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.

Research design: In order to develop a model, an inductive approach (Chinn & Kramer 2011:216) was adopted together with a qualitative, exploratory, descriptive and contextual research design (Chinn & Kramer 2011:216; Holloway & Wheeler 2010:2; Ravitch & Carl 2016:68,148).

Ethical consideration: The researchers obtained permission to conduct the study from University of Johannesburg Academic Ethics Committee and Higher Degrees Committee, and University of the Witwatersrand Human Research Ethics Committee (medical) – (reference numbers: AEC-01-56-2014, HDC-01-55-2014 and M150249). Permission was also obtained from the Chief Executive Officer of the public psychiatric hospital where the research was conducted. Ethical principles of respect for autonomy, non-maleficence, beneficence and justice (Dhai & McQuoid-Mason 2011:13–14) were taken into consideration. The principle of respect for autonomy was respected through allowing the women living with BPD to make an informed decision before signing an informed consent form; their confidentiality was respected throughout the research by not exposing their names. The participants participated in the study voluntarily and could withdraw their participation at any time during the study. Privacy was ensured to all the participants during the interviews. The principle of non-maleficence was ensured through providing debriefing sessions to participants when required. The researcher being sensitive during the interviews and avoiding harm and discomfort to the participants ensured the principle of beneficence. The researcher ensured the principle of justice through the selection of the participants fairly and without discrimination.

Population and sample: The population included all women between the ages of 18–40 years who were diagnosed with BPD. Purposive sampling of eight women diagnosed with BPD was performed, based on the following inclusion criteria: aged between 18 and 40 years, diagnosed with BPD and those who were admitted to the psychotherapy ward in a public psychiatric hospital in Johannesburg. The participants between the ages of 18–40 years were chosen because in a study conducted by Biskin (2015:304), it is reported that the course of BPD during adolescence is not very stable and there is an absence of evidence regarding the course and outcomes of patients who do meet the full criteria for BPD in childhood. The cut-off limit of 40 years old was chosen because in a 16-year prospective follow-up study conducted by Zanarini et al. (2012:480), it is stated that most patients with BPD improve with time and as the participants grew older they no longer met the criteria for BPD.

Data generation procedure: The first author conducted in-depth interviews. These interviews were performed mostly at the public psychiatric hospital where the participants were admitted and some at their homes. The autonomy of the women living with BPD was respected by allowing the participants to make an informed decision before signing an informed consent form; their confidentiality was respected throughout the research by not exposing their names and using codes to identify the interviews. The participants were not under any compulsion to participate in the study and could withdraw from the study at any time. This was indicated in the participant’s information letter. Privacy was maintained by conducting in-depth interviews in a private space. The women living with BPD were asked the central question ‘Tell me your life story?’ Each in-depth interview with the women living with BPD was at least 30–45 min long. Data were collected from the eight in-depth interviews, observational notes during the in-depth interviews and the field notes. The first author made field notes after each in-depth interview. The field notes included accurate descriptions of the experiences of the first author whilst conducting the in-depth interviews, non-verbal communication that is observed from the participants and recording of any other activities, and the interpretation of those activities during the in-depth interviews. The in-depth interviews were transcribed, which included the observational and field notes. Data saturation was achieved at the fifth interview and three additional interviews were conducted to confirm the findings.

Data analysis: Data analysis was conducted using Tesch’s method (Creswell 2014:186). This method is used to organise the data collected from the in-depth interviews into data that have meaning. Data were coded by developing and applying a list of codes to new segments of data each time an appropriate segment was encountered. The first author and an independent coder had a consensual discussion about the themes and categories that were derived.

Measures to ensure trustworthiness: Trustworthiness is the degree of confidence that researchers have in their data. Measures of trustworthiness were assessed by using the criteria of credibility, transferability, dependability and confirmability (De Vos et al. 2011:419–420). All of these criteria were applied to this study.

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. 2016).

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.

Findings of the study: The findings of this study indicated that there were childhood experiences such as living in an unsafe space as a result unhealthy family dynamics, boundary violations and educational challenges. These women living with BPD experienced chronic feelings of emptiness in relationships with the self. They also presented with a pattern of unstable interpersonal relationships and compromised mental health, which was apparent through the early onset of mental problems, emotional upheavals, longings for emotional escape and having different trigger factors. These women yearned for facilitated mental health (Ntshingila et al. 2016:110–119)

Identification of the central concept: The central concepts were derived from the findings of the researchers’ previous study (Ntshingila et al. 2016:110–119) (see Figure 1 for identification of the central concepts from the findings of the experiences of women living with BPD). The themes were used in identifying the central concept. The experiences of women living with BPD indicated that these women were disempowered. Facilitation of self-empowerment as a central concept was identified.

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 2011:161). Essential attributes for the definition of the central concept were identified from dictionary and subject definitions. ‘Facilitation of self-empowerment’ was defined based on the essential attributes as follows (see Table 1) (Ntshingila et al. 2016:437–443).

A final definition was formulated, synthesising all the attributes of the definition contained in the dictionary and subject definitions as indicated in Table 1. The definition includes the two central concepts, indicating the relationships amongst the central concepts. In the facilitation of self-empowerment of the women living with BPD, the psychiatric nurse assists in the progress through a dynamic, interactive process by creating a positive environment through mobilising resources in order to promote the mental health of these women. Self-empowerment is achieved when the woman living with BPD knows what is best for herself and takes charge of her own life by taking an active role in the journey of self-discovery and feeling secure and connected by developing a sense of meaning and coherence (Ntshingila et al. 2016:442).

The central concepts were then classified by using Dickoff, James and Wiedenbach’s (1968:425) survey list, which asks: ‘Who is the agent?’, ‘Who is the recipient?’, ‘What is the procedure?’, ‘What is the dynamics?’, ‘What is the context?’ and ‘What is the outcome?’.

The central concept was classified by using Dickoff et al.’s (1968:425) survey list as follows:

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 2017:2–16). The assumptions that underlie this model are reflected in the following statements (University of Johannesburg 2017):

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 2013:46). Facilitation of self-empowerment is implemented by creating a positive therapeutic environment for the woman living with BPD, and by mobilising resources to facilitate self-empowerment as integral part of mental health.

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 Figure 2. The context is represented by the peach-coloured border, which indicates the safety of the psychotherapy unit (Empower-yourself-with-colour-psychology 2015). The peach colour is calming and makes one feel safe and secure, unlike the environments that the woman living with BPD has been exposed to in her life.

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 2015) which, in the context of this study, is represented by the increase of acting out behaviour of the woman living with BPD, such as suicidal behaviour, mood instability and chaotic interpersonal relationships. The red colour is also applied to the relationship phase of the model because of the emotional status that the woman living with BPD comes in during the relationship phase.

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 2015). The psychiatric nurse represents provision of a healing presence of unconditional acceptance, patience, loving kindness, a non-judgemental attitude, understanding, good listening skills, honesty and empathy (Kniesl & Trigoboff 2013:50). All of these qualities are ones the psychiatric nurse should display towards the woman living with BPD. The psychiatric nurse will walk the road with the woman living with BPD.

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 2015:129). When the psychiatric nurse creates a positive environment, the outcomes of the mental health patient are improved (Twigg & McCullough 2014:91). The psychiatric nurses mobilise resources through their skills to provide individual therapy, group therapy, mental health education and life-skills training as resources to women living with BPD. The psychiatric nurse is the appropriate person to mobilise these resources because they spend the most time with the woman living with BPD. Once this is achieved, the woman living with BPD should experience that she is in a safe space and can proceed to the working phase.

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 2015:2). The psychiatric nurse assists the woman living with BPD to take an active role in the journey of self-discovery. This is performed through a process where the psychiatric nurse assists the woman living with BPD to understand her strengths and weaknesses, what are her goals and how does she plan on achieving those goals (Dunstan 2015:2). The woman living with BPD is assisted in acknowledging fears that are related to achieving her goals and to take an active role instead of a passive role to improve the current situation. The woman living with BPD is empowered to choose the option that will bring about more pleasant feelings (Dunstan 2015:5).

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 2018).

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.