Borderline personality disorder (BPD) is characterised by emotional dysregulation, feelings of worthlessness, impulsivity, suicidality and poor relationships. As a result of the challenges in the treatment of women living with BPD and the lack of skills from the psychiatric nurse, there was a need to develop a model for psychiatric nurses to facilitate the mental health of women living with BPD.
To describe the process that was followed in developing, describing and evaluating a model that could be used as a framework of reference for psychiatric nurses to facilitate the mental health of women living with BPD.
A theory-generative, qualitative, exploratory, descriptive and contextual study design was used to develop the model. The central concept of the model was derived from a previous study: ‘The experiences of women living with borderline personality disorder’. The process entailed the identification of the central concept and other essential criteria, the classification of the central concepts and describing the relationships between the concepts.
The central concept was identified as ‘facilitation of self-empowerment’ of women living with BPD. The concepts ‘facilitation’ and ‘self-empowerment’ were defined and classified. The identified and defined central concepts were placed into interrelated statements. The model to facilitate self-empowerment of women living with BPD was developed, described and evaluated. The model has not been implemented.
The model provides a framework of reference for psychiatric nurses to facilitate self-empowerment of women living with BPD.
Borderline personality disorder (BPD) is a pervasive pattern of instability of interpersonal relationships, self-image, affects and marked impulsivity that begin by early adulthood (American Psychiatric Association [APA]
In the majority of clinical settings, BPD is mostly diagnosed in women with a ratio of 1:4 for men (APA
Psychiatric nurses working with women living with BPD have been said to experience distress, anxiety or confusion, and burnout at some point in their professional lives (Cambanis
These studies highlight the psychiatric nursing challenges in managing patients with BPD. The researchers of this study were then interested in what the women living with BPD were experiencing. A study was conducted focusing on the experiences of women living with BPD (Ntshingila et al.
Authors found that women living with BPD despite the challenges needed to be assisted with the mental health from the psychiatric nurse (Ntshingila et al.
There are existing models developed internationally that were found in the literature on the topic of BPD. Mortimer-Jones et al. (
There is no existing model that can be used as a framework of reference to facilitate the mental health of women living with BPD in South Africa. Stroud and Parsons (
The purpose of this research study is to describe the development of a model as a framework of reference for psychiatric nurses to facilitate the mental health of women living with BPD.
A model is a symbolic representation of empiric experience in the form of words, pictorial or graphic diagrams, mathematical notations or physical structure. It is a form of knowledge within the empirical pattern (Chinn & Kramer 2011:157). In this article, a model to serve as a framework of reference for psychiatric nurses to facilitate the mental health of women living with BPD was developed.
Psychiatric nurse is a professional nurse registered with the South African Nursing Council as a psychiatric nurse who has received a diploma or a baccalaureate qualification. This nurse works in a specialised setting to provide the bulk of the nursing care to the patients. They have a major responsibility to the public and have contact with patients at all stages of life (Kniesl & Trigoboff
According to the University of Johannesburg (
This is a state of well-being in which every individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community (World Health Organization [WHO]
The DSM 5 (APA
The steps of Chinn and Kramer (2011:163–182) for theory development were used. These steps are concept analysis, relationship statements, description of the model and the evaluation of the model.
Concept analysis took place in two phases. In phase one, the central concept was identified and in phase two the identified concept was defined and classified.
In order to identify concepts as building blocks for the model, the researcher used an inductive theory-generative research design (Chinn & Kramer 2011:216). The research design and procedures will be discussed below to describe how the concepts were identified.
Credibility was ensured by prolonged engagement with the women living with BPD. The in-depth interviews were approximately 45–60 min. Triangulation of data was performed using multiple data collection methods. An independent coder, who was knowledgeable about the analysis of qualitative data was consulted, and consensus was reached on the identified themes and categories in the data. The research results and model structure was presented at research forums and doctoral seminars, and corrections and modifications were made based on the recommendations of experts in research and model development.
Transferability was ensured through extensive description of the demographics of the women living with BPD and similarly a description of findings supported by direct quotations (Ntshingila et al.
Dependability was ensured through a detailed description of the research methodology. A dependability audit was conducted in which the three supervisors evaluated the study before it was presented to external assessors to ensure dependability.
The researchers monitored the whole research process for accuracy and relevancy of data. The researchers kept an accurate record of the research process of the study so that other researchers could emulate the process and reach a similar conclusion. An independent coder with expertise in qualitative research was used to collate the findings.
Identification of the central concept.
During this phase, the concept was given meaning (Chinn & Kramer 2011:177). The definition of concepts was performed connotatively as well as denotatively using dictionaries and available literature (Walker & Avant
The essential attributes of the concept ‘facilitation of self-empowerment’.
Central concept | Essential attributes |
---|---|
Facilitation | Assisting the progress of a person |
Dynamic, interactive process | |
Creating a positive environment | |
Mobilising resources | |
Self-empowerment | Taking charge of one’s life |
Taking an active role in the journey of self-discovery | |
Feeling secure and connected | |
Develop a sense of meaning and coherence | |
Knowing what is best for you |
Source: Ntshingila, N.,
A final definition was formulated, synthesising all the attributes of the definition contained in the dictionary and subject definitions as indicated in
The central concepts were then classified by using Dickoff, James and Wiedenbach’s (
The central concept was classified by using Dickoff et al.’s (
The agent is the person who will make certain that the nursing goal is achieved (Dickoff et al.
Recipients are the people who interact with the agent (Dickoff et al.
The context may include home, work, hospital, community and church, etc. The context of this study was a psychotherapy unit where the women living with BPD were currently admitted (Ntshingila
The dynamics may be barriers or enhancers of the implementation of the model which were the five themes identified from the experiences of women living with BPD. Women living with BPD experienced living in unsafe spaces as a child, chronic feelings of emptiness in relationship with the self, unstable interpersonal relationships and compromised mental health. The psychiatric nurse was motivated to facilitate the self-empowerment of women living with BPD (Ntshingila
The procedure was psychiatric nurse using the model as a framework of reference to facilitate self-empowerment as an integral part of mental health. The facilitation of self-empowerment took place in three phases: the relationship phase, the working phase and the termination phase (Ntshingila
The terminus, which is the outcome, was self-empowered women living with BPD as an integral part of mental health (Ntshingila
The identified and defined central concepts were placed into relationship statements (Chinn & Kramer 2011:180). The identified essential attributes were then used to construct relationship statements. Relationship statements help to give the concepts more clarity and add direction to the understanding of the phenomenon (Towell, Nel & Muller
The psychiatric nurse forms a trusting and therapeutic relationship with the woman living with BPD in a psychotherapy unit by creating a positive environment. The psychiatric nurse will mobilise resources to assist the woman living with BPD to be self-empowered. The psychiatric nurse will assist the woman living with BPD to take charge of her own life in order for the woman to be able to make choices about her life. The woman living with BPD needs to take an active role in the journey of self-discovery to achieve self-empowerment. She needs to feel secure and connected with herself, with others and with her environment to be self-empowered. The woman living with BPD needs to develop a sense of meaning and coherence; to know what is best for herself in order to make decisions that are best for herself. By achieving this, the woman living with BPD will be self-empowered.
The criteria for descriptive components of a model were used in describing the model (Chinn & Kramer 2011:186–196). The criteria used for describing the model as a framework of reference for psychiatric nurses to facilitate self-empowerment of women living with BPD included assumptions, purpose, concepts, definitions and relationships. The structure and processes of the model were also described.
The structure of the model is discussed using the headings as described by Chinn and Kramer (2011:185): purpose of the model, assumptions of the model and process description of the model.
The purpose of this model is to serve as a framework of reference for psychiatric nurses to facilitate self-empowerment as an integral part of the mental health of women living with BPD.
The assumptions of this model are based on the Theory for Health Promotion in Nursing (University of Johannesburg
A woman living with BPD is viewed holistically and in interaction with her environment. The environment consists of the internal and external environment. The internal environment comprises of body, mind and spirit dimensions, and the external environment consists of the physical, social and spiritual dimensions. (p. 4)
The psychiatric nurse facilitates the self-empowerment of the woman living with BPD through a dynamic and interactive process within a specific context, that is, the psychotherapy unit.
The psychiatric nurse establishes a therapeutic relationship with the woman living with BPD. The therapeutic relationship is a mutually defined, collaborative and goal-orientated professional relationship (Kniesl & Trigoboff
The facilitation of self-empowerment of the woman living with BPD happens in the context of the psychotherapy unit.
A model for psychiatric nurses to facilitate self-empowerment of women living with BPD is displayed in
A model to facilitate self-empowerment of women living with borderline personality disorder.
The woman living with BPD is represented in a red colour on the left-hand side of the model. The colour red in the triangle signifies higher energy levels and increased action (Empower-yourself-with-colour-psychology
The psychiatric nurse is represented by a triangle in yellow. The colour yellow provides clarity of thought and inspires the thought process (Empower-yourself-with-color-psychology
The facilitation of self-empowerment is indicated with a spiral-shaped diagram. The spiral was chosen as it demonstrates continuity in the process of facilitation by self-empowerment. The spirals also have arrows that are going up and down. The upward-facing arrows indicate the progression through the phases that the woman living with BPD will go through. The upward-facing arrows also indicate the self-empowerment skills that the woman is achieving as she is able to use the coping mechanisms to deal with the experiences of living in an unsafe space, chronic feelings emptiness, unstable interpersonal relationships and compromised mental health. These upward-facing arrows are large in size, indicating that the woman living with BPD achieves self-empowerment. The downward-facing arrows are small in size suggesting the possibility of relapse that the woman living with BPD may encounter. The spiral diagram is red during the relationship phase, orange in the working phase and yellow in the termination phase. These colours denote the phases that the psychiatric nurse is assisting in facilitating the woman living with BPD. The spiral ends with an arrow facing towards the outcome, which is the self-empowered woman living with BPD.
The model consists of three phases, which are the relationship phase, the working phase and the termination phase.
In the relationship phase, the psychiatric nurse establishes a relationship in order to create a positive environment for the woman living with BPD to mobilise resources. The psychiatric nurse will need the skills of creating rapport, safety and trust in order to create a positive environment in the psychotherapy unit (Townsend
The next phase is the working phase. In this phase, the psychiatric nurse works with the woman living with BPD to master knowing what is best for her; taking charge of her own life; taking an active role in the journey of self-discovery, feeling secure and connected, and developing a sense of meaning and coherence. The interventions are focused on the woman living with BPD being able to cope with life’s challenges in a thorough manner. The psychiatric nurse assists the woman living with BPD to master knowing what is best for her through gaining awareness of herself and noticing the obvious signs of distress. The woman living with BPD is assisted with awareness exercises, which will enable her to be grounded and to connect with herself. The psychiatric nurse assists the woman living with BPD to take charge of her own life through learning to take responsibility, and learning to identify and acknowledge feelings at a given time. This will assist the woman living with BPD to be in control of how she reacts when uncomfortable feelings are experienced. This control of feelings allows one to feel in charge of one’s life (Klein
In feeling secure and connected, the psychiatric nurse assists the woman living with BPD to understand that she must reach out when she needs emotional support, understand what her insecurities are and what makes her uncomfortable about those insecurities, and identify professionals whom she trusts and can go to for professional advice. The psychiatric nurse assists the woman living with BPD to develop a sense of meaning and coherence through engaging in activities that are important to her, having an attitude that will impact how well she copes with circumstances, and discussing and developing the coping strategies that seem most appropriate for dealing with stressful situations (Ntshingila
The last phase is the termination phase. In this phase, there is an evaluation of the achievement of self-empowerment, and the psychiatric nurse evaluates whether the woman living with BPD has achieved self-empowerment. In this phase, the psychiatric nurse also works on terminating the therapeutic relationship that has been built with the affected woman. The woman living with BPD also works on how to take on the mastered skills learned in the process of facilitating self-empowerment to ensure continuity and decreasing chances of relapse. The woman living with BPD needs to ensure that internal and external resources are in place. There is decreased involvement of the psychiatric nurse at this stage to ensure that the woman living with BPD is able to function by herself. This is the indication that the woman living with BPD has achieved self-empowerment.
The model was evaluated using the criteria from Chinn and Kramer (2011:137). These criteria for evaluating a model are clarity, simplicity, generalisability, accessibility and importance (Chinn & Kramer 2011:137). The model was evaluated by a panel of experts in research theory and advanced psychiatric nurses. Experts who evaluated the demographics of the model comprised of four full-time professors (P), one associate professor (AP), three senior lecturers with doctoral degrees (SL) and two lecturers currently busy with their doctoral studies (L). The model was found to comply with the criteria for model development. These criteria are discussed next.
‘It explains the aims of facilitating care by building up relationship with client first then working through the identified problem until achievement or termination phase clearly.’ (Participant SL1)
‘The model is clear as it shows the stages that the patient will go through to get self-empowerment.’ (Participant L2)
‘The model is clear as there is alignment to the other steps that is concept analysis.’ (Participant L1)
‘It describes the main process in the facilitation without complicated concepts.’ (Participant P1)
‘The model is simple and can be easily utilised by psychiatric nurse practitioner and other practitioners in nursing.’ (Participant P4)
‘Very simple and easy to understand.’ (Participant AP1)
‘It is suitable to reach objectives and easy to explain.’ (Participant P3)
‘This model can be used for not only for women with BPD by anyone who needs self-empowerment.’ (Participant L1)
‘The model is general and can be easily utilised.’ (Participant AP1)
‘It is accessible with regards to the trained professional nurse with appropriate knowledge and adequate workforce and is inexpensive. …’ (Participant P3)
‘It is accessible and could yield positive results.’ (Participant P2)
‘It looks accessible to the professional psychiatric nurse.’ (Participant SL3)
‘The model is very important for facilitating the mental health of women living with borderline personality disorder.’ (Participant P2)
‘Facilitating mental health is important and the nurses need a guideline for assisting patients to achieve self-empowerment.’ (Participant AP1)
‘It is important so much that nurses working with psychiatric patients will gain knowledge.’ (Participant SL3)
This study has not discussed the implementation of the model and the evaluation of the implementation of the model.
Recommendations for nursing practice are that the model could be used as a framework of reference in different contexts where there are women living with BPD. The model could be used to promote positive relationships between the psychiatric nurses and the women living with BPD. The model could also be used to enhance the benefits to the psychiatric nurses working with women living with BPD, thus shifting their negative attitudes about women living with BPD. Recommendations for nursing research is that the model could be used for further research in contexts where psychiatric nurses’ experiences could be explored in using this model. In nursing education, the model can be of benefit because it can be included in the undergraduate and postgraduate training of psychiatric nursing students. This could be beneficial to assist psychiatric nursing students to be better equipped to work with women living with BPD.
Developing a model as a framework of reference for psychiatric nurses to facilitate self-empowerment as an integral part of mental health of women living with BPD provided an original contribution to the theory in Psychiatric and Mental Health Nursing. This model can be used by psychiatric nurses as a tool to facilitate self-empowerment in women living with BPD. The purpose of the article was to describe the development of a model as a framework of reference for psychiatric nurses to facilitate the self-empowerment of women living with BPD. The steps of developing the model were described, along with the ethical considerations and measures to ensure trustworthiness. Limitations and recommendations were also discussed. The original contribution of this study was also discussed.
The authors thank Leatitia Romero for language editing of the manuscript.
The authors have declared that no competing interests exist.
All authors contributed equally to this work.
This research received funding from the University of Johannesburg and DHET.
Data sharing is not applicable to this article as no new data were created or analysed in this study.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.