Impact on staff attitudes of brief personality disorder training for acute psychiatric wards

Abstract

Purpose

Negative attitudes towards “personality disorder” are common among mental health professionals. This study aims to design a psychoeducational training targeting attitudes to “personality disorder” for staff working in a London psychiatric hospital. Its impact on staff attitudes was evaluated.

Design/methodology/approach

Mental health clinicians were recruited from five acute psychiatric wards. Feasibility of implementing the training was measured. A free-association exercise explored baseline attitudes to “personality disorder” and visual analogue scales assessed staff attitudes pre- and post-training. Content analysis of staff feedback was carried out.

Findings

Psychoeducational training was found to be feasible, well-attended and highly valued by ward staff (N = 47). Baseline results revealed negative perceptions of “personality disorder”. Post-training, significant improvements in understanding, levels of compassion and attitudes to working with service users with a diagnosis of a “personality disorder” were observed. Staff feedback highlighted desire for further training and support.

Research limitations/implications

The sample size was relatively small and there was no control group, so findings should be interpreted with caution.

Practical implications

The findings highlight the need for support for staff working with service users with diagnoses of “personality disorder” on acute psychiatric wards. Providing regular training with interactive components may promote training as a resource for staff well-being. Planning to ensure service users’ and carers’ views are incorporated into the design of future training will be important.

Originality/value

This study is innovative in that it investigates the impact of a brief psychoeducational training on “personality disorder” designed for mental health staff on acute psychiatric wards.

Citation

McDonald, C., Seaman-Thornton, F., Mok, C.L.M., Jakobsen, H. and Riches, S. (2022), "Impact on staff attitudes of brief personality disorder training for acute psychiatric wards", Mental Health Review Journal, Vol. 27 No. 1, pp. 89-99. https://doi.org/10.1108/MHRJ-09-2020-0066

Introduction

The relationship between service users with a diagnosis of “personality disorder” and mental health practitioners is important because diagnoses of “personality disorder” are prevalent in acute settings (Bach and First, 2018). Service users with a diagnosis of “personality disorder” often have multiple and diverse needs and are often high intensity users of health-care resources, especially psychiatric and emergency services (Byrne et al., 2014). Research into “personality disorder” has revealed that clinicians may perceive people with diagnoses of “personality disorder” more negatively than those with other diagnoses (Dickens et al., 2016; Egan et al., 2014; Markham, 2003; Markham and Trower, 2010; Sansone and Sansone, 2013). Such negative attitudes and perceptions have been linked with the challenges for staff in acute settings inherent in managing and responding to suicidality and self-harm (Bodner et al., 2011; James and Cowman, 2007; Weight and Kendal, 2013; Gedara et al., 2021). It has also been suggested that negative connotations of “personality disorder” were associated with service users’ difficulties in engaging with mental health support, which impacts on their quality of care received in services (Lawn and McMahon, 2015; Loader, 2017; Zacharia et al., 2020). Therefore, the importance of creating a workforce that has a better understanding of the “personality disorder” diagnosis and is more aware of its impact on service users, their families, agencies and society more broadly has been emphasised in the Personality Disorder Capabilities Framework (National Institute for Mental Health in England, 2003).

Novel approaches are needed to support and to train mental health staff in acute and crisis services, especially given the challenges of this setting (Kramarz et al., 2021; Riches et al., 2021). Mental health staff working in psychiatric hospitals have expressed a desire for further support in working with this client group (Bodner et al., 2015; McGrath and Dowling, 2012; O’Connell and Dowling, 2013). In particular, research has identified a need for training qualified mental health nurses working in acute services, with 89% of respondents requesting further acute care education post-registration (Jones and Lowe, 2003). Implementing targeted training can be an effective way to improve understanding, optimism and confidence, as well as improving staff attitudes towards service users with a diagnosis of “personality disorder” (Clarke et al., 2015; Darongkamas et al., 2020; Ebrahim et al., 2016; Lamph et al., 2014; Woodward et al., 2009). Training that is targeted at structuring the environments of service users diagnosed with “personality disorder” has been found to help staff develop a skillset for working effectively with service users who have difficulties in recognising and regulating emotions, through reflective practice, peer support and decreasing their levels of work-related stress (Burke et al., 2019). In a qualitative study of experts by experience in receiving a “personality disorder” diagnosis and accessing mental health services in community and forensic settings, service users believed that improved staff understanding and attitudes can support and facilitate recovery (Shepherd et al., 2017). However, less is known about the impact of “personality disorder”-focused staff training on acute psychiatric wards.

As brief, short-term interventions have been shown to work well in this setting (Bullock et al., 2021; Riches et al., 2021), the aim of the present study was to develop and evaluate a brief training intervention for mental health professionals and to explore the impact of it on staff attitudes towards service users with a diagnosis of “personality disorder” in an acute psychiatric setting. It was hypothesised that the training would lead to increased understanding and improve attitudes.

Methods

A one-hour, stand-alone, psychoeducational training session was developed by two senior clinical psychologists with extensive experience and training in working with people with a diagnosis of a “personality disorder” on acute psychiatric wards and a trainee clinical psychologist. It was informed by the Power Threat Meaning Framework (Johnstone and Boyle, 2018), Department of Health (2014), Mind (2015), Tyrer (2014) and identified clinical need on the wards where their psychology service was based. The objectives were to improve staff understanding of “personality disorder”; improve compassion and attitudes towards working with service users diagnosed with a “personality disorder” and to discuss the importance of individualised psychological formulation (Royal College of Psychiatrists, 2020). There were seven components in each training session:

1. an interactive free-association task that served as an introductory, “icebreaker” exercise;

2. psychoeducation about “personality disorder”;

3. clinical vignettes;

4. psychological formulation;

5. video of a person sharing their lived experience;

6. guidance about how to work effectively to support service users who may have received a diagnosis of a “personality disorder”; and

7. guidance about staff self-care and support systems.

The video was one that had been used previously for staff training and was not specifically commissioned for this training. Training sessions were co-facilitated by a clinical psychologist and a trainee clinical psychologist. The training was offered across five acute inpatient wards at a South London psychiatric hospital.

Demographic characteristics of staff, including age, gender, job role and stage of career, were recorded. For each training session, facilitators recorded the duration of the training, number of attendees, percentage of attendees who completed the questionnaires, percentage of whom remained for the duration of the training and they scored each training’s fidelity to the training protocol. Fidelity to the protocol was calculated by scoring the degree to which each component was completed within the training on a 0–10 scale (0 = not completed at all, 10 = fully completed). Mean scores for fidelity across all sections were calculated and converted into a percentage score.

A mixed methods design was used to evaluate the training and staff attitudes. Qualitative descriptions of “personality disorder” were collected to explore baseline attitudes, pre- and post-training visual analogue scales (VAS) assessed levels of understanding, compassion and attitudes (Bijur et al., 2001). Facilitators used a free association task to explore the question: What comes to mind when you think of service users who have a diagnosis of a “personality disorder”? As an ice breaker at the beginning of each training to elicit attitudes towards “personality disorder”. Idiosyncratic VAS from 0 to 100, adapted from previous research on staff training (Riches et al., 2019), were used to measure understanding, compassion and attitude pre- and post-training (“Please mark on the line how much you feel that you understand ‘personality disorder’”, “Please mark on the line how compassionate you feel towards service users with a diagnosis of a ‘personality disorder’”, “Please mark on the line how you feel in general about working with service users with a diagnosis of a ‘personality disorder’”). A score of 0 indicated a strong negative response (e.g. “no compassion”) and a score of 100 indicated a strong positive response (e.g. “very compassionate”). Post-training VAS were repeated. Additional VAS evaluated perceived impact of training (“Please mark on the line how you feel your attitude towards service users with ‘personality disorders’ has changed as a result of this training”; “Please mark on the line how much you enjoyed the training”; “Please mark on the line how much you learned from the training”).

A qualitative content analysis was conducted on staff written feedback. Open questions were asked post-training to obtain qualitative feedback of staff perceptions of the training (“What aspects of the training did you find helpful or unhelpful?”; “Do you have any suggestions for how this training could be improved in the future?”; “Do you feel that the training you attended today improved your understanding of ‘personality disorder’? If so, how?”; “Do you feel that this training affected the way that you feel about working with individuals diagnosed with ‘personality disorder’?”).

Quantitative data were analysed using IBM SPSS Statistics 24. Themes from the free association task were reported if they were endorsed by more than half the staff teams, i.e. three or more. Mean pre- and post-VAS scores were compared using related-samples Wilcoxon signed rank tests as the data was non-parametric. Qualitative responses to training evaluation questions were analysed using an inductive content analysis (Elo and Kyngäs, 2008). Each response was reviewed and coded by researchers and grouped into categories. Responses that met criteria for more than one category were duplicated and coded for each appropriate category. To ensure reliability and validity, data analysis was discussed within the research team. Frequency of responses in each category was recorded and reported where frequency exceeded two. Frequencies for content analyses were reported as the count of participant responses included in each category.

Results

Forty-seven multidisciplinary mental health clinicians attended the five sessions of training. There was a mean of 9.4 participants in each of the five sessions. Of these, 37 staff members (25 females; 12 males; with most in the 30–39 age range) completed the evaluation surveys (response rate = 78.72%). Most of the sample were nursing staff and participants were at a variety of career stages. Demographic characteristics are reported in Table 1. There was an 84% completion rate of training components. Where components or measures were not completed it was largely due to the challenges and high workload of the acute ward setting.

Free association themes which emerged from more than half of the training sessions were “splitting” (5), “challenging” (3), “difficult” (3), “manipulative” (3) and “self-harming” (3). Improvements in staff levels of understanding, compassion and attitude towards service users were indicated by the differences between pre- and post-training mean VAS scores. Wilcoxon signed rank tests indicated that self-reported levels of understanding (Z = 4.09; p < 0.001), compassion (Z = 2.00; p = 0.045) and attitude (Z = 2.58; p = 0.010) were all statistically significant, with small-to-medium effect sizes (r). See Table 2. Mean VAS scores for enjoyment, perceived improvement in attitude and perceived learning post-training were all above 68. Highest mean VAS scores (>77) indicated that staff experienced the training as enjoyable, and it provided an opportunity for learning.

Table 3 describes content analyses of participant responses to questions evaluating the training impact. Key themes indicated that participants found the psychoeducation, interactive exercises and practical guidance helpful and reported that these improved their understanding of “personality disorder”. Participants reported improved understanding as significant in developing a more positive attitude towards people with a diagnosis of a “personality disorder”. Participants also reported a desire for more time for the training and an opportunity for more training sessions and greater use of video clips and case studies

Discussion

This study aimed to develop a single-session psychoeducational training on “personality disorder” for mental health staff working on acute psychiatric wards and evaluate its impact on staff attitudes towards working with service users with a diagnosis of “personality disorder”. Training was found to be feasible, well-attended and highly valued by staff. The study was innovative in that it used a brief intervention and a novel sample of acute psychiatric ward staff. In a free-association exercise, participants described that their experiences were often challenging when working with service users with a diagnosis of “personality disorder”. This finding is consistent with the broader literature suggesting that health-care professionals often view service users with diagnoses of “personality disorder” more negatively than those with other diagnoses (Bodner et al., 2011; Dickens et al., 2016; Egan et al., 2014; Markham, 2003; Markham and Trower, 2010; Ross and Goldner, 2009; Sansone and Sansone, 2013). VAS data indicated that the staff training led to increased levels of understanding, improved attitudes and increased feelings of compassion in staff towards working with service users diagnosed with a “personality disorder”. This is consistent with findings from research suggesting that training and education can assist in the improvement of empathy, understanding and attitudes towards working with self-harm in service users with a diagnosis of a “personality disorder” (Commons Treloar and Lewis, 2008; Riches et al, 2019). In another previous study, training and psychoeducation was also reported to be a source of support for managing emotional reactivity through building confidence and understanding in mental health nurses working with service users diagnosed with a “personality disorder” (Woollaston and Hixenbaugh, 2008). In the present study, participants reported that they had learned a lot from the training. However, some of the effect sizes were small, and this may be attributed to the brevity of the training. Qualitative feedback indicated that the training was well-received and perceived to be helpful and enjoyable. Psychoeducation, interactive exercises and practical guidance were highlighted by staff as helpful features in improving understanding and attitudes. Participants expressed a desire for more time on training in the future to support them in their work with service users diagnosed with “personality disorder”. Although sessions with durations longer than the planned 60 minutes demonstrated improved fidelity and the potential of offering more thorough support and education for participants, there were occasions when not all participants were able to remain for the entire training session. This highlights the difficulty within acute mental health services in providing training when staff are subject to multiple demands on their clinical time (Currid, 2009; Jenkins and Elliott, 2004).

Strengths of the current study include development of brief, novel training on “personality disorder” for mental health practitioners on acute psychiatric wards and the mixed methods approach in capturing both quantitative and qualitative data reflecting participants’ experience and feedback. Overall, the findings indicate that a single-session training on “personality disorder” for staff on acute psychiatric wards was feasible, perceived to be helpful and appeared to lead to significantly improved understanding of and attitudes towards, service users diagnosed with “personality disorder” in an acute setting. Staff feedback also highlighted a desire for further training and increased focus on practical support towards working with service users diagnosed with a “personality disorder”. The suggested effectiveness of the training, in addition to the recognition of the pervasive negative attitudes towards “personality disorder” and staff requests for further training, emphasise the need for more support for staff and future research on the impact of further training. However, it is important to note that the one-hour training developed in the current study was very brief, with no involvement from service users with lived experience. The Knowledge Understanding Framework (KUF) three-day awareness level personality disorder training, which is part of the NHS long-term plan, could therefore be considered to incorporates lived experience as a core part of the training (Finamore et al., 2020). Other limitations include the small sample size, absence of a control group, the lack of validated measures, the fact that data was not collected on whether participants reported that any specific elements of the video led to changes in understanding or compassion or the fact that there was not more data recorded for the free association task and the practical difficulty in inviting staff to attend the training given the hectic pace of work and competing demands on acute psychiatric wards. Participants who attended the training were also self-selected based on their availability and responses to some of the VAS may be susceptible to social desirability bias.

Without further training, staff negative perceptions may persist and impact on their confidence and ability to support service users with a diagnosis of a “personality disorder”, potentially leading to a lower quality of care (Shepherd et al., 2017; Thorndycraft and McCabe, 2008). This would also raise concerns over public health challenge (Duggan, 2007) and work-related stress and burnout experienced by staff when continuing to work without further support whilst these negative attitudes are prevalent (Bodner et al., 2011; Morse et al., 2012).

Despite these persistent and pervasive negative perceptions of “personality disorder”, the findings indicate that providing a single-session training, alongside regular staff support, may be essential and efficacious in improving the experiences and perceptions of staff when working with service users, which would in turn support the delivery of high-quality care. Staff should be encouraged to attend reflective practice groups to support them with their difficult experiences working with this client group. If staff are given protected time for training, it may lead to longer-term benefits for both staff and service users. Case discussion sessions should also be regularly offered by the psychology service to promote understanding, empathy and psychological mindedness when working with complex or challenging clients in acute inpatient settings (Turel et al., 2020).

Future research could incorporate findings from the current study to provide improved support and training to ward staff in the future. For example, future staff training for “personality disorder” could provide practical support to guide staff in their work. Interactive exercises could be prioritised. Future researchers and clinicians could also consider providing e-learning programmes as a refresher course to consolidate knowledge and understanding obtained through face-to-face training, given the challenges associated with staff attending face-to-face training during their clinical hours (Lamph et al., 2018). Future research could investigate the impact of a period of regular training on staff attitudes to “personality disorder”; how staff perceive and make use of reflective practice groups, to promote this space as a resource for staff training and wellbeing and staff views on what support is most helpful to promote effective and positive interactions with service users with a diagnosis of a “personality disorder” (Maltman and Hamilton, 2011). Whether staff had had relevant previous training might also have an impact on training effect. This was not evaluated in the present study but would be important to consider in future research. It would also be crucial to consider ways to incorporate the experiences of service users and their carers into the design of future training to ensure accurate representation of their voices and to promote collaborative working in service design and delivery. Follow-up examination on the longer-term impact of training on staff (i.e. whether there may be a reduction in changes of training impact over a period post training) and what it may mean for training providers (i.e. need for ongoing supervision and reflective practice) would also be valuable to consider in future studies.

Table 1

Demographic characteristics of staff who attended the personality disorder training

Demographic	Frequency N (%)
Gender (N = 37)
Female	25 (68)
Male	12 (32)
Age (N = 35)
20–29	5 (14)
30–39	14 (40)
40–49	10 (29)
50–59	6 (17)
Career stage (N = 29)
Student	1 (3)
< 1 year qualified	6 (21)
1–2 years qualified	3 (10)
2–3 years qualified	4 (14)
> 3 years qualified	9 (31)
Other	6 (21)
Job role (N = 37)
Doctor	3 (8)
Nurse	20 (54)
Occupational therapist	2 (5)
Activity coordinator	2 (5)
Clinical support worker	3 (8)
Other	7 (20)

Table 2

Visual analogue scales on staff levels of understanding, compassion, attitude, enjoyment, perceived improvement in attitude and learning (N = 37)

VAS	Pre-training Mean (SD)	Post-training Mean (SD)	Test	Effect size (r)
Level of understanding	52.57 (22.2)	67.36 (17.05)	4.09; p < 0.001*	0.48
Level of compassion	61.76 (21.67)	66.67 (20.46)	2.00; p = 0.045	0.23
Attitude	55.95 (18.59)	61.53 (16.90)	2.58; p = 0.010*	0.30
Enjoyment of training	–	83 (14.51)	–	–
Perceived improvement in attitude	–	68.89 (18.83)	–	–
Perceived learning	–	77.64 (16.10)	–	–

Notes:

Test = Wilcoxon signed rank test (Z);

*

= Statistical significance at p < 0.016 (two-tailed) level based on a Bonferroni correction for controlling for Type 1 error

Table 3

Content analysis of staff experience in participating in the personality disorder training (N = 37)

Question	Response categories	Frequency	Illustrative quote(s)
Helpful/ unhelpful aspects of the training	Interactive exercises	13	“The video was helpful to get an insight from a person with personality disorder” (#36)
	Psychoeducation	12	“Getting to know what they go through in their mind and how the environment has affected and made them who and what they are.” (#31)
	Practical strategies	7	“Coping strategies, tips, advice.” (#30)
	Everything	7	“All aspects were helpful.” (#2)
Suggestions for future training	More time/training sessions	13	“It could be for more hours – 2–3-hour training.” (#2)
	More interactive exercises	6	“Show more clips” (#32) “Perhaps more case study too.” (#1)
	More focus on practical strategies	5	“Would have liked more time thinking about working with people with PD.” (#14)
Aspects of training that improved understanding	Psychoeducation about PD	14	“Yes, I wasn't aware that there isn't necessarily a trauma or negative life experiences for the disorder to develop.” (#4)
	Practical guidance	4	“Yes, how to cope with care delivery of patient with personality disorder.” (#10)
Reasons for improved attitude	Improved understanding	9	“Yes, more compassionate and understanding.” (#10)
	Improved compassion/ empathy	5	“Yes. Made me become more compassionate – better understanding what people with PD are going through.” (#23)
	Confidence to improve practice	5	“Yes – as above I feel that I can change my practice in small ways to help the patients express what they need.” (#11)