New research by Professor Seamus Cowman, Head of the Faculty of Nursing and Midwifery at RCSI, and Philip James, a Clinical Nurse Specialist from the Health Service Executive (HSE) has revealed that services for patients with borderline personality disorder need to be improved.

According to the October issue of the Journal of Psychiatric and Mental Health Nursing, 80% of psychiatric nurses believe that people with borderline personality disorder (BPD) receive inadequate care, despite the fact that one-in-50 adults suffer from the condition.

98% of nurses said service shortages played a role in inadequate care and 83% said that disagreements between staff on how to care for people with BPD was a factor.

Professor Cowman and Philip James found that more than a quarter of the nurses surveyed (27%) had daily contact with patients with BPD. Despite this, only 3% had received postgraduate training in BPD and, when training was provided, it tended to be a single workshop or lecture.

BPD is a serious mental illness characterised by persistent instability in moods, personal relationships, self-image and behaviour. This instability can affect aspects of the individual’s life and their sense of identity, resulting in self-harm and a significant rate of suicide attempts. It is more common in young women and sufferers often need extensive mental health services.

157 ward and community-based nurses working for a health service providing mental health inpatient and outpatient services were surveyed, with 67 (41%) completing the detailed questionnaire.

“A worrying finding of this study is that the majority of staff believe that multidisciplinary team disagreements lead to inadequate care,” said Professor Seamus Cowman. “This points to the need for greater guidance to avoid different approaches being taken to managing clients with the same disorder. The need for all services to develop policies on handling BPD was also highlighted by the Expert Group on Mental Health Policy in its 2006 report.”

Lack of specialist training was also a concern. “The majority of nurses strongly agreed that they had a key role to play in the assessment and management of people with BPD and 90% said they would be keen to receive further training in dealing with BPD,” said Professor Cowman. “We were concerned to note that only 3% had received postgraduate training. In contrast, Australian nurses receive 11 times as much post-graduate training in BPD as their colleagues in the Republic of Ireland. This lack of training needs to be addressed as other studies have shown that it can improve both knowledge of BPD and attitudes towards it.”

88% of the nurses who took part in the survey said that people with BPD were difficult to treat. 75% said they were very or moderately difficult to look after and 80% believed that they were more difficult to look after than other clients.

62% felt that lack of staff training or expertise contributed to inadequate care for people with BPD and 65% said that not telling people they had BPD was another factor.

Nurses were also asked how much they knew about the condition. The number of questions answered correctly ranged from two to nine and averaged 5.8.

When it came to how services could be improved, providing specialist services for people with BPD was the most favoured option (65%), followed by standard protocols for managing people with BPD (60%) and skills training workshops for staff (51%).

Improving undergraduate training (48%), improving in-service training (48%) and providing psychiatric staff who liaise with accident and emergency departments (42%) were also popular responses.

“This study shows that psychiatric nurses come into regular contact with patients with BPD and believe they have a role to play in caring for them,” said Professor Cowman. “But the majority see people with BPD as a difficult group to care for and feel that the overall care that is being provided is inadequate. It does however highlight a willingness for nurses to work with people with BPD and a desire to improve the services that they receive. We hope that this research will help to drive service improvements for people with BPD and provide staff with the education and guidance they need to make best use of their skills.”