Managing the nurse-patient relationship with people diagnosed with personality disorders in therapeutic community and secure mental health settings

Personal Author: Aiyegbusi, Anne 
Year: 2011.
Dissertation: Thesis (Ph.D.) -- Middlesex University, 2011. 
Supervisors: Daniel Kelly (Middlesex University); Janet Holmshaw (Middlesex University); Vicky Franks (The Tavistock Centre, London)

Background

In mental health nursing, the nurse – patient relationship is regarded as the main therapeutic tool for supporting recovery. It is well documented in the literature that in the field of personality disorders, nurses often struggle to establish and maintain the therapeutic relationship often perceiving the patients as unresponsive to nursing interventions. This perspective is associated with the way uncomfortable emotional distress characteristic of personality disorders is felt during interpersonal relations.

 

Research Aims

The research aimed to:

  1. Establish primary nurses’ experiences of managing the nurse – patient relationship with people who have personality disorders in therapeutic community and secure mental health settings
  2. Establish people diagnosed with personality disorders’ experiences of the nurse-patient relationship in therapeutic community and secure mental health settings
  3. Establish the interpersonal challenges experienced within the nurse-patient relationship with people who have personality disorders in therapeutic community and secure mental health settings from the perspectives of patients and nurses
  4. Establish what clinical processes and practices nurses and patients find helpful for managing the nurse – patient relationship in therapeutic community and secure mental health settings

 

Design

A sequential mixed methods study incorporating qualitative Delphi study data with qualitative insights based in the tradition of phenomenology and underpinned by a psychoanalytic paradigm.

 

Methods

The methods employed in this mixed methods study were:

  1. Quantitative Delphi with a purposive sample of 11 nurses to establish an expert nursing consensus regarding the key clinical processes and practices essential for managing the nurse-patient relationship with people diagnosed with personality disorders. The findings were used to inform topic guides for qualitative methods
  2. In-Depth qualitative interviews with a purposive sample of 13 primary nurses working with people diagnosed with personality disorders in therapeutic community and secure mental health settings
  3. In-Depth qualitative focus groups with 12 patients diagnosed with personality disorders and receiving care and treatment in therapeutic community and secure mental health settings

 

Findings

Qualitative data analysis identified three main themes. These were;

1. Pain: Processing or Passing On?

This theme is in keeping with findings from other studies (Bowers 2002, Woollaston and Hixenbaugh 2008) in identifying that nurses often experience their interpersonal transactions with patients diagnosed with personality disorders as being on the receiving end of an onslaught of emotional pain. By including the patient perspective however, it was possible to gain clarity about why and for what purpose, patients engaged in these painful processes. Rather than merely wishing to inflict discomfort for gratuitous purposes as suggested by nurses in previous studies (Bowers 2002, Woollaston and Hixenbaugh 2008) patients were actually attempting to communicate their own distress via the only mechanism available at the time, in the hope that they would be understood. Early histories of traumatic attachment experiences and abuse were understood to compromise care seeking skills, hence patients’ challenging presentations at times of distress. Some nurses were able to process these complex communications and provide support and care, while others could not and therefore passed the distress back to the patients which then created a vicious cycle. A ‘containing’ nursing approach which was informed by theories of attachment and psychological containment, emerged as a way of organising clinical thinking and practice to support patients’ recovery.

2. System of Social Defences

When the onslaught of trauma fuelled emotional pain was not taken into account in the design of services, a system of social defences (Menzies 1960) was created in an unconscious attempt by all involved in the organisation to contain the distressing and traumatic phenomena. The more services incorporated the appropriate level of functional containing structures, training and support into their design, the less need there was for an unconscious system of social defences, which was neither effective nor therapeutic in the long term.

3. What Helps?

Components of the nurse – patient relationship that were experienced as helpful by patients and nurses in this study share many of the qualities of attachment relationships. These include attunement and responsiveness to manifest care seeking behaviours, regardless of how indirect or obtuse, availability of the nurse, the provision of time to listen and understand, the development of a bond, trust, empathy and the patient experiencing sufficient security to explore their feelings and thoughts with the nurse, without fear of rejection or retaliation. To provide this type of relationship, nurses required containing skills to withstand the patients’ initial difficulties in establishing a relationship.

 

Discussion

By including the voice of patients, this research ‘normalises’ their distressing interpersonal characteristics, clarifying why they engage in painful behaviours within the nurse – patient relationship. By clarifying the care seeking function of these behaviours, it is possible to hypothesise that they have their roots in prior traumatic attachments which have left the patients vulnerable during times when their attachment system is activated such as when hospitalised and experiencing stress. By elucidating this vulnerability, the relevance of a therapeutic nursing approach informed by attachment theory (Bowlby 1969) and psychological containment (Bion 1962) becomes clearer. As such an intervention is offered which may more effectively support recovery on the part of patients diagnosed with personality disorder. Importantly, this approach may reduce the well documented stigma and exclusion (NIMHE 2003) associated with these disorders.  A training programme informed by these findings has been developed.

 

Contribution to Nursing Scholarship and Health Care Practice

The findings of this study contribute towards dispelling the strongly held belief amongst many nurses that personality disorders are unresponsive to nursing interventions and that the patients inflict deliberate distress onto nurses. By offering an explanation for complex, distressing interpersonal presentations, both the roots of the disorders and nursing needs become more understandable. By identifying a theoretical framework for informing the nurse – patient relationship that is derived from theories of attachment and psychological containment, the nursing theory base is expanded. As the theoretical approach has been developed into a training programme, nurses are offered an opportunity to develop practical skills which will support patients’ recovery.


References

 

Access the full e-thesis

Aiyegbusi, A M (2011) Managing the nurse-patient relationship with people diagnosed with personality disorders in therapeutic community and secure mental health settings (PDF 2MB), PhD, Middlesex University.

 

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