Table 2 Data extraction of study characteristics on borderline personality disorder related structural stigma in healthcare systems
From: Structural stigma and its impact on healthcare for borderline personality disorder: a scoping review
Author, Year, Country | MMAT v.18*/ JBI quality ratinga | Population data | Aim/purpose | Study design | Methods/intervention | Main findings |
|---|---|---|---|---|---|---|
Acres et al. 2019, AUS [10] | JBI, Level 1.b/ Level 4b | Carers (N = 1891). Emergency care settings. Sources of evidence (N = 10): research studies (n = 7), advocacy brief (n = 1), clinical practice guideline (n = 1), action plan (n = 1) | Explore, locate, and compile literature detailing the perspectives of family carers of people with BPD in Emergency Departments (ED) with a focus on nursing practices | Scoping review | Review of the literature | Carers perceived ED as the only option for emergency care in a crisis. Carers require information on how to manage a crisis with their loved one. Carers are often not consulted with by health professionals; and perceive that health professionals lack understanding of consumers distress and BPD—a key barrier to effective crisis care |
Bodner et al. 2011, IL [76] | *** | Health practitioners (N = 57): males (n = 35), females (n = 65) age, range (25–65 years old). Psychiatric hospital settings | Develop and use inventories that measure cognitive and emotional attitudes of health practitioners toward patients with BPD | Quantitative study | Surveys | Psychologists scored lower than psychiatrists and nurses on antagonistic judgments; nurses scored lower than psychiatrists and psychologists on empathy. Analyses conducted on the three emotional attitudes separately showed that suicidal tendencies of BPD patients explained negative emotions and difficulties in treating these patients |
Bodner et al. 2015, IL [77] | **** | Health practitioners (N = 710): age, range (40–47 years old). Years of service, range (11–21 years). Psychiatric hospitals (N = 4) | Improve Bodner et al. [76] sample; inspect if nurses’ tendency to express more negative attitudes toward BPD is evident in a larger sample | Quantitative study | Surveys | Nurses and psychiatrists reported higher number of patients with BPD, exhibited more negative attitudes, and less empathy toward these patients than other professions. Negative attitudes were positively correlated with caring for greater numbers of patients with BPD. Nurses expressed the greatest interest in studying short-term methods; psychiatrists expressed interest in improving professional skills for BPD |
Borschmann et al. 2014, UK [7] | **** | People with BPD (N = 41) males (n = 7, 17%), female (n = 34, 82%). Mean age (SD) 36, (11). Community services | Examine crisis care preferences of community-dwelling adults with BPD | Qualitative study | Thematic analysis of crisis plans | Participants gave clear statements in their crisis plans about the desire to recover from the crisis and improve their social functioning. Key themes included: the desire to be treated with dignity and respect; to receive emotional and practical support from clinicians; and preferences for treatment refusals during crises such as, psycho-tropic medication and involuntary treatment |
Buteau et al. 2008 [1] | ***** | Carers of people with BPD/ families (N = 12). Males (n = 2), and females (n = 10) | To learn from families what their experiences have been in four key areas: (1) knowledge about BPD, (2) BPD treatments, (3) coping with BPD, and (4) reasons for hope | Qualitative study | Semi-structured interviews | Families identified five key areas of concern: (1) difficulty accessing current evidence-based knowledge about BPD/ treatments, (2) a stigmatizing health care system, (3) prolonged hopelessness, (4) shrinking social networks, and, (5) financial burdens. To improve the quality of services for families affected by BPD, social workers must educate themselves on BPD, BPD treatment options, information, and resources |
Carrotte et al. 2019, AUS [62] | ***** | A total of 12 participants comprising, people with BPD (n = 9), carers (n = 3) | Identify treatment and support services accessed by people with BPD and their carers; perceived benefits and challenges associated with these services; and recommended changes to services | Qualitative study | Semi-structured interviews, focus groups | Themes revealed: identity and discovery; (mis)communication; complexities of care; finding what works; an uncertain future; and carer empowerment. Participants described community-based psychotherapy as critical for reducing symptoms of BPD and improving services. Macro- and micro-levels relating to costs, service access, and clinician-client factors were discussed |
Clarke et al. 2015, UK [55] | **** | Health practitioners (N = 44): years of service, range (1–10 years or more). Inpatient setting | To assess whether training in neurobiological underpinnings of BPD could improve knowledge and attitude change of staff | Within-subjects, quantitative survey design | Surveys relating to delivery of ‘The Science of BPD’ training | Attendance at the training session was associated with significant increases in theoretical knowledge, perspective taking and mental health locus of origin. There were no changes observed in empathic concern. A brief training session utilizing a neurobiological framework can be effective in facilitating knowledge and attitudinal change among health practitioners working with BPD |
Commons Treloar et al. 2008, AUS [85] | **** | Medical and health practitioners (N = 140). Males (n = 48), females (n = 92). Years of service, range (1–16 years). Emergency care, Mental health services settings | To assess the attitudes of clinicians towards patients diagnosed with BPD | Quantitative study | A purpose-designed survey | Significant differences were found among emergency medical and mental health staff in their attitudes to people with BPD. The strongest predictor of attitudes to self-harm were whether the practitioner worked in emergency medicine or mental health, years of experience, and training in BPD |
Commons Treloar et al. 2009a, AUS [84] | ***** | Medical and health practitioners (N = 140). Males (n = 48), females (n = 92). Emergency medicine, Mental health services settings (N = 3) | To explore health practitioners’ experiences and attitudes in working with patients with BPD | Qualitative study | Qualitative survey | Results revealed four themes: BPD patients generate an uncomfortable personal response in health practitioners, characteristics of BPD contribute to negative health practitioner/service responses, inadequacies of the health system in addressing BPD patient needs, and strategies needed to improve services for BPD. Findings suggest that interpersonal and system difficulties may have impacted the services for BPD |
Commons Treloar et al. 2009b, AUS [53] | *** | Registered health practitioners (N = 65). Males (n = 26, 40%), females (n = 39, 60%). Years of service (1 year or more. Psychiatric hospital settings | To examine two theoretical educational frameworks (cognitive-behavioural and psychoanalytic), compared with no education to assess subsequent differences in health practitioners’ attitudes to deliberate self-harm behaviours in BPD | A randomized comparative quasi-experimental study | Surveys/‘cognitive behavioural therapy program’, ‘psychotherapy program’ training | Compared with participants in the control group (N = 22), participants in the cognitive-behavioural program (N = 18) showed significant improvement in attitudes after attending the training, as did participants in the psychoanalytic program (N = 25). At six-month follow-up, the psychoanalytic group maintained significant changes in attitude. Results support the use of brief educational interventions in sustaining attitude change to working with this population |
Day et al. 2018, AUS [86] | *** | Mental health practitioners (N = 66). Males (n = 22, 33.3%), female (n = 44, 66.7%). Public health service settings | To investigate mental health practitioners’ attitudes to individuals with BPD where attitudes were compared over time | Longitudinal mixed methods design | Surveys, Semi-structured interviews | The 2000 sample (n = 33) endorsed more negative descriptions (e.g.,) ‘attention seeking’, ‘manipulative’), and the 2015 sample (n = 33) focused more on treatment approaches and skills (e.g.,) ‘management plan’, ‘empathy’). The 2015 sample endorsed more positive attitudes than the 2000 sample. This positive attitudinal shift may reflect a changing landscape of the mental health system and greater awareness and use of effective treatments |
Deans et al. 2006, AUS [57] | **** | Registered psychiatric nurses (N = 47). Males (n = 14, 30%), females (n = 34, 70%). Age, range (21–60 years old). 15 years or more (53%) of service. Psychiatric inpatient and community services | To describe psychiatric nurses’ attitudes to individuals with BPD | Quantitative study | Survey | Results show that a proportion of psychiatric nurses' experience negative reactions and attitudes to people with BPD, perceiving them as manipulative, and feeling angry towards them. One third of nurses reported they ‘strongly disagreed’ or ‘disagreed’ that they know how to care for people with BPD |
Dickens et al. 2016, UK [52] | JBI, Level 1.b/ Level 4b | Mental health nurses (N = 1197). 9 studies across 6 Countries | To collate evidence on interventions devised to improve the responses of mental health nurses to people with BPD | Systematic Review | Review of the literature | Eight studies were included in this review, half of which were judged to be methodologically weak, and the remaining four studies judged to be of moderate quality. Only one study employed a control group. The largest effect sizes were found for changes related to cognitive attitudes including knowledge; smaller effect sizes were found in relation to changes in affective outcomes. Mental health nurses hold the poorest attitudes to people with BPD |
Dickens et al. 2019, UK [51] | **** | Mental health nurses (N = 28, training and pre-and post- surveys; N = 16, 4-month survey; N = 11, focus groups). Inpatient and community settings | To evaluate mental health nurses’ responses and experiences of an educational intervention for BPD | Mixed methods | Surveys, focus groups/‘positive about borderline’ training | Results revealed some sustained changes consistent with expected attitudinal gains in relation to the perceived treatment characteristics of this group, the perception of their suicidal tendencies and negative attitudes. Qualitative findings revealed hostility towards the underpinning biosocial model and positive appreciation for the involvement of an expert by experience |
Dunne & Rogers, 2013, UK [2] | ***** | Carers (N = 8). Community Personality Disorder Service | To explore carers’ experiences of the caring role, and mental health and community services | Qualitative study | Focus groups | The first carers’ focus group exploring the role of mental health services produced four super-ordinate themes. The second carers’ focus groups experiences in the community produced six super-ordinate themes. It seems carers of people with BPD are often overlooked by mental health services, and subsequently require more support to ensure their own well-being |
Ekdahl et al. 2015, SE [73] | ***** | Carers/ significant others (N = 19). Of the 19, 11 were involved in focus groups. Males (n = 5), females (n = 14). Age, range (43–75 years old). Psychiatric and health service settings | To describe significant others’ experiences of living close to a person with BPD and their experience of psychiatric care | Qualitative study | Qualitative survey, focus groups | Results revealed four categories: a life tiptoeing, powerlessness, guilt, and lifelong grief, feeling left out and abandoned, and lost trust. The first two categories describe the experience of living close to a person with BPD, and the last two categories describe encounters with psychiatric care |
Fallon 2003, UK [65] | **** | People with BPD (N = 7). Psychiatric services | To analyse the perspectives and lived experiences of participants with BPD contact with psychiatric services | Qualitative study | Unstructured interviews | Results found that people with BPD valued contact with psychiatric services despite negative staff attitudes and experiences. Relationships with others was vital in containing their distress despite trusting issues. Overcoming this was achieved by consistent long-term involvement with staff, containing relationships, encouraging participants to contribute to their care, and improving understanding of BPD |
Hauck et al. 2013, USA [88] | **** | Psychiatric nurses (N = 83) males (n = 8, 9.6%); females (n = 75, 90.3%). Age, range (21–65 years old). Psychiatric hospitals (N = 3) | To explore the attitudes of psychiatric nurses to patients with BPD experiencing self-harm | Descriptive, correlational design | Surveys | Psychiatric nurses had positive attitudes toward hospitalized BPD patients with deliberate self-harm. Psychiatric nurses with more years of nursing experience and self-reported need for further BPD education had more positive attitudes |
Horn et al. 2007, UK [68] | ***** | People with BPD (N = 5). Male (n = 1), female (n = 4). Age, range (23–44 years old). Mental health services | To explore user experiences and understandings of being given the diagnosis of BPD | Qualitative study | Semi-structured interviews | Analysis identified five themes: knowledge as power, uncertainty about what the diagnosis meant, diagnosis as rejection, diagnosis is about not fitting, hope and the possibility of change. Positive and negative aspects to these themes were apparent |
James et al. 2007 IL [121] | *** | Psychiatric nurses (N = 157) males (n = 21, 32%), females (n = 44, 68%) age, range (< 25- > 50) Years of service (< 2- > 15 years old). Various Psychiatric services | To describe the experiences and attitudes of nurses who deliver nursing care to people with BPD | Descriptive survey research design | Surveys | Results indicated that most nurses have regular contact with clients with BPD and nurses on inpatient units reported more frequent contact than nurses in the community. Eighty per cent of nurses viewed clients as more difficult to care for than other clients and believe that the care they receive is inadequate. Lack of services was the most important factor contributing to the inadequate care and the development of a specialist service as the most important to improve care |
Keuroghlian et al. 2006, USA [50] | **** | Medical and health practitioners (N = 297). Males (n = 25, 25.3%), females (n = 75, 74.7%) Mean years of service (SD) (17 years old (12). Medical centres, hospitals | To assess the effectiveness of Good Psychiatric Management workshops at improving clinicians’ attitudes to BPD; to assess if attitude changes relate to years of experience; and, compare the magnitude of change after GPM workshops to those from STEPPS workshop | Pre-post (repeated measures) design | Surveys/‘good psychiatric management’ training | Participants reported a decrease in the inclination to avoid, or dislike, patients with BPD, and belief that the prognosis is hopeless. were Participants also reported increased feelings of professional competence, belief that they can make a positive difference, and that effective psychotherapies do exist. Findings demonstrate Good Psychiatric Management’s potential for training health practitioners to meet the needs of people with BPD |
Knaak et al. 2015, CA [49] | *** | Health practitioners (N = 187) males (n = 28, 15%), female (n = 159, 85%. Mean age (39.1 years old). Mean years of service (22.2). Health services | To identify whether a generalist or specialist approach is the better strategy for anti-stigma programming for stigmatized disorders, and to examine the extent an intervention led to change in perceptions of people with BPD and mental illness | Pre-post design | Surveys/‘dialectical behaviour therapy’ training | Results suggest that the intervention was successful at improving healthcare provider attitudes and behavioural intentions towards persons with BPD. The results further suggest that anti-stigma interventions effective at combating stigma against a specific disorder may also have positive generalizable effects towards a broader set of mental illnesses |
Koehne et al. 2012, AUS [19] | ***** | Medical and health practitioners (N = 15). (Psychiatric hospitals (N = 3). Child and Adolescent Mental Health Services | Do mental health clinicians share diagnostic information about BPD with their adolescent clients, and if so, how? What are the factors that guide clinical practice in the decision to disclose or to withhold a diagnosis of emerging BPD to adolescents? | Qualitative study | Semi-structured interviews | Findings found that doctors, nurses, and allied health practitioners resisted a diagnosis of BPD in their work with adolescents. We delineate specific social and discursive strategies that health practitioners displayed including: team rules discouraged diagnostic disclosure, the lexical strategy of hedging when using the diagnosis, the prohibition and utility of informal ‘borderline talk’ among health practitioners reframed the diagnosis with young people |
Lawn et al. 2015a, AUS [3] | *** | People with BPD (N = 153). Age, range (18–65 years and older) | To explore the lived experiences of health service access from the perspective of Australians with BPD | Quantitative study | Survey | Responses from 153 consumers with BPD showed that they experience significant challenges and discrimination when accessing public and private health services. Seeking help from emergency departments during crises was challenging. Community support services were perceived as inadequate to meet patient needs |
Lawn et al., 2015b, AUS [4] | *** | Carers (N = 121). Males (n = 24, 25.5%), female (n = 78, 76.5%). Age, range (mostly 50-60 s). Various health and community services settings | To explore their experiences of being carers, attempts to seek help for the person diagnosed with BPD, and their own carer needs | Quantitative study | Surveys | Responses from 121 carers found carers experience significant challenges and discrimination when accessing health services. Comparison with consumers’ experiences showed that carers/families understand the discrimination faced by people BPD, largely because they also experience exclusion and discrimination. Community carer support services were perceived as inadequate. General Practitioners (GP) were an important source of support however, service providers need more education and training to support attitudinal change that addresses discrimination, recognizes carers’ needs, and provides support |
Lohman 2017, USA [89] | ***** | People with BPD (N = 500)/ BPD Resource Centre | To build on the BPD services knowledge base by characterizing the experiences of consumers, caregivers, and family members seeking BPD resources | Qualitative study | Retrospective data analysis of brief unstructured interviews (N = 500)/ Data from resource centre transcripts (N = 6253) | Results found that primary services and resources requested were: outpatient services (51%) and educational materials (13%). Care-seekers identified family services, crisis intervention, and mental health literacy as areas where available resources did not meet demand. Factors identified as potential barriers to accessing appropriate treatment for BPD included stigmatization and marginalization within mental health system and financial concerns |
Ma et al. 2009, TW [109] | ***** | Mental health nurses (N = 15). Females (n = 15). Age, range (20- > 40). Years of service (4–10 years). Various health and community service settings | To explore the contributing factors and effects of Taiwan’s mental health nurses’ decision-making patterns on care outcomes for patients with BPD | Qualitative study | Semi-structured interviews | The informants’ caring outcomes for BPD patients were involved with interactions across five themes: shifting from the honeymoon to chaos stage, nurses’ expectations for positive vs. negative outcomes, practicing routine vs. individualized care, adequate or inadequate support from healthcare teams and differences in care outcomes |
Markham 2003, UK [104] | *** | Mental health nurses (N = 71). Males (n = 18), females (n = 47). Mental health inpatient facilities | To evaluate the effects of the BPD label on staff attitudes and perceptions | Repeated measures factorial design | Surveys | Registered mental health nurses expressed less social rejection towards patients with schizophrenia and perceived them to be less dangerous than patients with BPD. Staff were least optimistic about patients with a BPD and were more negative about their experience of working with this group compared to the other patient groups |
Markham et al. 2003, UK [122] | *** | Mental health nurses (N = 48). Males (N = 12, 25%), females (N = 33, 69%). Mean age (SD), 38 (9.3). Mean years of service (SD), 12.7 (8.9). Mental health inpatient facilities | To investigate how the BPD label affects health practitioners’ perceptions and causal attributions about patients’ behaviour | Within-participants survey design | Survey | Patients with BPD attracted more negative responses from nurses than those with a label of schizophrenia. Causes of their behaviour were rated as more stable and they were thought to be more in control of their behaviour, then patients with other mental illnesses. Nurses reported less sympathy towards patients with BPD and rated their personal experiences as more negative than experienced with other patients |
Masland et al. 2018, USA [48] | **** | Mental health practitioners, researchers (N = 193). Mean age (SD), 48.84 (13.47). Mean years of service (SD), 18.12, (12.37). Various health services | To examine if the 1-day training can change health practitioners’ attitudes to BPD, which persist over time | Repeated measures design | Surveys/‘good psychiatric management’ training | Staff attitudes did not change immediately after training, but 6-months later had changed significantly. Findings indicated that brief training fosters improvements in health practitioners’ attitudes and beliefs about BPD |
McGrath et al. 2012, IE [110] | ***** | Registered psychiatric nurses (N = 17). Males (n = 5), females (n = 12). Mean years of service (n = 16). Community mental health service settings | To identify themes from an analysis of the nurses’ interactions with people with BPD, and to describe their level of empathy to this patient group | Qualitative study | Semi-structured interviews | Results found four themes: challenging and difficult, manipulative, destructive and threatening behaviour, preying on the vulnerable resulting in splitting staff and service users, and boundaries and structure. Low levels of empathy were evident in most participants’ responses to the staff-patient interaction response scale. Findings provide further insight on nurses’ empathy responses and views on caring for people with BPD |
Millar 2012, SC [119] | **** | Psychologists (N = 16). Females (n = 16). Years of service, range (1–32 years) | To explore psychologists’ experiences and perceptions of clients with BPD | Qualitative study | Focus groups | The following themes emerged from the analysis: negative perceptions of the client, undesirable feelings in the psychologist, positive perceptions of the client, desirable feelings in the psychologist, awareness of negativity, trying to make sense of the chaos, working in contrast to the system, and improving our role |
Morris 2014, UK [111] | ***** | People with BPD (N = 9). Males (n = 2), females (n = 7). Age, range (18–65 years old). Various voluntary sector organisations in the North-West of England | To explore people with BPD’s experience of mental health services to understand what aspects of services are helpful | Qualitative study | Semi-structured interviews | Three themes were generated including: the diagnostic process influences how service users feel about BPD, non-caring care, and it’s all about the relationship. Participants identified practical points which services could implement to improve the experiences of service users |
National Health and Medical Research Council 2012, AUS [16] | Agree II Instrument level 6 | Health practitioners | To provide current evidence for the effective treatment to improve the diagnosis and care of people with BPD in healthcare services in Australia | Clinical guidelines | Treatment and crisis management | Health professionals at all levels of the healthcare system and within each type of health service should recognize that BPD treatment is a legitimate use of healthcare services. Having BPD should never be used as a reason to refuse health care to a person. A tailored management plan, including crisis plan, should be developed for all people with BPD who are accessing health services |
Nehls 1999, USA [112] | ***** | People with BPD (N = 30). 30 Females (N = 30). Psychiatric, outpatient, and community services | To generate knowledge about the experience of living with the diagnosis of BPD | Qualitative study | Semi-structured interviews | Three themes were identified: living with a label, living with self-destructive behaviour perceived as manipulation, and living with limited access to care. The findings suggest that mental health care for persons with BPD could be improved by confronting prejudice, understanding self-harm, and safeguarding opportunities for dialogue |
Nehls 2000, USA [113] | ***** | Case managers (N = 17). Community mental health centre | To study the day-to-day experiences of case managers who care for persons with borderline personality disorder | Qualitative study | Semi-structured interviews | The analysis showed a pattern of monitoring self-involvement. The case managers monitored themselves in terms of expressing concern and setting boundaries. These practices highlight a central and unique component of being a case manager for persons with BPD, that is, the case manager's focus of attention is on self. By focusing on the self, case managers seek to retain control of the nature of the relationship |
Ng 2016, AUS [123] | JBI, Level 1.b/ Level 4b | People with BPD (N = 1122), carers and health practitioners’ perspectives reflected in consumer studies | To review the literature on symptomatic and personal recovery from BPD | Systematic review | Review of the literature | There were 19 studies, representing 11 unique cohorts meeting the review criteria. There was a limited focus on personal recovery and the views of family and carers were absent from the literature. Stigma associated with the diagnostic label hindered trust formation and consumers ability to fully engage |
O’Connell 2013, IE [120] | *** | Community psychiatric nurses (N = 15). Years of service, range (3–15 years). Irish adult community mental health service | To explore the experience of psychiatric nurses who work in the community caring for clients with BPD | Qualitative study | Semi-structured interviews | The nurses’ understanding of BPD and their experiences of caring for individuals with the condition varied. Participants identified specific skills required when working with clients, but the absence of supervision for nurses was a particular difficulty, and training on BPD was lacking |
Perseius et al. 2005, SE [8] | ***** | People with BPD (N = 10) age, range (22–49 years old) | To investigate life situations, suffering, and perceptions of encounters with psychiatric care among patients with BPD | Qualitative study | Semi-structured interviews | Findings revealed three themes: life on the edge, the struggle for health and dignity, a balance act on a slack wire over a volcano, and the good and the bad act of psychiatric care in the drama of suffering. Theme formed movement back and forth, from despair and unendurable suffering to struggle for health and dignity and a life worth living |
Pigot et al. 2019, AUS [47] | ***** | Mental health practitioners (N = 21). Males (n=10), female (n = 11). Mean age, 39.5 (9.7). Public mental health services | To understand the facilitators and barriers to implementation of a stepped care approach to treating personality disorders | Qualitative study | Semi-structured interviews /‘stepped care approach’ training | Participants identified personal attitudes, knowledge, and skills as important for successful implementation. Existing positive attitudes and beliefs about treating people with a personality disorder contributed to the emergence of clinical champions. Training facilitated positive attitudes by justifying the psychological approach. Findings suggests specific organizational and individual factors may increase timely and efficient implementation of interventions for people with BPD |
Proctor et al. 2020, AUS [106] | *** | People with BPD (N = 577), comprising 153 consumers in 2011, and 424 consumers in 2017 | To understand Australian consumer perspectives regarding BPD | Quantitative study | Surveys | Many people diagnosed with BPD experience difficulties when seeking help, stigma within health services, and barriers to treatment. Improved general awareness, communication, and understanding of BPD from consumers and health professionals were evident |
Ring et al. 2019, AUS [34] | JBI, Level 1.b/ Level 4b | People with BPD (N = 12), Health practitioners (N = 18) across 30 studies in total | To compare and contrast what stigma looks like within mental health care contexts, from the perspective of patients and mental health professionals’ and how it is perpetuated at the interface of care | Literature review | Review of the literature | Thirty studies were found: 12 on patient’s perspectives and 18 on clinician’s perspectives. Six themes arose from the thematic synthesis: stigma related to diagnosis and disclosure, perceived un-treatability, stigma as a response to feeling powerless, stigma due to preconceptions of patients, low BPD health literacy, and overcoming stigma through enhanced empathy. A conceptual framework for explaining the perpetuation of stigma and BPD is proposed |
Rogers 2012, UK [69] | ***** | People with BPD (N = 7). Male (n = 1), female (n = 5) age, range (22–66 years old) | To explore the experience of service users being treated with medication for the BPD diagnosis | Qualitative study | Semi-structured interviews | The main themes to emerged were: staff knowledge and attitudes, lack of resources and the recovery pathway for BPD. Service users felt that receiving the BPD diagnosis had a negative impact on the care they received, with staff either refusing treatment or focusing on medication as a treatment option. The introduction of specialist services for this group appears to improve service user satisfaction with treatment and adherence to the National Institute for Clinical Excellence guidelines |
Shaikh et al. 2017, USA [33] | JBI, Level 1.b/ Level 4 | Health practitioners (N = 5136). 56 studies. Emergency care | To review the advice to physicians and health-care providers who face challenging BPD patients in the ED | Systematic review | Review of the literature | Results found that crisis intervention should be the first objective of health practitioners when dealing with these patients in emergency departments. Risk management processes and developing a positive attitude and empathy towards these patients will help them in normalizing in an emergency setting after which treatment course can be decided |
Sitsti 2016, USA [108] | **** | Psychiatrists (N = 134). Male (n = 88, 65.7%), females, (n = 46, 34.3%). Years of service, range (0- > 20). Psychiatric services | To examine whether Psychiatrists had ever withheld/not documented patients’ BPD diagnosis | Quantitative study | Survey | Fifty-seven percent of participants indicated that they failed to disclose BPD to their patients, and 37 percent said they had not documented the diagnosis. For those respondents with a history of not disclosing or documenting BPD, most agreed that either stigma or uncertainty of diagnosis played a role in decisions |
Stapleton et al. 2019, UK [71] | JBI, Level 1.b/ Level 4 | People with BPD (N = 90) across all 8 studies. Age, range between 21 and 61 years. Acute Psychiatric inpatient wards | To conduct a meta-synthesis of qualitative research exploring the experiences of people with BPD on acute psychiatric inpatient wards | Meta-synthesis | Review of the literature | Eight primary studies met the inclusion criteria. Four themes included: contact with staff and fellow inpatients, staff attitudes and knowledge, admission as a refuge, and the admission and discharge journey. Opportunities to be listened to and to talk to staff and fellow inpatients, time-out from daily life and feelings of safety and control were perceived as positive elements of inpatient care. Negative experiences were attributed to a lack of contact with staff, negative staff attitudes, staff’s lack of knowledge on BPD, coercive involuntary admission, and poor discharge planning |
Stroud et al. 2013, UK [39] | ***** | Registered Community Mental Health Nurses (N = 4). Male (n = 1, female (n = 3). Age range (30–59 years old). Community Mental Health team | To gain a fuller understanding of how community psychiatric nurses make sense of the diagnosis of BPD and how their constructs of BPD impact their approach to this client group | Qualitative study | Semi-structured interviews | Results suggested that participants ascribe meaning to the client’s presentation ‘in the moment’. When they had a framework to explain behaviour, participants were more likely to express positive attitudes. As participants were deriving meaning ‘in the moment’, there could be fluidity with regards to participants’ attitudes, ranging from ‘dread’ to a ‘desire to help’, and leading participants to shift between ‘connected’ and ‘disconnected’ interactions |
Sulzer 2015, USA [114] | ***** | Mental health practitioners (N = 22). Inpatient and out-patient settings | To evaluate how health practitioners describe patients with BPD, how the diagnosis affects the treatment provided, and the implications for patients | Qualitative study | Semi-structured interviews | Findings suggest patients with BPD are routinely labelled difficult, and subsequently routed out of care through a variety of direct and indirect means. This process creates a functional form of demedicalization where the actual diagnosis of BPD remains de jure medicalized, but the treatment component of medicalization is harder to secure for patients |
Sulzer 2016a, USA [115] | ***** | Mental health practitioners (N = 22). BPD activists | To understand how health practitioners communicate the diagnosis of BPD with patients, and to compare and evaluate these practices with patient communication preferences | Qualitative study | Semi-structured interviews | Most participants sampled did not actively share the BPD diagnosis with their patients, even when they felt it was the most appropriate diagnosis. Most patients wanted to be told that they had the disorder, as well as have their providers discuss the stigma they would face. Patients who later discovered that their diagnosis had been withheld consistently left treatment |
Sulzer 2016b, USA [118] | **** | Mental health practitioners (N = 39). Men (n = 15), female (n = 24). Various public and private health services | To examine how clinicians navigate providing treatment to BPD in the context of the DSM 5, deinstitutionalization, and the biomedical model | Qualitative study | Semi-structured interviews | Health practitioners faced pressures to focus on biomedical treatments. Treatments which emphasized pharmaceuticals and short courses of care were ill-suited compared to long-term therapeutic interventions. This contradiction is the ‘biomedical mismatch’; Gidden's concept of structuration is used to understand how health practitioners navigate care. Social factors such as, stigma and trauma, are insufficiently represented in the biomedical model of care for BPD |
National Institute for Health and Care Excellence, 2009 UK [107] | Agree II Instrument level 5 | Targeting Health practitioners | To advise on the treatment and management of BPD | Clinical guidelines | Treatment and crisis management | Findings provide evidence-based guidance on interventions for health practitioners supporting people with BPD and families/carers. People with BPD should not be excluded from accessing health services because of their diagnosis or suicidality. Health practitioners should build a trusting relationship, work in an open, engaging, and non-judgmental manner, and be consistent and reliable when working with people with BPD and carers |
Vandyk et al. 2019, CA [117] | ***** | People with BPD (N = 6). Emergency care settings | To explore the experiences of persons who frequently present to the ED for mental health-related reasons | Qualitative study | Semi-structured interviews | Two broad themes included: the cyclic nature of ED use, coping skills and strategies. Unstable community management that leads to crisis presentation to the ED often perpetuated access by participants. Participants identified a desire for human interaction, feelings of loneliness, lack of community resources, safety concerns following suicidality as the main drivers for visiting ED. Participants identified strategies to protect themselves against unnecessary ED use and improve health |
Veysey 2014, NZ [72] | ***** | People with a BPD (N = 8). Male (n = 2), female (n = 7). Age, range (25–65) | To explore people with BPD encounters of discriminatory experiences from healthcare professionals | Qualitative study | Semi-structured interviews | Themes found that discriminatory experiences contributed to participants’ negative self-image and negative messages about the BPD label. A history of self-harm appeared to be related to an increased number of discriminatory experiences. Connecting with the person and ‘seeing more’ beyond an individual’s diagnosis and/or behaviour epitomized helpful experiences |
Warrender 2015, UK [45] | ***** | Nurses (N = 9). Acute mental health wards, hospital setting (N = 1). Health services | To capture staff perceptions of the impact of health. Mentalization-based therapy skills training on their practice when working with people BPD in acute mental health | Qualitative study | Focus groups/‘mentalization-based therapy skills training | Mentalization-based Therapy Skills training promoted empathy and humane responses to self-harm, impacted on participants ability to tolerate risk and changed some perceptions of BPD. Staff felt empowered and more confident working with people with BPD. The positive implication for practice was the ease in which the approach was adopted and participants perception of Mentalization-based Therapy skills as an empowering skill set which also contributed to attitudinal change |
Warrender et al. 2020, UK [35] | JBI, Level 1.b/ Level 4 | Health practitioners 46 studies. A total of N = 3714 participants comprising: people with BPD (n = 2345), carers (n = 184), Health practitioners (n = 1185). Various healthcare settings | To explore the experiences of stakeholders involved in the crisis care of people diagnosed with BPD | Integrative review | Systematic review of the literature | Four themes: crisis as a recurrent multidimensional cycle, variations and dynamics impacting on crisis intervention, impact of interpersonal dynamics and communication on crisis, and balancing decision making and responsibility in managing crisis |
Wlodarczyk et al. 2018 AUS [42] | ***** | A total of 22 participants comprising GP (N = 12); research team (n = 5); People with BPD (n = 2); Carers, 3. GPs: males (n = 6), females (n = 6). GP Partners Australia | To explore the nature and difficulties for GP, examine the reasons that caring for people with BPD in primary care is difficult and not well managed, and explore what strategies and actions might assist with improving the care of their patients with BPD | Qualitative study | Focus groups | Key themes identified were: challenges regarding the BPD diagnosis, clinical complexity, the GP–patient relationship, and navigating systems for support. Health service pathways are dependent on the quality of care provided and GP capacity to identify and understand BPD. GP need support to develop the skills necessary to provide effective care for BPD patients. Structural barriers obstructing attempts to address patients with BPD were discussed |
Woollaston et al. 2008, UK [116] | ***** | Nurses (N = 6). Males (n = 4), females (n = 2). Age, range (20–40 years old). Years of service, range (2–17 years). Various hospital and community health services (N = 6) | To explore nurses’ relationships with BPD patients from their own perspective | Qualitative study | Semi-structured interviews | Results identified the following themes: destructive whirlwind’, idealized and demonized, and manipulation and threatening. The study concludes that nurses experience BPD patients negatively. This can be attributed to the unpleasant interactions they have with them and feeling that they lack the necessary skills to work with this group. Nurses report that they want to improve their relationships with BPD patients |