DECEMBER 2022/

inside: NEWS FEATURES RESOURCES JANUARY 2023

VOL 42 #6

Mental Health

BLUE SPACES and

wellbeing
WHY WATER improves
mental health
PLUS
Borderline
Personality
Disorder

interview
Scotland’s CNO
ALEX McMahon

News: One in four 17 to 19-YEAR-OLDS have A mental disorder


INTRODUCTION
I REMAIN POSITIVE DESPITE
THE CHALLENGES OF 2022
Evri Anagnostara, associate director of nursing,
Barnet, Enfield and Haringey Mental Health NHS Trust
H
ere we are again at the end of
another year. At the beginning
of 2022 we sighed with relief
knowing that we got a good grip on
COVID-19. The vaccination programme
appeared to have made a positive
impact and the healthcare system, albeit
always under pressure, seemed ready
to enter the much-discussed recovery
mode.
We believed that the worse had
probably passed, but at that exact
moment, nurses – along with other
clinicians – started voicing their
concerns about the state of our
healthcare system, the conditions
of work and of course, the overdue
proposed pay award.
These were not new complaints. They
were undoubtedly the manifestations of
observations and concerns accumulated
over the past years. There was never
going to be a perfect moment to air
these worries.
For mental health nurses in
particular, 2022 was the beginning
of another challenge. It was not until
later than other services, that some
mental health teams started feeling the
aftermath of COVID-19.
The pressure had been building up
and while everyone was previously
praising nurses and our commitment
to the work, suddenly the conversation
changed, to a more difficult narrative.
For me, it felt almost as if the
conversation about nurses and our
worth, in terms of our ethos and values,
shifted from being a hero to a villain –
and it saddens me to know that we are
going to close this year in a climate of
uncertainty and dispute.
There is the obvious difference
of opinion between unions and the
government, and then the public, no
doubt couched in fear and exhaustion.
2 MENTAL HEALTH NURSING December 2022/January 2023
And of course, all this stuff is
happening while the NHS is on the
verge of exhaustion and silently at risk
of collapsing around us.
This year, we have also seen a great
number of nurses leaving the NHS and
the profession, and the number of new
entrants being at a record low.
However, in spite of everything, I
refuse to give in to negativity. I know
that 2023 will bring new challenges and
with that, there will be some resolution
to longstanding issues.
Our chief nursing officer Ruth May
continues to be committed to renewing
the reputation of our profession and I
think there has never been a time when
I have felt more proud to be a nurse.
From taking time to uphold our
professional standards, to enhancing our
portfolios, to working with colleagues to
retain or recruit more nurses, I know we
will all seize the opportunities that the
new year will bring.
But first, let’s take some time to
regroup and think about our next steps
with clarity and recognising our worth.
Finally, I wanted to wish you all the
best for this festive season and share
the hope that 2023 will be filled with
many exciting things for us all. Have a
fantastic new year, colleagues. n
DECEMBER 2022/
inside: NEWS FEATURES RESOURCES JANUARY 2023
VOL 42 #6
Mental Health
BLUE SPACES and
wellbeing
WHY WATER improves
mental health
PLUS
Borderline
Personality
Disorder
Pexels from Pixabay
interview
Scotland’s CNO
ALEX McMahon
News: One in four 17 to 19-YEAR-OLDS have A mental disorder
Editor: Phil Harris
mhneditor@gmail.com
Editorial board
•฀ Hollie Roblin, clinical team manager,
Leeds and York Partnership NHS
Foundation Trust, and chair of editorial
board
•฀ Evri Anagnostara, head of nursing,
Barnet, Enfield and Haringey Mental
Health NHS Trust
•฀ Mark Brown, development director,
Social Spider Community Interest
Company
•฀ Terez Burrows, clinical service
manager, Royal Edinburgh Hospital and
Associated Services
•฀ Lawrence Benson, senior lecturer in
healthcare management and policy,
University of Manchester, and service
user representative
•฀ Vanessa Gilmartin Garrity, mental health
nurse and independent consultant
•฀ Joanna Johnston, mental health nurse
•฀ Steven Jones, Professor (mental health),
University of Chester
•฀ Donna Kemp, lecturer, University of
Huddersfield
•฀ Nicky Lambert, director of teaching and
learning/associate Professor, Middlesex
University
•฀ Stephen McKenna Lawson, lecturer,
Swansea University
•฀ Athia Manawar, senior nurse practice
placement facilitator, Tees Esk Wear
Valleys Foundation Trust
•฀ Dave Munday, lead professional officer,
Health Sector, Unite the Union
•฀ Neil Murphy, senior lecturer, University
of Salford
•฀ Emily Prescott, mental health nurse,
care homes sector
•฀ Mike Ramsay, senior lecturer in nursing
(mental health)/postqualifying BSc lead,
University of Dundee
•฀ Jonathon Slater, trainee approved
clinician, Nottinghamshire NHS
Foundation Trust
Publisher
Mental Health Nurses Association
©MHNA 2022
Advertising
Mental Health Nurses Association
mhneditor@gmail.com
Subscriptions
MHN is free to members of the Mental
Health Nurses Association. Annual
subscription (six issues/one volume) for
non-members £72.45/£108.75 Institutions
(VAT and postage included). No part-
volume orders accepted. Orders (cheques
payable to Unite the union) to:
MHN subscriptions, PO Box 35,
Robertsbridge TN32 5WN
Tel: 01580 883844 Email: mhn@c-cms.com
The views expressed in Mental Health
Nursing are not necessarily those of the
publisher nor of the editor, except where
expressly stated. While every care has
been taken in compiling this publication
and the statements it contains, neither the
promoter nor the publisher can accept any
responsibility for any inaccuracies, or for the
products or services advertised
ISSN 1353-0283 (online version ISSN 2043-7051)
 CONTENTS

CONTENTS
04
NEWS
• Mental health organisations urge Prime Minister to
take action on cost of living crisis • Obituary: Professor
Patrick J Carr • Rise in number of people accessing
mental health services last year • Increase seen in
section 136 Mental Health Act detentions • One in four
aged 17 to 19 have mental disorder

07
UNITE/MHNA UPDATE
A round-up of activity by lead professional
officer Dave Munday

14
08 NURSING ATTITUDES TO
NEWS FEATURE: CQC SURVEY PEOPLE WITH BORDERLINE
HIGHLIGHTS POOR COMMUNITY PERSONALITY DISORDER
MENTAL HEALTH EXPERIENCES WHO SELF-HARM:
A LITERATURE REVIEW
The 2022 survey by the Care Quality Commission
shows people continue to report poor experiences of Kennedy Brown examines the research to explore
NHS community mental health services what attitudes nursing staff have towards borderline
personality disorder and self-harm

10
BLUE SPACES: WATER, WELLBEING
20
AND MENTAL HEALTH STUDENT FOCUS:
BRIDGING THE GAP BETWEEN
Catherine Kelly explores the benefits of ‘blue spaces’ in
protecting and improving mental health
NURSING SPECIALTIES
Mental health nursing student Mike Palmer and
adult nursing student Carlie Andrews outline
how a different approach to education could
bring benefits

22
INTERVIEW:
INSIDE THE MIND OF...
ALEX MCMAHON
Mental Health Nursing meets Professor Alex
McMahon, Scotland’s Chief Nursing Officer, and
mental health nurse

December 2022/January 2023 MENTAL HEALTH NURSING 3

 NEWS

Mental health organisations urge Prime

Minister to take action on cost of living crisis
Nineteen mental health organisations “This should worry us all. It is a rise in mental ill health.
have written an open letter to the shameful and unnecessary situation The letter was signed by leaders
Prime Minister, urging him to take in the UK. As leaders of mental health from the Samaritans, Mental Health
more action to tackle the cost-of-living organisations there is growing demand First Aid England, Mind, Mental Health
crisis and its mental health impact. for our services. We will, of course, UK, the Mental Health Network of
The letter says: “Dear Prime Minister, continue to do our absolute best to NHS Confederation, the National
In the UK the cost-of-living crisis runs provide the necessary support. Survivor User Network, Mental
deep in every community and is having “But we want to be crystal clear: the Health Innovations, the Centre for
a significant impact on mental health. first intervention to reduce mental ill Mental Health, MindForward Alliance,
“High levels of inflation affect health and prevent suicide is to ensure the Royal College of Psychiatrists,
everyone as the price of necessities every household has the means to be Young Minds, The Mix, the Helplines
including food and energy increase. safe and warm with enough to eat. We Partnership, the Association of Mental
However, the impact is not felt equally. urge the Prime Minister to act with Health Providers, Place2Be, the Mental
We know those already experiencing speed and compassion to tackle the Health Foundation, the Anna Freud
inequality, poverty and hardship are root causes of destitution and in doing Centre, Student Minds and Rethink
being hardest hit. And poverty is the so prevent suicide and an inevitable Mental Illness.
single biggest driver of poor mental
health in children.
“We also know that people living in
the most deprived 10% of areas in the
UK are more than twice as likely to die
from suicide than those living in the
wealthiest 10% of areas.
“In 2022 the Trussell Trust who
provide emergency support to people
in crisis issued 1.3 million food parcels
between April and September. 94%
of people accessing emergency food
parcels are experiencing destitution.

Frantisek Krejci from Pixabay

That means they are well below the
poverty line and cannot afford the
essentials to eat, stay warm and dry,
and keep clean.

Obituary: Professor Patrick J Carr

Unite/MHNA was saddened to hear
of the passing of Professor Patrick J
Carr, writes Phil Draper.
Known as Paddy to his friends at
the Community Psychiatric Nursing
Association (CPNA), later the Mental
Health Nursing Association, he
regularly attended the society’s
conferences.
Professor Carr had a wealth of
experience in his clinical nursing
career, in both mental and general
nursing, working in over a dozen
hospitals in the UK.
He was a former head of nursing
studies at Manchester Polytechnic (now
Manchester Metropolitan University).
He was also the chief executive of the
Registered Nursing Home Association.
Paddy wrote the first book on
community psychiatric nursing,
together with Tony Butterworth and BE
Hodges, which was published in 1979.
He was also a valued trustee of the
Trustees of the CPNA (1994), a charity
established with the help of MSF (now
Unite) with charitable funds held by
the former CPNA.
His valued insightful advice and
huge knowledge base enabled
many mental health nurses achieve
bursaries towards personal training
or support to their service users.

4 MENTAL HEALTH NURSING December 2022/January 2023


Rise in number of
people accessing
mental health
services last year
The number of people in contact with
NHS mental health services in England
(including those referred and those seen)
has increased by 16.2% in the last year.
During 2021-22, 3,256,695 people were
in contact with NHS-funded secondary
mental health, learning disabilities and
autism services – up from 2,803,244 in
2020-21 and 2,878,636 in 2019-20.
This means that 5.8% of people in
England were known to be in contact with
those services during the year. This is
compared to 5.0% of people in 2020-21
and 5.1% of people in 2019-20.
Published by NHS Digital, the Mental
Health Bulletin, 2021-22 Annual report
also includes breakdowns by age, gender,
ethnicity and deprivation.
The number of under-18s in contact with
NHS mental health services in England
increased by 29.2% in the last year to
992,647 in 2021-22 – up from 768,083 in
2020-21 and 763,888 in 2019-20.
Figures show that 18.2% of the country’s
16-year-olds (114,203) and 16.6% of the
country’s 17-year-olds (101,694) were in
contact with NHS mental health services.
Girls aged 16 are most likely to be in
contact with NHS mental health services,
with 22.8% of the population (69,580)
having been in contact with these services
during 2021-22.
The Mental Health Bulletin, 2021-22
Annual report can be viewed at: https://
digital.nhs.uk/data-and-information/
publications/statistical/mental-health-
bulletin/2021-22-annual-report.
Lukas_Rychvalsky from Pixabay
Increase seen in section 136
Mental Health Act detentions
New data published by the Home Office
has revealed an 8% increase in people
detained under section 136 of the Mental
Health Act, with total detentions reaching
36,594.
Section 136 allows the police to take
anyone who appears to have a mental
health condition and is ‘in need of
immediate care or control’ to a place of
safety.
A person can only be held at a place of
safety for up to 24 hours, although this
can be extended by a further 12 hours if
a clinical assessment is not available at
that time.
The data shows that where the details
were known, 52% were detentions of
males, 94% of cases were adults aged
18 or over and 84% were detentions of
people from the white ethnic group.
Where the details were known, the
person being detained was taken to a
health-based place of safety in over two-
thirds (68%) of cases. Twenty-nine per
cent of detainees were taken to accident
and emergency as a place of safety, and
264 people (0.8%) were taken to a police
station.
Rheian Davies, head of the charity
Mind’s legal unit, said: “Nearly 37,000
people were detained under section
136 of the Mental Health Act in the
year ending March 2022 – roughly the
population of Falmouth or Great Malvern
in real terms.
“This is an unacceptable increase of
8% on the previous year. We know that
the nation’s mental health has been at
breaking point for some time, but now
that the equivalent of a mid-sized British
town’s worth of people with mental
health problems are annually held by
police, the situation has hit a new low.
“Police officers often come into
contact with people experiencing
mental health problems – who are
more likely to be victims of crime than
others – and can play an important role
in managing situations to make sure
December 2022/January 2023 MENTAL HEALTH NURSING
NEWS
everyone stays safe.
“We know that years of underfunding
to both the police force and NHS,
alongside increased demand for mental
health services, has meant that police
officers are spending more time helping
people with mental health problems.
“Just a few days ago, Sir Mark Rowley,
chief of the Metropolitan Police,
recognised that the number of people
sectioned by police under the Mental
Health Act has more than quadrupled
since 2013.
“For people from racialised
communities, things are even grimmer.
People from Black, Asian, mixed and
other ethnic groups continue to be
overrepresented, making up 16% of
overall detentions, despite only 13%
of the population belonging to these
groups.
“We know that people from these
backgrounds, particularly Black people,
are more likely to access mental health
support via uncomfortable and ‘sharper’
routes like the criminal justice system,
often due to being turned away at earlier
preventative stages.
“Although just under 1% of detainees
were taken to a police station as a place
of safety, this still means that 264 people,
while at their lowest, were for all intents
and purposes treated like criminals.
This can be deeply traumatising and
humiliating for people in crisis, who
have not committed a crime and instead
need therapeutic care in an appropriate
environment.
“This data shows how urgently
overdue reforms to the Mental Health
Act are. While the publication of the
Draft Mental Health Bill earlier this year
was a landmark moment for people
with mental health problems, and we
welcome many of its measures such
as the removal of police stations and
prisons as designated places of safety;
we need to see the bill go much further
on issues like anti-racism.”
5
 NEWS
One in four aged 17 to 19 have mental disorder
The rate of mental disorders among 17 to
19-year-olds has increased in the past year,
from one in six in 2021 to one in four in
2022, according to new NHS figures.
The Mental Health of Children and Young
People in England 2022 report, published
by NHS Digital, shows that among 17
to 19-year-olds, the proportion with a
probable mental disorder increased from
17.4% in 2021 to 25.7% in 2022.
The report explores the mental health of
children and young people in England in
2022 and how this has changed from 2017,
2020 and 2021. It examines their views
and experiences of family life, education,
household circumstances, services and
employment.
The findings draw on a sample of 2,866
children and young people who are now
aged between 7 and 24 years old, while
information was also provided by parents
for children aged 7 to 16. The publication is
part of a series of follow-up reports to the
2017 Mental Health of Children and Young
People in England survey.
The Strengths and Difficulties
Questionnaire was used to assess
different aspects of mental health,
including problems with emotions,
behaviour, relationships, hyperactivity and
concentration. Responses from parents,
children and young people were used to
estimate the likelihood that a child might
have a mental disorder, and this was
classified as either ‘unlikely’, ‘possible’ or
‘probable’.
In 2017, 10.1% of 17 to 19-years-olds
had a probable mental disorder. The rate
increased to 17.7% in 2020 but remained
stable between 2020 and 2021, when it
was 17.4%.
Among 7 to 16-year-olds, the proportion
with a probable mental disorder was
18.0% in 2022. This was up from the 12.1%
figure seen in 2017 but a similar rate to
2020 when it was 16.7% and 2021 when it
was 17.8%.
In 2022, among those aged 7 to 10,
prevalence of a probable mental disorder
was nearly twice as high in boys (19.7%) as
in girls (10.5%).
6 MENTAL HEALTH NURSING December 2022/January 2023
Rates of a probable mental disorder
were similar in boys (18.8%) and girls
(22.0%) aged 11 to 16. Among 17 to
24-year-olds, the prevalence was much
higher in young women (31.2%) than
young men (13.3%).
The report also reveals:
Children with a probable mental
disorder were more likely than those
without to live in a home experiencing
financial strain. Among 17 to 22-year-olds
with a probable mental disorder, 14.8%
reported living in a household that had
experienced not being able to buy enough
food or using a food bank in the past year,
compared with 2.1% of those unlikely to
have a mental disorder.
One in five (19.9%) 7 to 16-year-olds
lived in households that experienced a
reduction in household income in the
past year. This was more than one in four
(28.6%) among children with a probable
mental disorder.
17.8% of children aged 7 to 16 with
a probable mental disorder lived in a
household that had fallen behind with bills,
rent or mortgage, compared with 7.6% of
those unlikely to have a mental disorder.
13.6% of children with a probable
mental disorder lived in a household
where they could not afford to keep the
house warm enough, compared with 6.0%
of those unlikely to have a mental disorder.
Olly Parker, head of external affairs
at the charity YoungMinds, said: “These
figures demonstrate the unprecedented
crisis happening in young people’s mental
health, with one in four young people
aged 17-19 now having a probable mental
health problem – a staggering rise from
one in ten, five years ago.
“It is also deeply worrying that three
quarters of young women in this age range
have a possible eating disorder. We know
young women in particular face a wide
range of pressures that can affect their
mental health, including concerns about
body image often exacerbated by social
media.
“Month on month we see the crisis for
young people continue to deepen, with
referrals for treatment reaching record
breaking highs and thousands of young
people facing an agonising wait for help.
“Politicians have promised to end the
crisis in young people’s mental health
but the reality is that with every month of
inaction, things are getting worse.
“The government must deliver on its
promise of a ten-year mental health plan
which includes the changes that tens of
thousands of young people have already
called for – a national network of early
support hubs in every community, so
young people can access help for their
mental health when they first start to
struggle without having to wait for an
appointment or referral, as well as better
support in schools, and NHS services that
meet demand.”
Newscast

MHN lead
professional
officer update
Dave Munday, Unite in Health. Twitter: @davidamunday
S
ometimes negotiations can feel like a
bit of a dance. You hope the two sides
can try to correctly align and work
out the rhythm, and at the end everyone
has something to show for it. Watching
the English government’s behaviour, since
my last update, you have to wonder how
many partners’ toes it has stamped on.
On the railways it worked to kibosh its
own negotiations, probably on purpose,
by pulling in the issue of driver-only
operating at a time when there was
supposedly the potential for a deal.
The Secretary of State for Health and
Social Care Steve Barclay MP has similarly
side-stepped the opportunity to at least
avert pre-Christmas strikes from the Royal
College of Nursing. I’m writing this on the
‘historic’ day that their members go on
strike in some workplaces across England.
All they asked from Barclay? To at
least engage in talks that included pay.
His response was to have a meeting but
refused to discuss anything except non-pay
issues. I hope the public will remember
this decision when they think about what
support they want to offer NHS staff who
do strike.
In my last update, I described the
“Our members are
under extreme
pressure from the
economy and the
problems inherent
in the NHS”
complexity of the differing picture across
not only the four UK countries as a whole
but between and in organisations in each
country. I have been busy supporting
members who work in the ambulance
service as Unite members in the West
Midlands, North West, North East and
Yorkshire & the Humber will be on the
picket line on 21 December in their first
day of industrial action.
We have a number of other strike ballots
ongoing that will close just this side of
Christmas. As with the recent strike ballot
by the Royal College of Midwives, we know
that turnout will be adversely affected by
the Royal Mail strike action, but we push
on with trying to secure the legal mandates
in organisations where members wish
to take industrial action. I have no doubt
that this will not reduce as we turn the
calendar page into 2023.
Government ‘lines’ and reality
While the government and right-wing
press would want to present these strikes
as being perpetrated by ‘union barons’,
I hope you know the reality. We have
members being put under extreme
pressures both by the failing economy and
the problems inherent in our NHS, caused
by years of austerity and neglect.
I sometimes come across people who
work in the NHS who share the same
‘lines’ that the government is currently
espousing, that to pay nurses would cost
too much. Prime Minister Rishi Sunak
himself argued that each family in the
UK would have to pay £1,000 more if all
public sector workers were given an 11%
pay rise, getting close to the rampant RPI
December 2022/January 2023 MENTAL HEALTH NURSING
MHNA UPDATE
inflation figure.
I agree with the response that these
figures are disingenuous. While the total
itself ignores plenty that makes it much
higher than the real cost, for example
that it fails to count the percentage pay
rises already agreed and budgeted for,
it misses the fact that for each £1 paid to
public sector workers, a large proportion
would be liable in tax which would go
straight back to the treasury and much of
the rest would be recycled into the local
community. But if you direct more money
to those at the top the money gets ‘hidden’
from HMRC.
I’ve also mentioned previously the
research that Unite has published on
the real causes of inflation rather than
the government’s narrative that it is
workers’ wage rises, which ‘ironically’
they’re not getting while inflation rages
away (see https://www.unitetheunion.org/
news-events/news/2022/june/new-unite-
investigation-exposes-how-corporate-
profiteering-is-driving-inflation-not-
workers-wages).
As we go into 2023, I want to say again
thank you to every MHNA member for the
amazing work you have done this year.
I also want to say an extra special thanks
to each member who has contributed
to the work of the association and the
wider union, including those members
on the national organising professional
committee and on this journal’s editorial
advisory board.
I look forward to meeting more of you
next year. From me and mine to you and
yours, merry Christmas and a happy New
Year. n
7
 NEWS FEATURE
CQC survey highlights
poor community mental
health experiences
P
eople are consistently reporting
poor experiences of NHS community
mental health services, according
to the latest annual survey from the Care
Quality Commission (CQC).
CQC’s 2022 Community Mental Health
Survey areas that returned poor results
historically have not improved and some
have declined further.
Access to care has deteriorated, fewer
people are saying they have seen NHS
community mental health service services
enough to meet their needs and many
people have not been told who is in charge
of organising their care and services.
Consistent with the results from the
2021 survey, findings this year showed
that people who received their care via
telephone, younger people (aged 18-35)
and those with more challenging and
severe non-psychotic disorders were less
likely to report positive experiences.
Additionally, CQC analysed 13 questions
of key improvement areas, reported on
between 2018 to 2022, and found eight
showed their lowest result to date, with
Newscast Online
8 MENTAL HEALTH NURSING December 2022/January 2023
seven moving in a downward trend over
the last five years.
However, some of the results show
signs of improvement in areas, such as
NHS talking therapies received as part of
a wider package of care and when people
had their care reviewed, they felt included
in the decisions made about their care.
Survey analysis
The 2022 Community Mental Health
Survey received feedback from
adults who received specialist care or
treatment for a mental health condition
between September and November 2021.
Fieldwork took place between February
2022 and June 2022. The survey received
responses from 13,418 people, a response
rate of 20.9%.
The findings include:
• Four in ten (40%) reported not having
their care reviewed with NHS mental
health services in 12 months.
More than a fifth (22%) of people did not
get the help they needed from crisis care
services.
• Over a quarter of people (28%) would not
know who to contact out of office hours in
the NHS if they had a crisis, an increase of
2% since 2021.
• Almost a third of people (31%) had not
been told who is in charge of their care, an
increase of three percentage points since
2021.
• 40% of people had ‘definitely’ been seen
by an NHS mental health service often
enough for their needs, in the past 12
months.
• 88% of people who knew who managed
their care, said that this person organised
their care ‘very well’ or ‘quite well’.
Younger people (aged 18 to 35) reported
worse than average experiences across
multiple areas of care. Out of the 18
themes analysed, younger people reported
worse than average experiences in 12
areas.
In line with previous survey years,
findings showed that people with
challenging and chaotic non-psychotic
disorders reported worse than average
experiences of care across multiple areas.
In contrast, those with a diagnosis
of first episode psychosis consistently
reported better than average experiences
in most themes.
Findings showed that people who
received care via telephone reported
worse than average experiences.
This was found across seven of the 18
themes analysed. People who received
care face-to-face or via video call reported
better than average experiences across
multiple themes.
The survey results have been released
for providers to review the experiences of
people who use their services and to make

Key negative results
31% 40%
had not been had not had a care review
told who is meeting with someone from
in charge of community mental health
their care services in the last 12 months
improvements where needed.
The CQC will continue to use the findings
as part of its wider monitoring of the
quality of mental healthcare in England.
Reaction
Chris Dzikiti, director of mental health at
the CQC, said: “It is hugely concerning that
we have seen year-on-year deterioration
in people’s experiences of NHS community
mental health services.
“We have seen how services can adapt
rapidly to deal with extreme pressure,
but sadly these are only likely to increase,
with typical seasonal pressures amplified
by COVID-19 and a cost-of-living crisis that
could impact on people’s mental health.
“Poor access to services risks people
reaching crisis point, leading to being
admitted to environments that don’t
support their recovery and risk their
mental health deteriorating.
“Longstanding issues need urgent
action and innovative planning for the
future, and better integration with other
Key positive results
96%
said they knew how to
contact the person who
was in charge of organising
their care
88%
said the person that
organised their care did so
‘very well’ or ‘quite well’
45%
were not always
given enough time
to discuss their
needs
supporting services and systems to ensure
people get the right care at the right time.
“We know staff are doing all they can to
provide good care and it is encouraging
to see some improvements being made,
however, we need to address these issues
urgently to ensure people get the support
they need.”
Dave Munday, Unite in Health lead
professional officer, said: “The government
had an opportunity to address deep
problems in the NHS, caused by 12 years of
mismanagement, at the recent economic
statement. The chancellor, in a past life,
argued about the importance of safe
staffing with a view to the medium and
long term. Unforunately now he has the
levers to make much-needed changes in
his hands, he has spectacularly failed to
pull them.
The NHS is on life support and with
proper pay and funding it may not survive.
This is why NHS workers are standing up:
Follow MHNA on social media
Stay informed online through the MHNA’s social media connections.
Facebook:
http://www.facebook.com/
UniteMHNA
December 2022/January 2023 MENTAL HEALTH NURSING
NEWS FEATURE
28%
would not know who
to contact out of office
hours in the NHS if
they had a crisis
they know that decent pay is essential to
the service’s future.
“We welcome the clear recognition from
the CQC’s director of mental health and
wholeheartedly agree that mental health
services and staff are at breaking point,
with staffing shortages affecting people’s
care and putting safety at risk. Further
we join in demanding again that there is
longer-term national workforce planning
in mental health nursing.
“We know that austerity did so much
damage to mental health service and
to the people that desperately need to
access them. To set course on austerity
again is deeply devastating and the wrong
approach.”
More information on the 2022
Community Mental Health Survey,
including results for all 54 providers and
the summary report, can be seen at: https://
www.cqc.org.uk/publications/surveys/
community-mental-health-survey. n
Twitter:
http://twitter.com/Unite_
MHNA (@Unite_MHNA)
9
 BLUE SPACES
Blue spaces:
Water, wellbeing and
mental health
T
he COVID-19 pandemic spate
of multiple lockdowns saw
a wave of immense societal
claustrophobia and adverse mental
wellbeing where humans reached out
in huge numbers, to nature, and in
particular to water, for solace.
Nature-connection values have
since been strongly reinforced
(Lu et al, 2021; Labib et al, 2022).
This commentary offers a brief
contextualisation of ‘blue space’
wellbeing and gives an overview of the
mental health benefits associated with
it.
Blue spaces and wellbeing
Water environments account for 71%
of the planet’s surface; 96% of which
are made up of saltwater oceans and
seas (US Geological Survey, 2019).
‘Blue space’ is a term used to
describe all natural surface waters
(Volker and Kistemann, 2011), although
some argue, validly, for the inclusion
of man-made features such as canals,
swimming pools, spas, thermal baths
and fountains as part of a wider
definition.
In essence, ‘blue space’ denotes the
presence of water. While often taken
for granted as a just a backdrop to
leisure and wellbeing, oceans, seas,
lakes and rivers are, in fact, often
pivotal in human health, as emerging
research is beginning to show.
Blue spaces are also now being
linked to wellbeing in a more proactive
and co-creative manner.
10 MENTAL HEALTH NURSING December 2022/January 2023
Catherine Kelly
They can be framed as ’therapeutic
landscapes’ (Gesler, 1992), where our
physical, psychological, and social
wellbeing parameters are improved.
For several decades, research has
focused on the importance of nature,
or green spaces, in human wellbeing
(Mitchell and Popham, 2007; Maas et al,
2008; White et al, 2013). Seminal work
by Ulrich et al (1991), demonstrated the
positive psychological effects that even
views of nature can create.
Ecotherapists addtionally refer to
the concept of ‘soft fascination’ – the
brain-calming effects of the textures of
nature (Hinds and Jordan, 2016).
Walking barefoot on grass or sand,
touching a tree bark, or noticing
the dappled light as the sun shines
between leaves in a forest all
contribute to a sense of wellbeing in
our bodies and minds.
Historically, specific blue spaces have
gained long-standing reputations for
healing or wellness, including ‘sacred’
springs, holy wells, Eastern European
terme (thermal baths), Greek, Roman
and Turkish baths, Japanese onsen and
the Scandinavian penchant for mixing
hot saunas with ice water dips (Foley
2011; Bell et al, 2015).
Gesler’s work on therapuetic
landscapes began, in fact, with a
study at Lourdes in France, thereby
mixing the spiritual with the physical/
psychological. The term is used widely
now by various disciplines to denote
natural spaces that improve our
wellbeing.
A complex picture
In more recent years, focus has turned to
blue spaces and the ways in which water
can improve our health and wellbeing.
However, blue spaces are complex
to research, regulate and direct policy
for, as they fall under the remit of
multiple sectors. They are governed by
environmental departments, marine
or inland waterway agencies, tourism,
leisure and sport organisations,
and more recently public health
and wellbeing sectors. This creates
difficulties in terms of a synergistic
approach to their study, use and
management.
A plethora of concerns abound across
these fields – water quality, pollution,
physical access, trespass, fitness, socio-
cultural access and mental health.
The challenges lie in a cross-sectoral
partnership approach to maximise blue
space sustainable use for wellbeing and
long-term inclusive engagment.
Several EU-funded research
programmes have examined the role of
blue spaces from multiple perspectives
in the last decade or so.
Horizon 2020 funded a ‘Blue Health’
programme at the UK’s University of
Exeter (with mulitple EU partners),
which was led by researchers at the
European Centre for Environment and
Human Health.
It focuses on environmental
psychology, blue infrastructure,
landscape planning and the ways in
which ‘blue’ environments can be used
to improve health and wellbeing.

The growth of this genre of work is
gaining momentum year on year as
policymakers and user groups call for
more evidence on the relationships
between human wellbeing and these
valued water environments.
Yet another focus of research comes
from the physiological benefits of
water, particularly outdoor (cold water)
swimming.
The University of Portsmouth in the
UK conducts research where the specific
physical health benefits of water are
examined in a scientific manner (van
Tulleken, 2017; Tipton et al, 2018).
A current National Institute for Health
and Care Research (NIHR) project is
also under way using a randomised
controlled trial approach to investigate
the relationship between depression and
cold water swimming.
As more and more evidence-based
research emerges, the opportunity for
trusts, GP services and the public health
sector to become involved increases.
The EU’s recent Horizon 2020 research
programme, for example, also provided a
large funding call for projects to ‘develop
nature-based therapy for health and
wellbeing’. It called for new work that
would ‘develop a common framework
to increasingly recognise and promote
contact with nature, including protected
areas and other green and blue spaces,
as a cost-effective response for the
prevention and treatment of human
health and wellbeing’.
It also acknowledged that multiple
types of scientific expertise are needed,
‘in both health and natural sciences, as
well as social sciences and humanities,
together with a variety of community
and health sector representatives,
businesses, civil society organisations
and citizens’ (Horizon Programme, 2022).
Spanning sectors
Work on nature-based/blue spaces
policy and guidance to date in the UK
spans across various sectors, from the
broad sweep of public health economics
programmes, to work by mental
health charities, Natural England, the
New Economics Foundation and the
traditional Environment Agency, which is
now turning to a wider conceptualisation
of water and wellbeing.
In the past, this government agency
framed water and health in the realm of
water quality/pollution/bacteria, or flood
defences as default health indicators –
but has recently set up a new national
think-tank, the Blue Spaces Forum,
to gather lived experiences on the
relationships between health, wellbeing,
equality and access to water.
The panel comprises nature-based
and water government agencies and
departments, academics, water-user
groups, charities representing disability
and health, and cultural diversity groups,
all with the aim of better informing
the government departments on policy
changes that are needed as the world we
live in changes.
It is critical that issues of blue
space access – both physical, cultural,
socioeconomic and legal – are examined
in a joined-up manner, for the benefit
of all. Change is therefore afoot in the
research world of blue spaces.
Benefits of blue spaces
There is a general concensus that
‘wellbeing’ can be defined and measured
in many different ways, for different
purposes and across different cultural
contexts (Smith and Kelly, 2008; New
Economics Foundation, 2011; Office for
December 2022/January 2023 MENTAL HEALTH NURSING
BLUE SPACES
Pexels from Pixabay
National Statistics, 2013; Department of
Health, 2015).
Blue space engagement is particularly
beneficial for ‘salutogenic wellbeing’,
where the focus is on activities and
behaviours that improve or maintain
our general balance of physical,
psychological and social or spiritual
wellbeing with the aim of preventing ill
health.
Research shows us that blue spaces
impact our wellbeing in three main
areas: physcial, psychological and social
(Tipton et al, 2017; Harper, 2017; Denton
and Aranda, 2019; Kelly, 2021).
When we run, walk or swim, surf
beside/in water our cardiac health
improves, as with most forms of
exercise. Water is the preferred human
environment to walk, run or sit beside
– its calming properties improve our
psychological health too.
Our breathing slows down and our
negative stress hormones, adrenaline
and cortisol reduce, while our positive
serotonin and dopamine hormones
increase (Nichols, 2014; Kelly, 2021)
Wallace J Nichols’ seminal book ‘Blue
Mind’ (2014) examines the calm state of
mind that being in or near water induces
in the human brain. He speaks of the
creative mental space of ‘drift’ when we
look at the water, and the importance of
counteracting our everyday ‘red mind’
stress state.
11
 BLUE SPACES
“Water is the
preferred human
environment to
walk, run or
sit beside”
Research is beginning to point to the
anti-inflammatory properties of cold
water immersion. The vagus nerve is
stimulated and immersion in water
under 15 degrees for just three minutes
can cause a minor stress response in the
body, until breathing becomes regulated.
There is a concept called ‘cross-
adaptation’, where exposure to this
small, regular stressor, via cold water
swimming, and possibly cold showers,
allows us to feel more mentally strong,
and prepared to take on the stresses of
our daily lives after our regular cold
water exposure (Harper, 2022).
More research is needed but there are
examples of social-prescribing coming
into force in certain parts of the UK.
The Wave Project, a charity that offers
surf therapy for young people with
different disabilities, has been a huge
success story and is linked to health
services in the South West although it
operates across the country (Devine-
Wright and Godfrey, 2020).
A useful case study for reference is led
by the Devon Local Nature Partnership,
which runs initiatives based on the fact
that spending time in nature is proven to
benefit everyone’s health and wellbeing.
The Devon Naturally Healthy
initiative aims to link up the health and
environment sectors and ensure that
contact with nature is promoted as part
of a health and wellbeing service.
The initiative is led by a steering
group, chaired by North Devon GP Dr
James Szymankiewicz, while day-to-day
work is led by Active Devon and Devon
County Council.
Organisations involved include GPs,
Devon Clinical Commissioning Group,
Devon County Council’s public health
team, National Parks UK, The Woodland
Trust, Devon Wildlife Trust, areas of
12 MENTAL HEALTH NURSING December 2022/January 2023
outstanding natural beauty, the National
Trust, local authorities and interested
small naturally healthy providers across
Devon (Devon Local Nature Partnership,
2022). It is an excellent example of
collaborative practice, and shows the
need to look outside the mental health
field for interventions and action.
What does the future hold?
Blue space therapies – from activities
next to, as well as immersed in, water,
are gaining ground.
The research evidence is building.
Alongside that are the very valid and
self-reported evaluations of humans just
feeling better when they are in or by
water.
The mental health sector must find
ways to join with other partnerships
outside the traditional realm of its own
field and practices in order to explore
opportunities.
Acknowledgment must be made
however, of a spectrum of blue space
health interventions. A wide range of
References
Bell SL, Phoenix C, Lovell R, Wheeler BW. (2015) Seeking
Everyday Wellbeing: The Coast As A Therapeutic Landscape.
Social Science and Medicine 142. 56-67.
Department of Health. (2014) Wellbeing – Why It Matters To
Health Policy? Available at: https://www.gov.uk/government/
uploads/system/uploads/attachment_data/file/277566/
Narrative__January_2014_.pdf. UK Government (Accessed 1
August 2022).
Devine-Wright H, Godfrey C. (2020). The Wave Project:
Evidencing Surf Therapy for Young People in the UK. Global
Journal of Community Psychology Practice 11(2): 1-15.
Foley R. (2011) Performing Health in Place: The Holy Well as a
Therapeutic Assemblage. Health Place 17: 470-9.
Gesler W. (1992) Therapeutic Landscapes: Medical Issues In The
Light of the New Cultural Geography. Social Sciences and
Medicine 34: 735-46.
Harper M. (2022) Chill: The Cold Water Swim Cure – a
Transformative Guide to Renew Your Body and Mind.
Chronicle Books: San Francisco.
Harper M. (2017) The Healing Madness of Sea-Swimming.
Head Talks. Available at: https://www.youtube.com/
watch?v=0pXLF0sucDU (Accessed 1 August 2022).
Hinds J, Jordan M. (2016) Ecotherapy: Theory, Research and
Practice. Palgrave: London.
Horizon 2020. (2021) Developing nature-based therapy for
health and well-being. Horizon Europe – Work Programme
2021-2022. Division of Food, Bioeconomy, Natural Resources,
Agriculture and Environment. European Commission:
Brussels.
Kelly C. (2021) Blue Spaces: How and Why Water Can Make You
Feel Better. Welbeck: London.
Labib SM, Browning MH, Rigolon A, Helbich M, James P.
(2022) Nature’s Contributions In Coping With A Pandemic In
The 21st Century: A Narrative Review Of Evidence During
COVID-19. Science of The Total Environment 155095.
Lu Y, Zhao J, Wu X, Lo SM. (2021) Escaping To Nature During A
Pandemic: A Natural Experiment In Asian Cities During The
COVID-19 Pandemic With Big Social Media Data. Science of
the Total Environment 777: 146092.
Maas J,Verheij R, Spreeuwenberg P, Groenewegen P. (2008)
Physical Activity As A Possible Mechanism Behind the
Relationship between Green Space and Health: A Multi-Level
Analysis. Public Health 8: 260-73.
Mitchell R, Popham F. (2007) Greenspace, Urbanity and Health:
Relationships in England. Journal of Epidemiology and
conditions exist along a continuum of
mental non-wellbeing, to severe mental
illness. Therefore a one-size fits all
approach is to be avoided.
In addition, there is a varied mix of
water experience, abilities and cultural
as well as physical, comfort levels
with water engagement. All must be
accounted for.
As we progress in this area, proper
training for outdoor swim therapists,
blue space practitioners and for mental
health professionals to be trained to
bring patients (and indeed, themselves)
to water will be paramount in allowing
the benefits of this healing medium to be
brought to those who need it most.
The time is right to bring blue space
wellbeing to wider mental health
audiences. n
Catherine Kelly is a senior lecturer at the
University of Brighton. She is the author
of the book ’Blue Spaces: How and
Why Water Can Make You Feel Better’
(published by Welbeck Balance, 2021)
Community Health 61: 681-3.
National Social Prescribing Network in England. (2019) Quality
Assurance for Social Prescribing. Available at: https://www.tcv.
org.uk/wp-content/uploads/2020/09/tcv-quality-assurance-
for-social-prescribing.pdf (Accessed 1 August 2022).
New Economics Foundation. (2011) Five Ways to Wellbeing.
New Economics Foundation: Sussex. Available at: http://
neweconomics.org/projects/five-ways-well-being (Accessed 1
August 2022).
Nichols WJ. (2014) Blue Mind: the surprising science that shows
how being near, in, on or under water can make you happier,
healthier, more connected and better at what you do. Little,
Brown and Co: New York.
Office for National Statistics. (2013) Measuring What Matters:
Understanding The Nation’s Wellbeing. Available at: http://
www.ons.gov.uk/ons/interactive/well-being-wheel-of-
measures/index.html (Accessed 1 August 2022).
Smith M, Kelly C. (2006) Journeys of the Self: The Rise of the
Wellness Tourism Sector. Tourism Recreation Research 31(1):
15-25.
Tipton MJ, Collier N, Massey H, Corbett J, Harper M. (2017)
Cold Water Immersion: Kill or Cure? Experimental
Physiology: 102(11): 1335-55.
Ulrich RS, Simons RF, Losito BD, Fiorito E, Miles MA, Zelson
M. (1991) Stress Recovery During Exposure to Natural and
Urban Environments. Journal of Environmental Psychology
11: 201-30.
US Geological Survey. (2019) How Much Water is There on
Earth? Water Science School. Available at: www.usgs.gov
(Accessed 1 May 2022).
Van Tulleken C, Tipton M, Massey H, Harper CM. (2018) Open
Water Swimming as A Treatment For Major Depressive
Disorder. British Medical Journal Case Reports. Available at:
https://doi.org/10.1136/bcr-2018-225007 (Accessed 1 August
2022).
Volker S, Kistemann T. (2011) The Impact Of Blue Space On
Human Health And Wellbeing – Salutogenic Health Effects
Of Inland Surface Waters: A Review. International Journal of
Hygiene and Environmental Health 214: 449-60.
White M, Smith A, Humphryes K, Pahl S, Snelling D, Depledge
M. (2010) Bluespace: The Importance of Water for Preference,
Affect, and Restorativeness in Ratings of Natural and Built
Scenes. Journal of Environmental Psychology 30: 482-93.
White MP, Pahl S, Ashbullby K, Herbert S, Depledge MH. (2013)
Feelings of Restoration from Recent Nature Visits. Journal of
Environmental Psychology 35: 40-51.
 The Awards
2023
Recognising clinical
excellence in nursing

Do your colleagues deserve

recognition for their clinical practice?

ENTER NOW
To view categories and ENTER NOW
visit www.bjnawards.co.uk
or scan QR Code

Sponsored and supported by

National Infusion and

Vascular Access Society

24th March 2023

Banking Hall | 14 Cornhill | London EC3V 3ND
For more information: nurseledconferences@markallengroup.com
 SELF-HARM
Nursing attitudes to people
with borderline personality
disorder who self-harm:
a literature review
Kennedy Brown Lecturer in mental health nursing, University of Huddersfield
Abstract
Borderline personality disorder,
also known as emotionally unstable
personality disorder, is a mental health
epidemic, with more and more service
users being admitted or referred to
hospital under crisis. Negative nursing
attitudes can have a distressing and
detrimental impact on service users
and treatment success. This literature
review examined current research to
attempt to understand what attitudes
nursing staff have towards borderline
personality disorder and self-harm,
how this impacts on care provided
and the effect it has on nursing staff
performance. The literature review
incorporated both quantitative and
qualitative research. Four themes
emerged after using interpretative
phenomenological analysis: 1. Training
and support; 2. Negative attitudes
and outlook; 3. Paucity of knowledge/
stigma; 4. Emotional strain. The themes
gave an understanding of nursing
attitudes in this context. Appropriate
education and training on working with
borderline personality disorder and
self-harm improved attitudes and the
clinical pathway.
Key words
Borderline personality disorder,
emotionally unstable personality
disorder, self-harm
Introduction
Service users who self-harm and have
a diagnosis of borderline personality
disorder/ emotionally unstable personality
disorder (BPD/EUPD) require complex
intensive and unique support, therefore
understanding nursing staff attitudes
14 MENTAL HEALTH NURSING December 2022/January 2023
towards this is imperative for the best care
and recovery outlook.
Nursing attitudes towards treating self-
harm and borderline personality disorder
in an inpatient setting have consistently
been found to be negative, affecting the
care service users receive, and few pieces of
research have found staff to have positive
attitudes (Shaw and Sandy, 2016; Hodgson,
2016).
Dickens et al (2016) found that nursing
staff responses when treating service users
was counterproductive and stated further
observational research is essential to clarify
the link between attitudes and clinical
practice. Furthermore, negative attitudes
are more likely to lead to non-compliance
toward treatment and impulsiveness in
behaviour (Shaikh et al, 2017).
Loader (2017) articulated how the
negative nursing staff attitudes when
working with service users leads to a
nihilistic approach, increasing the chance
of malpractice, errors and unprofessional
behaviour.
Loader stated that positive attitudes
can improve services user outcomes and
support during a crisis. The understanding
nursing staff have with service users
appears to influence the level of optimism
and hope they hold regarding the care
provided and their potential recovery
(Westwood and Baker, 2010).
With the current pressures within NHS
accident and emergency departments,
we need to understand how best to help
service users with BPD/EUPD.
A&E nursing staff have reported
frustration and a lack of understanding
on working with patients who self-harm,
highlighting negativity towards these
presentations and a perception that it
is an ‘ingenuine’ (Pawaskar et al, 2022).
Self-harm is heavily prevalent in those
diagnosed with BPD/EUPD.
Research has found negative attitudes
present in nursing staff. However, it is not
clear what these consist of and how staff
feel they could overcome the negative
perceptions.
It has been noted that some nurses will
distance themselves from service users,
becoming withdrawn and providing poor
care (Weight and Kendal, 2013).
Understanding why negative attitudes
occur for treating people diagnosed with
BPD/EUPD could reduce pressure on
staff, decrease the chance of attrition,
and potentially facilitate a recovery
focused approach and positive therapeutic
relationships.
Methodology
For this literature review a search was
conducted systematically, then the papers
identified were analysed for common
themes and knowledge gaps, and to
highlight areas for future research. The
inclusion criteria when selecting articles
included being peer-reviewed, focused
on BPD/EUPD and being set in a hospital
A&E or acute psychiatric inpatient ward.
Research that involved student nurses or
training nursing associates was included.
 SELF-HARM

Due to self-harm being significantly Table 1. Search terms used

present within services users in crisis in Search Search term Papers Papers meeting
hospital and A&E, research articles that engine retrieved inclusion criteria
look at self-harm within BPD/EUPD were
PubMed Nursing staff AND attitudes AND “borderline 37 37
also reviewed.
personality disorder” OR EUPD AND “self-
The exclusion criteria for articles used harm” AND “inpatient” OR “accident and
within the research included papers not emergency”
originally published in English, articles that
CINAHL Nursing staff AND attitudes AND “borderline 32 32
needed to be paid for (due to budgetary personality disorder” OR EUPD AND “self-
constraints) and articles involving patients harm” AND “inpatient” OR “accident and
who did not stay overnight in hospital. emergency”

The Boolean searches were (“psychiatric
staff OR “nursing staff’) AND (“attitudes
OR perceptions”) AND (“borderline
personality disorder” OR “emotionally
unstable personality disorder” OR EUPD”)
AND (“inpatient” OR “emergency room”
OR “accident and emergency”) AND (“self-
harm” OR “deliberate self-harm”).
All studies included in the final analysis
were subject to the Critical Appraisal Skills
Programme (CAPS) tool to ensure studies
were of the appropriate quality. The use
of the CASP tool resulted in a structured
approach to assessing the rigour of studies
being reviewed (Smith and Noble, 2015).
The CASP tool was originally developed
for health-related research and is deemed
to be an effective measure of research
practice (Long et al, 2020). Research used
for this study had to comply with the strict
criteria on top of the inclusion and the
Cochrane Nursing staff AND attitudes AND “borderline 1 1
personality disorder” OR EUPD AND “self-
harm” AND “inpatient” OR “accident and
emergency”
range of geographical locations as location Using the guidance of Smith et al (2008),
was not an exclusion criterion. interpretative phenomenological analysis
As stated in the inclusion criteria, the (IPA) was used for a qualitative research
study must be conducted on an inpatient analysis in order to develop themes and sub
ward or an overnight stay in accident and themes.
emergency. One study involved people A benefit of using IPA is that it is a
who work with female offenders but valuable methodology for examining topics
on a psychiatric ward, so this study was that are complex, unclear and emotionally
included. Otherwise, the studies were in laden (Smith and Osborn, 2014). IPA was
either accident and emergency settings or used by creating themes with common
acute psychiatric inpatient wards. phrases used throughout the research
Figure 1. PRISMA flow diagram
Records identified Additional records
through database identified through other
searching (n=70) sources (n=0)
Identification

exclusion criteria.
Cochrane, CINAHL and PubMed were
used in the literature search, as these have
Records after duplicates removed (n=69)
been determined as suitable (Cooper et al,
2018). Table 1 shows the terms used when
searching for the research papers used
Records screened Records excluded
Screening

within the final analysis. Figure 1 shows the (n= 69) (n= 58)
PRISMA flow chart for the literature review.

Results Full-text articles Full-text articles

assessed for eligibility excluded, with reasons
Eligibility

Of the seven pieces of research used for

(n=11) (n=4) Didn’t fit criteria
this current research, five were qualitative
and two were quantitative. Three of the
qualitative studies used a semi-structured
Studies included in
interview or interview technique and the qualitative synthesis
remaining two used a focus group-based (n=5)
Included

interview. All three of the quantitative

reviews used questionnaires.
All the papers reviewed involved Studies included in
primary research. The seven studies used quantitative synthesis
(meta-analysis) (n=2)
include registered and student nurses. The
reviewed papers used came from a wide

December 2022/January 2023 MENTAL HEALTH NURSING 15

 SELF-HARM

Table 2. Summary of the qualitative journal papers used

Authors Sample Sample Methods Outcomes

Koning K, Emergency Department
McNaught A, Staff Beliefs About
Tuffin K. (2017) Self-Harm: A Thematic
Framework Analysis
Emergency department
staff were recruited using
a poster requesting that
interested participants
contact the lead
researcher
Interview questions
including: Could you tell
me about the sorts of self-
harm you have observed,
or worked with in the past?
Qualitative based study
Five major themes:
A Release or Way of Coping, A
Way of Asking for Help, A Way of
Gaining the Attention of Others,
In Response to Social Isolation, As
an Escape

Thomas J, How people who self-harm
Haslam C. (2017) negotiate the inpatient
environment: the mental
healthcare workers’
perspective
Ten mental healthcare
staff with an age range
from 23 to 31 (8 females
and 2 males) and
experience of working in
an inpatient environment
A qualitative method. An
interview schedule was
designed with open ended
questions. The schedule was
tested in a pilot interview
and modified based on the
feedback.
Participants described that when
unable to self-harm, service users
were observed to experience
increased/continued distress as
a result of not being able to self-
harm. The increased/continued
distress was not understood and
managed well, service-users would
be motivated to find another way
to manage their distress

Warrender D, Student nurse perceptions Second year pre- Data collection took place in Three main themes: placement
Macpherson S. of experiential learning to registration mental health meeting rooms within the experiences, perceptions of
(2018) understand personality nurses, 25 students university in single sessions teachings, implications of practice
disorder participated in the which lasted between 30
session and 60 minutes. Discussions
were digitally recorded then
transcribed verbatim and,
while transcripts were not
handed back to participants
for comment or correction

Warrender D. Staff nurse perceptions
(2015) of the impact of
mentalization-based
therapy skills training when
working with borderline
personality disorder in
acute mental health: A
qualitative study
9 staff nurses participated
in the study. A purposive
sample was identified as
RMN’s, working across
4 acute mental health
wards in 1 hospital,
having completed the
training with at least
6 months to use the
approach in clinical
practice
Through 2 focus groups
this study assessed the
perceptions of 9 staff
nurses. An interpretive
phenomenological
approach was utilised in
data analysis.
Participants found the approach
easy to grasp, improving of
consistency between staff and
flexible in its use in planned or
‘off the cuff’ discussions. Training
promoted empathy and humane
responses to self-harm, impacted
on participants’ ability to tolerate
risk and went some way to
turning the negative perception
of BPD. Staff felt more confident
in working with people with a
diagnosis of BPD

Moore E, Working with women
Andargachew S, prisoners who seriously
Taylor P. (2009) harm themselves: Ratings
of staff expressed emotion
On the healthcare unit,
6 nurses, 4 healthcare
assistants and 10 prison
officers were thus
eligible; and on the
detox unit, 4 nurses, 2
assistants and 9 officers
A semi structured interview
lasting up to 1.5 hours
about his/her experiences
of working in the prison,
and of suicidal behaviour in
particular. After describing
this, each participant was
asked to think of an inmate
who had attempted suicide
or harmed himself/herself in
some way that made this a
plausible assumption
Staff opened with a comment
about the prisoner, which was
neutral to negative, but not critical
in tone (eg ‘she is a very mixed-
up person’), but then, after a
description of initial difficulties in
establishing a relationship, there
was evidence of warm and positive
remarks

papers, and they were noted within the
margins.
Papers were read and re-read to highlight
any emerging ideas that may have been
missed. Themes emerged and links could be
seen between the different research papers.
Table 2 shows summaries of the
qualitative research papers used, while
Table 3 shows the quantitative papers.
Theme 1: Training and support
The need for training for nursing staff and
the lack of support for nursing BPD and self-
harm frequently was mentioned by staff, so
this was developed to be a main theme.
Having specific training was described
as being able to understand BPD/
EUPD and deliberate self-harm. Having

16 MENTAL HEALTH NURSING December 2022/January 2023

 SELF-HARM

Table 3. Summary of the quantitative journal papers used

Authors Sample Sample Methods Outcomes

Commons Professional 40 registered health practitioners
Treloar A, Lewis Attitudes Towards across two Australian health
A. (2008) Deliberate Self- services. Mental health and
Harm in Patients emergency department staff
With Borderline of these health services were
Personality asked to participate if in the
Disorder course of their employment
they encountered patients
diagnosed with BPD. The cohort
of participants in this study
included 48 men and 92 women.
Statistical analysis was performed
using SPSS. Participants were
provided with a purpose-
designed demographic
questionnaire. No identifying
information was collected. The
participants also completed the
Attitudes Towards Deliberate Self-
Harm Questionnaire.
There was a significantly higher
attitude score among the
nursing participants who had
received training. Emergency
medicine clinicians see BPD
patients following episodes of
self-harm and this may result
in such professionals having a
greater difficulty in maintaining
an empathetic attitude to such
patients

Giannouli H, Attitudes, Nurses (n=127) in 15 psychiatric The 23-item questionnaire of As for the staff’s attitudes towards
Perogamvros L, knowledge and wards. Overall, 69 of 127 nurses Cleary et al (2002) was used services that treat BPD patients,
Berk A, Svigos A, experience of answered the questionnaire in this study, with the authors’ the belief that their management
Vaslamatzis G. nurses working (response rate 54.3%). permission. It was translated and is inadequate is dominant.
(2009) in psychiatric adapted to the Greek population Respondents believe that they play
hospitals in by the researchers. Questions an important role in the patients’
Greece, regarding about their education regarding management (72%). The staff’s
borderline BPD, the frequency with which specialised education on BPD of
personality they come into contact with the staff in general is evidently
disorder: a clients with BPD and their opinion small (4.3%)
comparative study regarding the competence in
managing people with BPD

specific training allowed the staff to feel
less frustrated due to the self-inflicting
nature of the presentation (Koning et al,
2017). A sub-theme was staff seeking out
specific training as development for their
professional career. Nurses who had
received specific training for working with
people diagnosed with BPD/EUPD and
self-harm became part of the pathway for
referral, for example:
“...assess their injuries, ensure that
they’re safe and treated, and then make
sure they’re seen by someone with more
extensive training in mental health
support”. (Koning et al, 2017: 818)
After receiving specialist training, nurses
reported a significantly more positive
attitude:
“Such training is more effective for
nursing and medical clinicians, who
showed significant improvement in their
attitude ratings if they had attended
training” (Commons Treloar and Lewis,
2008: 583).
In light of this, it was explained that it
empowered nurses to look at the situation
as a whole after receiving training:
“I think it makes it less frustrating, if you
can kind of sit back and think about why
the person is doing it” (Warrender 2015:
629).
Despite this link between a change in
attitude from training, some research
is suggesting less than 5% of the nurses
involved in a study receive specific training
for working with service users diagnosed
with BPD (GiannouliI et al, 2009).
Theme 2: Negative attitudes and outlook
Nurses showing negative attitudes and
perceptions was also found to be common.
The sub-themes developed from this theme
reflect phrases and actions the nursing staff
voiced:
“...the great majority of nurses (85.5%)
believe the management of patients with
BPD is moderate to difficult, while 65.2%
perceive it to be more difficult than other
disorders” (GiannouliI et al, 2009: 483).
“I found it frustrating seeing the same
patients multiple times, it is something I still
struggle with” (Koning et al, 2017: 818).
In their study Koning et al (2017)
developed “a way of getting attention” as
a main theme. They explained how staff
members who see deliberate self-harm
as negative attention seeking then act
negatively towards the service user:
“...minor things that is going to cause/
need treatment, kind of timewasting type
stuff from our point of view, versus you
know, legitimate stuff” (Koning et al, 2017:
819).
Nursing staff involved would often use
negative and unhelpful language when
talking about their experience of working
with people diagnosed with borderline
personality disorder:
“She is dangerous, extremely dangerous,
a polydrug user and manipulative – she
knew others were ill and would pull
attention to herself...” (Moore et al, 2011:
73).
Commons Treloar and Lewis (2008)
found that 75% of nursing staff state that
self-harming behaviour in their patients
was difficult to manage. Significantly, 65%
of the sample also reported that they found
it difficult to build a relationship with
clients who self-harm.
Staff who work in A&E had statistically
lower scores on a questionnaire looking
at attitudes compared with psychiatric
nursing staff (Commons Treloar and Lewis,
2008). Negative attitudes including using
words such as ‘manipulative’, ‘impulsive’,
‘dangerous’ and ‘attention-seeking’.
Service users are aware of the negative
attitudes nursing staff have and it can have
an impact on service users’ behaviour and
recovery:
“Sometimes responses from staff can
be quite punitive, then they can maintain

December 2022/January 2023 MENTAL HEALTH NURSING 17

 SELF-HARM
the behaviours and maintain the distress”
(Thomas and Haslam, 2017: 485).
Theme 3: Paucity of knowledge/stigma
Sub-themes developed from the main
theme, for example the paucity of
knowledge surrounding borderline
personality disorder, led to the
development of the sub-themes: attitudes
leading to a reduced sympathy and
empathetic approach for the service
users from the nursing staff and also
manipulative behaviours from service
users.
A lack of understanding led to reduced
compassion and empathy from nursing
staff, yet with time and knowledge the
opinion of nursing staff can change:
“Well since working here. Like I used to
think that they were pretty much a waste
of space, but ...hearing some of the story, I
guess it does feel that there is no other way
out for some people. I think it is pretty sad”
(Koning et al, 2017: 818).
GiannouliI et al (2009) highlighted that
less than 50% of nursing staff working in
either a psychiatric hospital or clinic felt
confident in treating patients with BPD.
Nurses reported that they see behaviours
in a negative aspect and have negative
opinions due to being unaware of BPD:
“RMNs experience personal distress
in working with people diagnosed with
BPD, seeing their patients as demonising,
threatening, manipulating, time
consuming” (Warrender, 2015: 625).
Linked in with training and
manipulation, previous research has
attempted to look at how viewing BPD as
manipulative can be reduced:
“Clinicians who equate BPD patients
with acting manipulatively are reluctant
to engage with them ...there is evidence
that training and education can assist in
the improvement of professional attitude”
(Commons Treloar and Lewis, 2008: 583).
In contrast to this, one study based in
forensic settings found that staff have
increased empathy for service users:
“...and to empathise with them, with staff
making attributions about self-harm and
suicide as an expression of frustration or
distress, which was not under the service
users’ control” (Moore et al, 2011: 68).
18 MENTAL HEALTH NURSING December 2022/January 2023
Theme: Emotional strain
The emotional strain of nursing service
users diagnosed with BPD and deliberate
self-harm was found to be a significant
issue. There was a sub-theme of staff
fearing treating self-harm due to the
uncertainty, along with being unsure what
to say to a patient who has self-harmed.
It appears that staff who are working
with service users on a ward often distance
themselves from service users who
engage in impulsive behaviour, although
it is uncertain if this is subconsciously or
consciously:
“Staff relationships with patients who
communicate distress through suicidal
behaviours are often characterised by
emotional distance and hostility, which can
lead to ‘malignant alienation’” (Moore et al,
2011: 64).
Within the research staff have been
found to struggle with what to say to service
users without leading the service users to
further distress. Staff seek to control the
deliberate self-harm of service users as
they want to keep them safe, however this
can result in staff counter-productively
increasely risk (Thomas and Haslam, 2017).
In having negative attitudes towards
service users, clinicians experience a range
of mixed emotions causing them distress
and inner conflict, which predisposes them
towards an absence of empathy (Commons
Treloar and Lewis, 2008).
Discussion
In the studies reviewed, it is evident
that negative nursing attitudes are still
very prominent within the nursing staff
environment. Key words/phrases such
as ‘manipulation’ and ‘attention-seeking’
are spoken by nursing staff, and there are
perceptions of poor recovery.
The negative attitudes of nursing staff
have a direct impact on service users’ care,
and the service users are aware of how
staff feel. The emotional strain on nurses
of working with people diagnosed with
BPD and deliberate self-harm is evident to
nursing staff, but seeking support seems
sparse.
Staff fear working with service users
whom self-harm as they feel unsure about
what to say as they do not want to make
situations worse, and because of the impact
it has on the staff.
Nursing in general still has a lack of
knowledge of BPD/EUPD, and although
nurses have a good understanding of
self-harm they struggle to understand
why service users repeatedly engage
in self-harming behaviours. This lack
of knowledge leads to a greater stigma
attached to BPD/EUPD and deliberate self-
harm. There is a stigma suggesting that
service users are ‘attention-seeking’ and
‘playing games.’ Service users receive less
empathy and compassion from nursing
staff due to their poor knowledge.
The review found that nurses in all
care contexts actively seek out education
surrounding BPD/EUPD and deliberate self-
harm, but no specific training course has
been developed nationally in the UK.
Nursing staff who received specialised
training in BPD and deliberate self-harm
had a reduction in negative attitudes and
provided better care for service users
(Koning et al, 2017; Warrender, 2015;
Commons Treloar and Lewis, 2008).
In addition, Karman et al (2014) found
that training changes staff attitudes and
perceptions, so they become motivated to
work with service users.
Negative attitudes of nursing staff were
the main theme in this research. The
studies used show that nursing attitudes
towards working with the service users is
negative Koning et al, 2017; Moore et al,
2011).
In support of this, other research has
highlighted the negativity found among
staff when working with service users
with BPD/EUPD, with service users being
considered to be ‘time-wasters’, and
following this service users are less likely to
seek out support (Hodgson, 2016; Shaw and
Sandy, 2016).
Likewise, a correlation study has found
a positive correlation between nursing
staff attitudes and the impact of care on the
service users who self-harm (O’Connor and
Glover, 2016).
A lack of knowledge and understanding
was developed into a main theme due to
consistent reports of staff being unsure
of how to help a service user or being
unaware of what to say (Warrender, 2015).

In support of this, Loader (2017)
explained how a lack of understanding
and knowledge lead to defensive nursing
practice. A lack of knowledge leads to staff
viewing behaviours such as self-harm as
manipulative and time-wasting, and leads
nurses to have lower levels of optimism for
client recovery (Weight and Kendal, 2013).
The emotional strain of nursing service
users with BPD/EUPD and deliberate
self-harm was significantly prominent
throughout the analysis.
Nurses were noted to be consciously
distant from service users who disclose
distressing information (Moore et al, 2011).
This is supported by O’Connor and Glover
(2016), who found that staff were ‘fearing
the harm of self-harm’. This could be due
to the burnout and fatigue associated with
working with deliberate self-harm, or their
lack of understanding around why service
users behave this way (Pintar Babic et al,
2020).
Limitations
Using IPA to develop themes can be
biased by one’s own personal beliefs and
opinions. It has been understood that the
writer conducting IPA can be an obstacle
in making sense of the evidence gathered
(Peat et al, 2018).
Another limitation of this study is
the personal experience to carry out a
literature review. It was the first time the
author had undertaken a literature review
using completed primary research, so being
a novice researcher may have limited the
findings. However, due to the amount of
literature and evidence of statements used
within the paper, the author feels that
arguments are supported and justified.
While some of the research articles
mentioned in this paper are dated, it was
felt the significance of the findings needed
to be discussed and explored more into a
literature review. Understandably there
may be more up-to-date research since the
paper was written. The highly negative
perception around BPD and DSH from
these articles remains unmissable.
Finally, the implications and
recommendations made may be limited
due to funding and abilities of specific NHS
trusts.
Conclusion
From this literature review it is evident
that some nursing staff are still unsure
about working with service users with
BPD/EUPD due to their own personal fears
and frustrations.
Unfortunately, there is a lack of evidence
from papers identifying what training
those nurses received, which makes it
more difficult to understand what causes a
change in attitude and perception.
From conducting and completing the
study of nursing attitudes and perceptions
in BPD and self-harm, it is disappointing to
see such negative attitudes from healthcare
professionals.
For personal and professional
development of practice, it is imperative to
reduce stigma and improve patient-centred
care to prevent negative and potentially
avoidable incidents from occurring.
It is evident that more research needs
to be conducted observationally in order
to establish the behaviours nursing staff
References
Commons Treloa A, Lewis A. (2008) Professional Attitudes Towards
Deliberate Self-Harm in Patients With Borderline Personality
Disorder. New Zealand Journal Of Psychiatry 42(7): 578-84.
https://doi.org/10.1080/00048670802119796.
Cooper C, Booth A, Varley-Campbell J, Britten N, Garside R. (2018)
Defining the process to literature searching in systematic reviews:
a literature review of guidance and supporting studies. BMC
Medical Research Methodology 18(1). https://doi.org/10.1186/
s12874-018-0545-3.
Dickens G, Lamont E, Gray S. (2016) Mental health nurses’
attitudes, behaviour, experience and knowledge regarding adults
with a diagnosis of borderline personality disorder: systematic,
integrative literature review. Journal Of Clinical Nursing 25(13-
14): 1848-75. https://doi.org/10.1111/jocn.13202.
Giannouli H, Perogamvros L, Berk A, Svigos A, Vaslamatzis G.
(2009) Attitudes, knowledge and experience of nurses working in
psychiatric hospitals in Greece, regarding borderline personality
disorder: a comparative study. Journal Of Psychiatric And Mental
Health Nursing 16(5): 481-7. https://doi.org/10.1111/j.1365-
2850.2009.01406.x.
Hodgson K. (2016) Nurses’ attitudes towards patients hospitalised
for self-harm. Nursing Standard 30(31): 38-44. https://doi.
org/10.7748/ns.30.31.38.s44.
Karman P, Kool N, Poslawsky I, van Meijel B. (2014) Nurses’
attitudes towards self-harm: a literature review. Journal Of
Psychiatric And Mental Health Nursing 22(1): 65-75. https://doi.
org/10.1111/jpm.12171.
Koning K, McNaught A, Tuffin K. (2017) Emergency Department
Staff Beliefs About Self-Harm: A Thematic Framework Analysis.
Community Mental Health Journal 54(6): 814-22. https://doi.
org/10.1007/s10597-017-0178-8.
Loader K. (2017) What are the effects of nurse attitudes towards
patients with borderline personality disorder?. British Journal Of
Mental Health Nursing 6(2): 66-72. https://doi.org/10.12968/
bjmh.2017.6.2.66.
Long H, French D, Brooks J. (2020) Optimising the value of the
critical appraisal skills programme (CASP) tool for quality
appraisal in qualitative evidence synthesis. Research Methods
In Medicine &Amp; Health Sciences 1(1): 31-42. https://doi.
org/10.1177/2632084320947559.
Moore E, Andargachew S, Taylor P. (2011) Working with women
prisoners who seriously harm themselves: Ratings of staff
expressed emotion (EE). Criminal Behaviour And Mental Health
21(1): 63-74. https://doi.org/10.1002/cbm.795.
O’Connor S, Glover L. (2016) Hospital staff experiences of their
relationships with adults who self-harm: A meta-synthesis.
Psychology And Psychotherapy: Theory, Research And Practice,
90(3): 480-501. https://doi.org/10.1111/papt.12113.
December 2022/January 2023 MENTAL HEALTH NURSING
SELF-HARM
develop when having a negative attitude
towards treating BPD/EUPD and deliberate
self-harm.
In addition, the development of the
appropriate training scheme for nursing
staff is a must. However, before this
happens it is important to establish what
kind of education is needed.
Moreover, it would be of great benefit
to have more research conducted with
service users with BPD/EUPD who self-
harm, in order to identify the needs
required to aid recovery, to determine
how nursing staff can help or hinder this
process, and to provide the nursing staff
with the training to empower them in all
contexts.
Finally, it is imperative that the correct
nursing protocol for working with service
users diagnosed with BPD/EUPD and
deliberate self-harm is found to prevent
staff experiencing negative attitudes and
developing defensive practice, as this will
improve recovery for service users. n
Pawaskar R, Mahajan N, Wangoo E, Khan W, Bailey J, Vines R.
(2022) Staff perceptions of the management of mental health
presentations to the Emergency Department of a rural Australian
Hospital: Qualitative Study. BMC Health Services Research 22(1).
https://doi.org/10.1186/s12913-022-07476-7.
Peat G, Rodriguez A, Smith J. (2018) Interpretive phenomenological
analysis applied to healthcare research. Evidence Based Nursing
22(1): 7-9. https://doi.org/10.1136/ebnurs-2018-103017.
Pintar Babič M, Bregar B, Drobnič Radobuljac M. (2020) The
attitudes and feelings of mental health nurses towards adolescents
and young adults with nonsuicidal self-injuring behaviors. Child
And Adolescent Psychiatry And Mental Health 14(1). https://doi.
org/10.1186/s13034-020-00343-5.
Shaikh U, Qamar I, Jafry F, Hassan M, Shagufta S, Odhejo Y,
Ahmed S. (2017) Patients with Borderline Personality Disorder in
Emergency Departments. Frontiers In Psychiatry 8. https://doi.
org/10.3389/fpsyt.2017.00136.
Shaw D, Sandy P. (2016) Mental health nurses’ attitudes toward
self-harm: Curricular implications. Health SA Gesondheid 21:
406-14. https://doi.org/10.1016/j.hsag.2016.08.001.
Smith J, Noble H. (2015) Reviewing the literature. Evidence-Based
Nursing 19(1): doi: http://dx.doi.org/10.1136/eb-2015-102252.
Smith J, Larkin M, Flowers P. (2008) Doing interpretative
phenomenological analysis. SAGE: London.
Smith J, Osborn M. (2014) Interpretative phenomenological analysis
as a useful methodology for research on the lived experience
of pain. British Journal Of Pain 9(1): 41-2. https://doi.
org/10.1177/2049463714541642.
Thomas J, Haslam C. (2017) How people who self-harm negotiate the
inpatient environment: the mental healthcare workers perspective.
Journal Of Psychiatric And Mental Health Nursing 24(7): 480-90.
https://doi.org/10.1111/jpm.12384.
Warrender D. (2015) Staff nurse perceptions of the impact of
mentalization-based therapy skills training when working
with borderline personality disorder in acute mental health: a
qualitative study. Journal Of Psychiatric And Mental Health
Nursing 22(8): 623-33. https://doi.org/10.1111/jpm.12248.
Warrender D, Macpherson S. (2018) Student nurse perceptions of
experiential learning to understand personality disorder. British
Journal Of Mental Health Nursing 7(4): 173-88. https://doi.
org/10.12968/bjmh.2018.7.4.173.
Weight E, Kendal S. (2013) Staff attitudes towards inpatients with
borderline personality disorder. Mental Health Practice 17(3): 34-
8. https://doi.org/10.7748/mhp2013.11.17.3.34.e827.
Westwood L, Baker J. (2010) Attitudes and perceptions of mental
health nurses towards borderline personality disorder clients in
acute mental health settings: a review of the literature. Journal Of
Psychiatric And Mental Health Nursing 17(7): 657-62. https://
doi.org/10.1111/j.1365-2850.2010.01579.x.
19
 STUDENT FOCUS
Bridging the gap between
nursing specialties
Mike Palmer, mental health nursing
student, Swansea University
A
s a student mental health nurse
approaching completion of my
first year of training, I have often
wondered why nurses are split into
specialities so soon.
While each speciality possesses its own
skills, in my experience there is a stigma
not just surrounding mental health in
general, but also around being a nurse
working in mental health from some
nurses and students in other specialities.
In my view, this stems from a lack of
context, understanding and awareness
of what the role of a mental health nurse
entails, which leads to false ideas of what
people think the profession is, versus the
reality of the role.
This makes sense in many ways, as a lot
of mental health nursing work is internal
and less easily quantifiable. You can’t
necessarily see or measure the mental
wounds or scars of a patient, often you
need to scratch beneath the surface and dig
deeper. Likewise, large parts of what could
be considered general nursing are perhaps
more visible and tangible – catheters,
cannulation, ECGs, nasogastric tubes or
resuscitations for example.
My view is that this partly stems from
student nurses not doing mandatory
placements in each other’s specialities. I
believe this leads to a fundamental lack of
awareness, insight and exposure to other
areas.
At university there are shared lectures
and lectures on each speciality. This is an
addition to practical experience and not a
replacement. The famous doctor William
Osler once stated that medicine is learnt by
the bedside, not in the classroom.
I feel the same could be said for nursing
20 MENTAL HEALTH NURSING December 2022/January 2023
Mike Palmer and Carlie Andrews
and exposure to each speciality. You
need to do it at a ground level to fully
understand it.
I have heard and am aware of historic
derogatory attitudes that mental health
nurses are not proper nurses compared to
adult nurses.
If we had placements in adult wards
for mental health nurses, and vice
versa, I feel this would not only enhance
everyone’s clinical skills, but would also
help to eliminate any misconceptions by
experiencing what each role is and isn’t.
It would foster greater understanding and
connection between the specialities.
There is an argument currently for
greater specialisation within nursing,
and that there needs to be an increased
recognition of mental health nurse’s
specialist skills.
I understand that there has also been
discussion about the generalist nature of
the nursing Practice Assessment Document
(PAD) in Wales.
My question is, should we really be
wanting to zoom in so soon within our
training, and what core competencies
should encompass what a nurse is,
regardless of speciality?
Also, should more dual speciality
nursing qualifications be available at the
start of training? We advocate for holistic
treatment in nursing, yet fundamentally
we encourage splitting the profession,
which restricts knowledge and promotes a
narrowing of understanding.
When all you have is a hammer in your
toolbelt, all you will see is a nail. A more
generalist approach would mean we have
more tools and techniques in our toolkits.
As an aside, the chief nursing officer for
Wales, Sue Tranka, is qualified as a nurse
within midwifery, mental health and adult
nursing, and I imagine this significantly
aids her understanding across the
profession. Certainly, more dual qualified
nurses would be a benefit to the NHS as
they would have a broader and holistic
understanding.
As nurses, we all have so much to learn
from each other. There are so many
important transferrable skills, and by
becoming too specialised too soon I fear we
risk becoming deskilled.
Should mental health nursing skills be
updated regularly for other specialities,
and should more general nursing skills be
updated for mental health nurses?
All our specialities are interwoven, and
by undertaking learning from different
ones we will be able to look at patients
and the nursing profession from a wider
perspective and think across fields.
We have the chance to have bespoke
placements, however this is not the same
learning experience as undertaking a block
placement.
One of my lecturers at Swansea
University, Ed Lord, highlights that mental
and physical wellbeing are interlinked,
and that any attempt to separate mind and
body is fundamentally flawed.
Psychological and physical stress go
hand in hand. Care contexts and social
determinants of health also do not neatly
divide into adult, mental health, child and
learning disability.
“Any attempt to
separate mind
and body is
fundamentally
flawed ”

I feel there is a strong argument
for having the option of rotation at a
professional level, particularly at the start
of our careers, and for people wishing to
advance to management and advanced
nurse practitioner roles.
This may not be suitable for everyone
given their life situations, but it certainly
has an appeal. My sister is a doctor who
currently practices as a GP, and she
says that the year she spent training
in psychiatry was incredibly helpful
and formative in her ability to practise
successfully as a GP. The mental health
skills she has developed are invaluable to
her and have significantly enhanced her
practice, and I think they would be to any
other nurse, doctor or other healthcare
professional.
We need greater integration and less
segregation within nursing. The harmful
effects of segregation are clear within
society in terms of the social determinants
of physical and mental health.
I also feel that this separation begins at
a student level. In my experience, student
nurses within each speciality do not have
enough interaction with each other, which
limits opportunities to learn from each
other and understand our professional
roles.
I have learnt so much from interacting
with other nursing students, such as
Carlie Andrews. I think we need to look
beyond our specialities, to stop thinking
in fields and start thinking across fields. I
will certainly be trying to incorporate this
approach into my own practice.
Carlie Andrews, adult nursing student,
Swansea University
I
agree with my colleague Mike that we
should not be segregating the mental
health and adult nursing disciplines.
As we have more and more people
now living with long-term conditions and
disabilities that require complex care
needs, large and growing inequalities in
health and social care, and the economy
being in a fragile state, the prevalence of
mental health conditions in the UK has
increased (Gilburt et al, 2019).
After years of underinvestment and the
gradual increased awareness placed on
mental health and changes in attitudes, the
UK has placed mental health services at the
forefront of the national agenda (Gilburt et
al, 2019; Stafford et al, 2018).
Interestingly, when investigating the
psychiatric impact of type 1 diabetes,
Dayan et al (2019) and Garrett and Ismail
(2020) highlight that multidisciplinary
teams do not provide enough psychological
attention and wellbeing support.
This evidence highlights the importance
of greater cooperation between
multidisciplinary teams and disciplines
to improve a patient’s physical and
psychological wellbeing.
The need for greater cooperation
between nursing disciplines has never
been more important. For example,
universities such as Southampton are now
offering dual-qualified degrees to bridge
the gap between mental health and adult
nursing (University of Southampton, 2022).
When combined, these two disciplines
offer patients a higher quality of care in
nursing practice due to the correlation
between physical and mental wellbeing
(The Kings Fund, 2013).
I am currently in my third year of
studying my degree in adult nursing at
Swansea University, and am on clinical
placement in an A&E department. This
winter, emergency departments across the
UK are facing unprecedented pressures
(RCN, 2022), and I have seen these first-
hand.
What I find difficult is the number of
patients with complex or common mental
health problems coming to the emergency
department. For example, Alzheimer’s
Research UK (2020) highlighted there
has been a large increase in the number
of patients admitted to hospital with
dementia, from 210,000 in 2010/2011 to
405,000 in 2017/2018.
I believe that in emergency departments
there is often a lack of understanding
of mental health conditions from adult
nurses, as there is a lack of training on how
to approach or effectively manage various
mental health conditions.
Student adult nurses are not trained
to manage patients appropriately and
effectively with specific mental health
needs. Of course, student adult nurses
December 2022/January 2023 MENTAL HEALTH NURSING
STUDENT FOCUS
are provided with manual handling and
violence and aggression training at the
beginning of the course, which includes de-
escalation and ‘breakaway’ techniques.
However, this is usually done in one
or two sessions, and it can be difficult to
remember the techniques. On occasions,
I have been at the receiving end of verbal
and physical abuse by patients with
severe mental health conditions. Also,
there have been occasions where patients
have required transfers from mental
health hospitals as they needed medical
interventions.
For example, one patient needed the
insertion of a catheter, but was unable to
have this completed in the hospital they
came from as some mental health nurses
are not usually trained in this procedure.
The gap between mental health and
adult nursing needs to be bridged to
provide effective and timely care for
patients, whether they are suffering from
mental or physical health issues.
There is a greater prevalence of mental
health issues in the UK, and given the
proven link between physical and mental
health we should not be separating them as
one affects the other.
Therefore, mental health and adult
nurses should be able to complete the same
clinical skills and have the same training
in effectively managing patients with
complex mental health conditions. n
References
Alzheimer’s Research UK. (2020) Cost of dementia for hospitals
in England doubles in a decade. Available at: https://www.
alzheimersresearchuk.org/cost-of-dementia-hospitals-england-
doubles (Accessed 2 December 2022).
Dayan CM, Korah M, Tatovic D, Bundy BN, Herold KC. (2019)
Changing the landscape for type 1 diabetes: the first step to
prevention. The Lancet 394(10205): 1286-96.
Garrett C, Ismail K. (2020) Forgotten: mental health interventions in
type 1 diabetes. The Lancet 395(10218): 115.
Gilburt H, Naylor C, Warren S. (2019) Mental health: our position.
The King’s Fund. Available at: https://www.kingsfund.org.
uk/projects/positions/mental-health#:~:text=One%20in%20
four%20adults%20have,a%20diagnosable%20mental%20
health%20problem (Accessed 2 December 2022).
Royal College of Nursing. (2022) Emergency department pressures:
System-wide solutions needed to tackle emergency care crisis.
Available at: https://www.rcn.org.uk/news-and-events/news/
uk-emergency-department-pressures-system-wide-solutions-
needed-210422 (Accessed 2 December 2022).
Stafford M, Steventon A, Thorlby R, Fisher R, Turton C, Denny S.
(2018) Briefing: Understanding the health care needs of people
with multiple health conditions. The Health Foundation: London.
The King’s Fund. (2022) Mental health. Available at:
https://www.kingsfund.org.uk/projects/time-think-
differently/trends-disease-and-disability-mental-physical-
health#:~:text=The%20connection%20between%20mental%20
and,depression%2Fanxiety%20(1) (Accessed 2 December 2022).
University of Southampton. (2022) Nursing (Adult and Mental
Health) (MNurs). Available at: https://www.southampton.ac.uk/
courses/nursing-adult-mental-health-degree-mnurs (Accessed 2
December 2022).
21
 INTERVIEW

Inside the mind of...

Alex McMahon
Mental Health Nursing meets Professor Alex McMahon,
Scotland’s Chief Nursing Officer, and mental health nurse

What is the biggest
challenge you are facing at
the moment?
It is fair to say that there are real
challenges across health and social
care and the government is doing
everything to support the system, not
just during this winter but for the
longer term too.
Part of my job is about supporting
the immediate and longer-term
development of a sustainable
workforce across health and social
care across a range of disciplines, not
just nursing and within the registered
and unregistered workforce.
We need to look into all avenues
and all opportunities in relation to
recruitment and retention.
What is the biggest
opportunity?
We are preparing a mental health
and wellbeing strategy that will be
published next year, and which will
also include our first national mental
and wellbeing workforce plan.
This will hopefully help us focus on
the things that mental health nurses
do that make a difference and that we
need to do more on.
Importantly, it will also look at how
we attract, employ, support and retain
our staff.
We are doing a number of things to
recruit staff. Of particular note this
year is the 20% increase in mental
health nursing students into the
undergraduate programme.
But in addition to this we have
created a Retire to Return policy,
which should make it easier for staff
in Scotland to continue working post
retirement.
We are also developing the assistant
practitioner role at band 4 and we
have also seen an increase in the
number of healthcare support workers
undertaking the Open University
programme.
We are also offering all of our
third year students a band 4 role for
between 7.5 and 11.5 hours per week.
What advice would you give
to mental health nurses?
What you do makes a genuine
difference to the quality of individuals
lives, and that of their families. That
can never be underestimated or
valued.
I would add that it is a hugely
rewarding profession and there are
so many opportunities once you are
qualified.
The world is your oyster.
What advice would you give
to your younger self?
Don’t change anything. Your pathway
will be unique but it will get you to
where you want to be.

“We need to look

into all avenues
and opportunities
PublicDomainPictures from Pixabay

in relation to
recruitment and
retention”
22 MENTAL HEALTH NURSING December 2022/January 2023
 INTERVIEW

“I did initially want

to switch from
mental health to
general nursing as
a student but I am
glad I didn’t”

What would you do if you

were made prime minister?
Gosh, that’s not really a job I have ever

MW from Pixabay
been interested in (LOL), but I would
ensure that I listen and that I am
visible as a leader.
Meaningfully tackling child poverty What is your ambition/ but I am glad I didn’t. It was the most
and inequality would also be a definite working goal? valuable thing I ever did and I still use
goal. To find longer-term options for a many of the skills I learned today!
sustainable workforce, in order to
Is there something you’d be deliver the best care that we can. What does the future hold
happy doing every single for you?
day for the rest of your If you could wind back Well to some degree I have reached
career? the clock to the start of the pinnacle of the nursing profession
Yes, having my latte and my croissant your career, would you do in Scotland, but I need to make sure
every morning! anything differently? that I can use this as an opportunity to
The thought of it definitely gets me No! However, having said that, I did improve the conditions for those that
out of bed. initially want to switch from the will come after me – and indeed those
mental health to the general nursing who may look after me and my loved
What’s the biggest programme as a first year student ones in years to come. n
professional decision you’ve
had to make?
Oh, that is a hard one.
There have been so many. But I
believe that listening to those who are
experts and looking at the evidence
will take you a long way to making the
right decision.
So many of the hardest decisions I
had to make in my career came during
the first wave of COVID-19.
Everyone would look to me for
the answers, and at that time as the
executive director for nursing in a
large board I didn’t always have the
answers, but again the principle of
working together, listening to others
and ‘following the evidence’ and latest
guidance helped hugely.
Being visible and having good, open
an transparent communication really
does help too.

December 2022/January 2023 MENTAL HEALTH NURSING 23

A new e-learning
platform designed
specifically for
primary care nurses
Nursing in Practice 365 offers you
choice, convenience, and flexibility
when it comes to your education.
Featuring eLearning modules written
by primary care experts, On-Demand
Webinars presented by clinical leaders,
and in-person and virtual free-to-
attend Events; there’s something to
suit every learning style.

“Easy to sign up, easy to navigate”

“Amazing like always”
“Informative, easy to follow,
relevant”
2022 members

Launching Spring 2023 – stay tuned

for more details coming soon!

L E A R N | AT T E N D | R E F L E C T