage recovery and help them believe that it is possible, also being aware of how my behaviour etc. at work can affect patients” (student 106)

“That PD is not something to be shied away from and there is chance of recovery and for the sufferer to be able to be a valued member of society” (student 03)

Challenging stigma“Not to be afraid to challenge negative attitudes to ‘PD’ from other professionals” (student 25)

“I have learnt not to listen to other peoples negative perceptions, and to be more understanding of people with personality disorder” (student101)

“Challenge stigma within teams & not let poor staff attitude influence my way of working” (student 120 )

Developing skills “I began the training thinking I would learn how to deal with people with personality disorders. I actually learnt about myself how my actions will impact on the relationships I have with clients .I realised the value of supervision when working with a difficult client group .I had previously thought of supervision as ‘optional’ ,now I realise it is imperative” (student 103)

“I feel I will have more understanding on ‘PD’ and I will be more open minded .I have a lot more patience with ‘PD’ and feel a lot more confidence in the diagnosis” (student 116)

“That there is more to a person’s behaviour than what is on the surface. It’s important to spend time with them to understand the root cause rather than dismissing the behaviour as disruptive” (student 107)

NICE (2009)1.1.4.1 When working with people with borderline personality disorder:• explore treatment options in an atmosphere of hope and

optimism, explaining that recovery is possible and attainable

• build a trusting relationship, work in an open, engaging and non-judgemental manner, and be consistent and reliable

• bear in mind when providing services that many people will have experienced rejection, abuse and trauma, and encountered stigma often associated with self-harm and borderline personality disorder.

2. Any other comments ?

Positive learning experience

Programme should be mandatory

Service user as facilitator

Positive learning experience • “Fantastic and informative” (Student 117)

• “Having worked with people with ‘PD’ previously I didn’t think I would learn much ,I was so wrong .I feel confident following my training & teaching” (student 103 )

• “Very good ,I enjoyed the variation between the distance learning at home and the classroom based learning” (student 19)

• “I have found the course extremely useful and informative .Thank you “ (student 7 )

‘Mandatory’• “ All health care professionals should receive

this training” (student 120)

• “Very insightful. I think this training should be mandatory for mental health professionals” (student 116)

• “This training should be provided for all students ,not just MH” (student 2)

‘Service user as facilitator’ • “I found having a survivor of ‘PD’

a good insight to the disorder and it makes you understand someone’s experiences of the service provided” (student 21)

• “It was a positive learning

experience and found J* a joy to learn from” (student 19)

• “I really thought the combination of trainers /service users and 1 lecturer worked really well”(student 112)

• “Really enjoyed the training and found it very informative having a service user teaching the training is fantastic and makes it more interesting as they have first-hand experience” (student 106)

• “very good that we get to listen to a person who has a diagnosis of ‘PD’ and understand it from their view” (student 119)

Strongly disagre

e

Disagree

Uncertain

Agree Stronglyagree

1. I feel that I have a good knowledge of the diagnosis of personality disorder. 1 2 3 4 5

2. I feel that I do not have enough knowledge about the nature and clinical characteristics of this client group. 1 2 3 4 5

3. I feel that I have a good understanding of how clients may develop a personality disorder. 1 2 3 4 5

4. I feel that I have a good understanding of why clients harm themselves or behave in self-destructive ways. 1 2 3 4 5

5. I have a good understanding of psychological models of personality disorder 1 2 3 4 5

6. I feel that I do not have the necessary clinical skills to work with this client group. 1 2 3 4 5

7. I feel confident that I can make a positive impact on the care of this client group. 1 2 3 4 5

8. I feel able to apply psychological models in my work 1 2 3 4 5

9. I feel understanding towards PD clients 1 2 3 4 5

10. I feel interested in PD clients 1 2 3 4 5

11. I feel able to help PD Clients 1 2 3 4 5

12. I feel pessimistic about PD clients 1 2 3 4 5

13. I feel frustrated with PD clients 1 2 3 4 5

14. I feel that clients with this diagnosis often engage in self-harming behaviour as a way of manipulating other people.

1 2 3 4 5

15. I often feel overwhelmed by the problems that clients with personality disorder have 1 2 3 4 5

16. I often feel that there must be something more that I could do to help clients with personality disorder 1 2 3 4 5

Results

• Statistically significant increase in all mean scores pre to post in

• Knowledge and understanding *• Attitudes • Capabilities

Q.5.I have a good understanding of psychological models of

personality disorder

Pre mean (disagree) Post mean(agree )

Change Significance (p - value)

2.19 4.07 + 1.88 0.00

Q.5.I have a good understanding of psychological models of

personality disorder

Pre mean (disagree) Post mean(agree )

Change Significance (p - value)

2.19 4.07 + 1.88 0.00

Q.2:I feel I do not have enough knowledge about the nature and

clinical characteristics of this group

Pre mean (agree)

Post mean(disagree )

Change Significance (p- value)

3.67 2.21 - 1.46 0.00

Q1:I feel I have a good knowledge of the diagnosis of personality

disorder

Pre mean(uncertain)

Post mean(agree)

Change Significance (p-value)

2.88 4.27 +1.39 0.00

Q14:I feel that clients with this diagnosis often engage in self

harming behaviour as a way of manipulating other people

Pre mean(uncertain)

Post mean(disagree)

Change Significance (p-value)

2.88 1.76 -1.12 0.00

Q13.I feel frustrated with PD clients

Pre mean(disagree/unceratin )

Post mean(strongly disagree/disagree )

Change Significance (p-value)

2.24 1.69 -0.55 0.00

Findings :after the programme • Pre registration mental health nurses showed

statistically significantly more positive attitudes to people diagnosed with Personality Disorder

• They identified a statistically significant improvement in their knowledge of Personality Disorder

• They statistically significantly improved their understanding of client behaviour and psychological models of care.

• They felt statistically significantly more confident that they could make a positive impact in the care of people with Personality Disorder

Strengths and weaknesses

• Sample :small /nursing students• Change in practice ? No follow up • Findings supported by other studies (Davies et

al (2014),Krawitz (2004))

Service user as co facilitator

• Effective and successful • Gains for students ,practitioner

/lecturer ,service user • Culture that supports SU involvement • Clear protocol

Implications /recommendations • Participation in KUF awareness may lead to

therapeutic optimism in nurse and increased competence and confidence in care

• This in turn may lead to improved outcomes for service users (model transferable)

• Recommended programme ,high quality support materials ,financial cost .

• Some tweaking to ensure depth appropriate to needs of Nursing students

Acknowledgements

• Judith Shaw • Pauline Walsh (Head of School) • Should you wish further information regarding

applying for the programmes please contact: Julie.Lawson@nottshc.nhs.uk

References

• Bolton, W., Feigenbaum, J., Jones, A., Sims, A. & Woodward, C. Development of the PD-KASQ. From KUF training materials

• Davies J,Sampson M,Beesley F,Smith D,Baldwin V (2014) An evaluation of Knowledge and Understanding Framework personality disorder awareness training .Personality and mental health 8:161-168

• Krawitz R(2004)Borderline personality disorder :attitudinal change following training Australian and New Zealand Journal of Psychiatry 38:554-559

• NICE(2009) ‘Borderline personality disorder: Treatment and management’ http://www.nice.org.uk/guidance/cg78 accessed 16th Sep 2014

• NIHME (2003) ‘Personality Disorder :no longer a Diagnosis of Exclusion’. London

• NIHME (2003a)Breaking the Cycle of Rejection :the personality disorder capabilities framework .London

• Knowledge and Understanding (Raising Awareness ) http://www.personalitydisorderkuf.org.uk/more_1.html accessed 16th Sep 2014