Journal of Mental Health

ISSN: 0963-8237 (Print) 1360-0567 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmh20

The experiences of people with borderline

personality disorder admitted to acute psychiatric
inpatient wards: a meta-synthesis

Anna Stapleton & Nicola Wright

To cite this article: Anna Stapleton & Nicola Wright (2017): The experiences of people with
borderline personality disorder admitted to acute psychiatric inpatient wards: a meta-synthesis,
Journal of Mental Health, DOI: 10.1080/09638237.2017.1340594

To link to this article: http://dx.doi.org/10.1080/09638237.2017.1340594

Published online: 07 Jul 2017.

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ISSN: 0963-8237 (print), 1360-0567 (electronic)

J Ment Health, Early Online: 115

2017 Informa UK Limited, trading as Taylor & Francis Group. DOI: 10.1080/09638237.2017.1340594

REVIEW ARTICLE

The experiences of people with borderline personality disorder

admitted to acute psychiatric inpatient wards: a meta-synthesis
Anna Stapleton1,2 and Nicola Wright1
1
School of Health Sciences, University of Nottingham, Nottingham, UK and 2Millbrook Mental Health Unit, Nottinghamshire Healthcare NHS Trust,
Sutton-in-Ashfield, UK

Abstract Keywords
Background: Acute psychiatric inpatient care is recommended for people with borderline borderline personality disorder, acute
personality disorder (BPD) to manage a crisis. Qualitative research exploring service user psychiatric, meta-synthesis, qualitative,
experience is valuable for the development of evidence-based treatment guidelines. systematic review, lived experience,
Aim: To conduct a meta-synthesis of qualitative research exploring the experiences of people inpatient, narrative accounts, health
with BPD on acute psychiatric inpatient wards. services research, crisis intervention
Methods: Literatures searches of five electronic databases. Data were analysed using a three-
stage theme identification process. History
Results: Eight primary studies and three first-hand accounts met the inclusion criteria. Four
overarching themes were found to explain the data: contact with staff and fellow inpatients; Received 9 May 2016
staff attitudes and knowledge; admission as a refuge; and the admission and discharge journey. Revised 10 February 2017
Conclusions: Similar experiences of acute psychiatric inpatient care were reported by people Accepted 5 March 2017
with BPD across the studies. Opportunities to be listened to and to talk to staff and fellow Published online 6 July 2017
inpatients, time-out from daily life and feelings of safety and control were perceived as positive
elements of inpatient care. Negative experiences were attributed to: a lack of contact with staff,
negative staff attitudes, staffs lack of knowledge about BPD, coercive involuntary admission
and poor discharge planning.

Introduction professionals towards people with BPD (Deans &

Meocevic, 2006; Markham, 2003; Markham & Trower,
Best practice in the treatment of borderline personality
2003; Morris et al., 2014; NIMHE, 2003).
disorder (BPD) is an area of contention due to a lack of
Livesley (2003) suggests that prolonged acute inpatient
robust evidence for the psychological, psychosocial and
admission provides more opportunities for people with BPD
pharmacological interventions commonly used (NICE,
to develop maladaptive patterns through interaction with staff
2009). A lack of specialist services for people with BPD
dynamics. Despite being recommended only as a last resort
has meant that the majority are managed within general
(CAAPC, 2015), the prevalence of inpatients with a diagnosis
mental health services such as community mental health
of BPD has been reported as between 15 and 25% (Weight &
teams (CMHTs) (NCCMH, 2009) and day hospitals (NICE,
Kendal, 2011). An alternative to unplanned inpatient admis-
2009). Current NICE (2009) guidance stipulates that people
sion is the use of regular brief planned admissions, also
with BPD should only receive short-term acute psychiatric
referred to within the literature as the brief admission
inpatient care in order to manage crises which cannot be
intervention (BAI). BAIs are incorporated into crisis plans
contained within other services due to a significant risk to self
which are developed jointly between patients and community
or others. The perceived difficulties of supporting people with
mental health professionals, with the duration of admission
BPD within mental health services are well-documented, with
stipulated as part of the plan (Helleman et al., 2014b). BAIs
this client group often being referred to as difficult and
are recommended by the Dutch Multi-disciplinary Guideline
disruptive (Piccinino, 1990, p. 22) and unpopular with
Committee (2008 cited by Helleman et al., 2014a) and a
staff (Fagin, 2004, p. 94). This is reflected by people with
recent review carried out in the Netherlands suggested that the
BPD who describe living with a label for which they feel
BAI was effective in the prevention of self-harm and suicide
judged, blamed and negatively perceived by health profes-
in people with BPD (Helleman et al., 2014a). However, this
sionals (Nehls, 1999). An abundance of empirical research
suggests that it was merely successful in controlling symp-
has demonstrated the negative attitudes of healthcare
toms of a crisis rather than having any long-term therapeutic
benefit. Indications for brief versus extended inpatient
Correspondence: Anna Stapleton, Nottinghamshire Healthcare NHS
Trust, Millbrook Mental Health Unit, Sutton-in-Ashfield, UK. E-mail: hospitalisation are also outlined in US practice guidelines
anna.s89@hotmail.co.uk for the treatment of patients with BPD (American Psychiatric
2 A. Stapleton & N. Wright
Association Practice Guidelines, 2001). Comparatively, UK
guidelines do not recommend BAIs as part of crisis manage-
ment; although they do suggest that the length and purpose of
the admission is agreed in advance (NICE, 2009).
Consideration of the feasibility, appropriateness and
meaningfulness of healthcare from the service users view-
point is important for the development of evidence-based
treatment guidelines (Korhonen et al., 2013). Exploration of
service users healthcare experiences is typically performed
through qualitative research (Korhonen et al., 2013) which
examines the experiences, feelings and attitudes of people in
relation to a particular phenomenon (Ryan et al., 2007). Some
primary qualitative research has explored the experiences of
people with BPD admitted to acute psychiatric inpatient
wards; however, a review of the findings from these existing
studies has not yet been undertaken. Therefore, using the
meta-synthesis methodology, a systematic literature search of
existing qualitative research was carried out with the aim of
understanding the experiences of people with BPD who have
been admitted to acute psychiatric inpatient wards. In contrast
to the narrative synthesis approach whereby words and text
are used to explain findings, including those from statistical
studies (Popay et al., 2006), the meta-synthesis approach
involves the amalgamation of qualitative data, i.e. words and
text, from several studies to aid deeper understanding of a
given topic area. It is anticipated that by synthesising
qualitative research which explores the experiences of
people with BPD in acute psychiatric wards, the role of
treatment for this client group in this setting, particularly that
provided by mental health nurses, can be better understood.
Methods
Meta-syntheses interpret aggregated findings from a number of
qualitative studies in order to produce novel insights and
theories (Walsh & Downe, 2005). The aim of a meta-synthesis
is to generate theories, generalisations or interpretations
through the integration or comparison of original findings
from qualitative studies (Sandelowski et al., 1997). Specifically,
meta-syntheses are useful for promoting greater understanding
of lived healthcare experiences (Walsh & Downe, 2005).
The development of a systematic search strategy was aided
by an initial literature search whereby relevant keywords were
identified in order to refine the search terms and criteria for
the present meta-synthesis. The PRISMA flowchart (Moher
et al., 2009), seen in Figure 1, was adapted for the meta-
synthesis approach and depicts the search process. Inclusion
and exclusion criteria were identified using the SPIDER
(sample, phenomenon of interest, design, evaluation, research
type) search strategy tool (Cooke et al., 2012). Table 1
outlines the inclusion and exclusion criteria using the
SPIDER tool components. In addition to these criteria, only
research published in English was included. A search for
journal-published studies and books was carried out in four
electronic databases (CINAHL, Medline, EMBASE and
PsycINFO) from their dates of inception until April 2015.
The following search terms were used: borderline person-
ality disorder or emotionally unstable and experience, looked for competing themes (Malterud, 2001). Malterud
attitude, view, perception, emotion, feeling or (2001) argues that agreement should not necessarily be the
perspective and psychiatric hospitals, psychiatric goal within qualitative research employing multiple
J Ment Health, Early Online: 115
units, psychiatric care, mental health ward or
mental health hospital, and patients, psychiatric
patients, inpatients, hospitalisation, patient admis-
sion, admit or admission. To achieve a wider and more
in-depth meta-synthesis (Walsh & Downe, 2005), a search
was also carried out on the OpenGrey European database of
grey literature. Potentially relevant articles were selected for
full text evaluation to ensure they met the inclusion criteria.
Overall, this resulted in the final selection of seven journal-
published qualitative studies, one unpublished thesis and three
journal published first-hand accounts of living with BPD.
Table 2 displays the characteristics and methodological
features of the included primary qualitative studies.
The Critical Appraisal Skills Programme (CASP) assess-
ment tool (e.g. Carlsen et al., 2007; Downe et al., 2007) was
used to assess the quality of the included studies. Variation
was found in the level of methodological rigour across the
studies; there was greater depth of description of the data
collection and analysis processes in some studies.
Consideration of the researchers own potential biases is an
important part of qualitative research, however, this was
lacking amongst the included studies (Milton Keynes Primary
Care Trust [MKPCT], 2002). Taken together, these limita-
tions impact upon the reliability of the findings from the first
authors. Despite this variability in quality, all of the studies
were included because knowledge is seen as constructed
within the qualitative research paradigm and the meta-
synthesists interpretations of the studies findings may be
different to those of the original researcher(s) (Walsh &
Downe, 2005). Reporting of the meta-synthesists own
positions and preconceptions can improve reflexivity rather
than introduce bias (Malterud, 2001). The present authors
interpretations of the data may be influenced by their
experiences of working with people with BPD as mental
health clinicians. Furthermore, the research question was
identified when negative staff attitudes towards the BPD
diagnosis were perceived by the first author during a
placement on an acute psychiatric ward as a student mental
health nurse; therefore, this may have lead to an expectation to
find patient reports supporting this within the literature.
Data analysis followed a three-stage process similar to that
used by Taylor et al. (2011). First, all data relevant to the
research question was extracted and labelled as first order
themes. Similar first order themes were then clustered together
to form second order themes. Finally, similar second order
themes were grouped together to form super-ordinate third
order themes (Walsh & Downe, 2005). Given that the lived
experience articles (Desmond, 2004; Van Gelder, 2008;
Williams, 1998) were not primary research studies, data from
these sources were not incorporated into the identification of
themes but was instead used to add depth to the meta-synthesis.
Given the nature of constructivist research, interpretation
of the data by other meta-synthesists may have been different.
Reflexive data analysis therefore involved cultivation of
dialogue between the authors; the identification of themes
was primarily carried out by the first author, with these
findings being critically reviewed by the second author who
DOI: 10.1080/09638237.2017.1340594 BPD - acute psychiatric inpatient experiences 3
Figure 1. PRISMA flowchart demonstrating
Records identified through Unpublished theses identified
the search process.
electronic database searching through OpenGrey database
(Medline, EMBASE, PsycINFO, (n = 2)
CINAHL)
(n = 931)

Records after duplicates removed Records excluded

(n = 787) (n = 18)

Not primary
research
Not qualitative
Inpatient
experiences not
explored
Records screened for Explored inpatient
evaluation of abstract settings other than
(n = 47) acute psychiatric,
e.g. forensic settings

Full-text articles
excluded
Full-text articles (n =16)
assessed for eligibility
(n = 28) Not qualitative
Participants had
diagnosis other than
BPD and it was not
possible to identify
the data related to
Primary studies participants with
included in meta- BPD
synthesis (n = 8) Not acute
psychiatric inpatient
Non-empirical research setting
included (n = 3) No exploration of
patient experience

Table 1. Inclusion criteria defined using the SPIDER search strategy tool.

Sample People with BPD

Phenomenon of Interest Experiences of people with BPD who had been admitted to an acute psychiatric inpatient ward
Design Data collection: Qualitative approaches such as interviews and focus groups
Data analysis: Qualitative methods such as interpretive phenomenological analysis and thematic analysis
Evaluation Experiences, attitudes, views, opinions, perceptions, feelings and thoughts about admission to acute
psychiatric ward by people with BPD
Research type Any research with a qualitative design, including grey literature and first-hand accounts published in
journals. Mixed methods research was also considered if it included usable qualitative data related to the
research question

researchers. However, in this case, consensus was achieved
between the authors in the initial identification of themes.
Results
The eight studies were from three countries: UK (4), USA (2)
and The Netherlands (2). The total number of participants
across all of the studies was 90, with the samples ranging
from 5 to 30. Small sample sizes are typical of qualitative
research; the use of large samples would hinder deep analysis
and thus reduce the internal validity of the findings
(Sandelowski et al., 1997). Data collection in six of the
eight studies used semi-structured interviews (Gregory, 2010;
Helleman et al., 2014b; Horn et al., 2007; Koekkoek et al.,
 4

Table 2. Summary of the characteristics of the primary qualitative studies which were included in the meta-synthesis.

Author(s), year
of publication, Data analysis
country Publication location Sample and sampling strategy Aim(s) Data collection method strategy
Fallon (2003), Journal of Psychiatric and Seven people with BPD (four female, three To analyse the lived experiences of Unstructured interviews (one hour Grounded theory
UK Mental Health Nursing male; age range 2545 years) people with BPD in contact with maximum) which took place at a
Recruited via their consultant psychiatrist psychiatric services (including setting of the participants choosing.
from a variety of settings within a mental inpatient experience). Follow-up interviews were carried
health trust. out to validate development of con-
A. Stapleton & N. Wright

cepts and theories.

Gregory Unpublished doctoral Eight people with formal diagnosis of BPD To identify what mental healthcare Semi-structured interviews lasting Grounded theory
(2010), UK thesis; Canterbury Christ (six female, two male) clinicians and service users diag- 3090 minutes took place where
Church University, Kent, Recruited from a wide geographical area nosed with BPD perceived as the participants were seen for
United Kingdom covering two NHS mental health trusts in the helpful service relationships for treatment.
South East of England. people with this diagnosis.
Invitations and information packs were pro-
vided to care-coordinators to inform potential
service users about the study.
Helleman International Journal of Seventeen people with BPD (age range; 28 Describe experiences of the brief Interviews with a duration of 45 Thematic
et al. (2014b), Mental Health Nursing 59 years) admission intervention for people 75 minutes and guided by an aide analysis
The Participants were all patients in care at a large with BPD. memoir consisting of keywords.
Netherlands mental health facility and were asked to The first question was always:
participate by their community clinician. could you tell me about your
The sample had a mean frequency of 12 uses experiences with the brief admis-
of the brief admission intervention in the past sion intervention? Participants
3 years. were then asked to describe their
experiences in greater detail.
Horn et al. Journal of Mental Health Five people with BPD (four female, one Explore the experiences and under- Semi-structured interviews took Interpretive
(2007), UK male; age range 2344 years) standings of those who have been part in therapy rooms provided by Phenomenologi-
Potential participants were approached by a given the label of BPD. local mental health services. cal Analysis
mental health professional involved in their Interviews lasted between half an
care. hour and one and a half hours and
All participants had used mental health stopped when the participant felt
services in the past 6 months as well as they had nothing more to say on the
having 2 or more years contact with mental subject.
health services in the past.
Koekkoek Perspectives in Eight females with BPD (age range 2461) Establish the effects of a prevent- Semi-structured interviews, average Thematic
et al. (2010), Psychiatric Care People who were receiving treatment in the ive psychiatric admission system, 45 minutes. analysis
The Community Mental Health Centre and had a patient service use and patient Main questions: how patients had
Netherlands history of repeated or long-term admissions views on the intervention. experienced the intervention and
were asked to participate. how it affected their relationships
with mental health professionals
and their daily lives.
Nehls (1994), Issues in Mental Health Five people with BPD To understand the clients lived Individual interviews asked what Hermeneutics
USA Nursing All participants were clients at a community experience of brief hospital treat- does it mean to you to have a brief
mental health centre and had been involved in ment plans. hospital treatment plan?
the brief hospital treatment programme for at
least one year.

(continued )
J Ment Health, Early Online: 115
DOI: 10.1080/09638237.2017.1340594 BPD - acute psychiatric inpatient experiences 5

phenomenology
2010; Nehls, 1994, 1999), one used unstructured interviews

Data analysis
(Fallon, 2003) and another used a focus group (Rogers &

Interpretive

Thematic
Dunne, 2011). All participants had a diagnosis of BPD and

analysis
strategy
their age, where reported in five of the eight studies, ranged
between 21 and 61 years.
Much of the rich qualitative data on the experiences of
living with BPD provided in the personal accounts is beyond

what is it like for you to live with

Focus group facilitated by ex-ser-

Individual interviews last approxi-
mately one hour. Initial question:

mean to you? then depending on

production of personal examples

vice users who had experience of

what does the diagnosis of BPD

Questions were agreed between

CPDS and facilitators and were
placed on a flipchart for discussion.
the scope of the present review; therefore, only data
supporting the themes identified in the empirical studies
were extracted from these sources. To offer a brief summary

facilitating focus groups.

the diagnosis of BPD? of each account, Williams (1998) suggests ways in which
Data collection method

mental health professionals can help in recovery from BPD,

including the role of hospital admission. Desmonds (2004)
account of living with BPD throughout her teenage years
and early adulthood includes her experiences as a psychiatric
ward inpatient. Van Gelders (2008) narrative aims to give the
reader a sense of what its like to live with BPD (p. 244)
and includes some reflections on her experiences of hospi-
talisation. Interestingly, each personal account appears to have
Understand what is unique about

ences of service users with a

To explore the inpatient experi-

been written from the perspective of being recovered from

living with the diagnosis of BPD.

BPD rather than being a current service user or inpatient.

The identified first order themes were clustered together to
develop the following 11 second order themes: talking; being
listened to; contact with fellow inpatients; staff attitudes
personality disorder.

towards BPD; staff knowledge and understanding of BPD;

time-out; safety; control; discharge planning; use of the
Mental Health Act (MHA) 1983; and dependency. These were
Aim(s)

then clustered together to develop the following four third

order themes: contact with staff and fellow inpatients; staff
attitudes and knowledge; admission as a refuge; and the
admission and discharge journey. The three stage process of
All participants were under the care of a

had been admitted to an acute psychiatric

ward. They were invited to participate by
Recruited from a crisis intervention service
of a community mental health clinic, an
outpatient mental health clinic and an acute

Ten people with BPD (nine female, one male;

community personality disorder service and

identifying themes is demonstrated in Table 3. Text from the

included studies is used here to assist in explaining the
findings; text quoted from the original authors is
indicated using single inverted commas (), whilst double
inverted commas () are used to directly quote participants
Sample and sampling strategy

speech.
age range of 2145 years)
Thirty females with BPD

their care coordinators.

Theme 1: contact with staff and fellow inpatients

psychiatric unit.

This most prevalent theme was represented by data in seven

studies (Fallon, 2003; Gregory, 2010; Helleman et al., 2014b;
Koekkoek et al., 2010; Nehls, 1994, 1999) and developed
from the three second order themes talking, being listened
to and contact with fellow inpatients. Having the oppor-
tunity to talk was perceived as a fundamental element of acute
psychiatric wards:
Research in Nursing and

Journal of Mental Health

I guess for me the brief term plan offers just a chance to

Publication location

talk. (Nehls, 1994, p. 6)

Therapeutic benefits were reported as a result of having the

Health

opportunity to talk to professionals such as mental health

nurses:

The nurses think about things which I cannot think about

Author(s), year
of publication,

&
Dunne (2011),

at such moments. What I can do to find distraction, for

Nehls (1999),

example (and) how to handle things the next time. You

learn what causes the problems, why you react the way you
country

Rogers
USA

did. (Helleman et al., 2014b, p. 446).

UK
Table 3. First, second and third order themes generated from data analysis.

First order themes

6

Gregory (2010) Helleman et al. (2014b) Koekkoek et al. (2010) Nehls (1994) Rogers & Dunne (2011) Second order Third order
themes themes

Id even phone the The nurses think about things which I While admitted, the Another client viewed Hell ask you what Talking Contact with
ward some nights just cannot think about at such moments. easy accessibility of the brief hospital treat- do you thinks best for staff and
to talk to somebody and What I can do to find distraction, for professionals is helpful, ment program as an you in your health?, fellow
sometimes they would example (and) how to handle things the although the lack of opportunity to alleviate and this is what I inpatients
talk to me for a while next time. You learn what causes the time and attention is loneliness through con- think is best for you,
but not often and thats problems, why you react the way you did. criticised by many. (p. versation. She said: I and well come to a
because I had no one I think about these conversations, even 131) guess for me the brief good middle agree-
else to talk to. (p. 70). after discharge. (p. 446) Contact with. . .staff term plan offers just a ment. (p. 229)
A. Stapleton & N. Wright

It can help if they know which nurse they increases participants chance to talk. (p. 6)
can talk to, and it is easier to approach the self-awareness of their
nurse if the nurse makes the conversation vulnerabilities. (p. 131)
informal, such as over a cup of coffee or
on a walk with them. (p. 446)
Contact with a nurse enabled patients to
reconnect with themselves. (p. 446)
Talking helps make things clear. (p.
446)
Without such contact [with a nurse], the
brief admission was viewed as not having
a positive effect.
It can be very frustrating. I felt so alone.
I thought the staff would check on me, but
they left me all alone. The panic didnt
become less. I didnt get any structure,
support or feedback. (p. 447).

First order themes

Fallon (2003) Gregory (2010) Helleman et al. (2014b) Koekkoek et al. (2010) Nehls (1994) Nehls (1999)

. . .participants stated [Service users] felt unhelpful services did . . .I felt heard, and I It is very important . . .its nice to have a A participant described Being Contact with
that it wasnt therapy not listen. . .especially when services were told her stuff. (p. 446) that I feel listened to. sympathetic ear. I dont what mattered to her listened to staff and
they were asking for, busy (e.g. on inpatient wards). They (p. 132) get that at home. (p. when she was contem- fellow
just to be listened to think oh let her shuffle up and down the 5) plating suicide: inpatients
and given time and [ward] corridor because as long as she is [the hospital] was the . . .caring sensitive
emotional support. locked in why should we care? (p. 69) only place where any- persons who just listen
(p. 397) body would listen to and hear and respond
me. (p. 7) from inside. . .(p. 290)

First order themes

Helleman et al. (2014b) Koekkoek et al. (2010) Rogers & Dunne (2011)

Contact with fellow patients is also reported to provide support. . . .contact with fellow BPD patients is considered I didnt know anything; I had to find out from the Contact with Contact with
Patients sometimes know each other from earlier admissions, and crucial for the success of preventative admissions, patients. (p. 230) fellow staff and
therefore, understand each others problems. (p. 447) contributing to emotional support that is hard to inpatients fellow
It can also be difficult to maintain clear and healthy boundaries when find in non-BPD patients. It felt very good to inpatients
in contact with other patients. In the beginning, I went helping know that I was not alone. It helped me to discuss
my problems more easily. (p. 131)
J Ment Health, Early Online: 115

(continued )
others. . .Now I say, just go to the nurse, thats what theyre here for. I The confrontation with acutely admitted patients
am here for my own problems. (p. 447) with differing forms of disruptive behaviour, how-
ever, is considered a negative side-effect of the
preventive admission. (p. 131)

First order themes

Fallon (2003) Gregory (2010) Horn et al. (2007) Rogers & Dunne (2011)
DOI: 10.1080/09638237.2017.1340594

Those that had been in Service user participants who had experi- Getting the diagnosis was how I got kicked out They always make you feel like youre taking up Staff attitudes Staff attitudes
psychiatric hospitals enced inpatient settings described trau- (in-patient ward). . .I had an interview or something space, youre wasting a bed because youve got a towards BPD and
identified that they matising experiences (e.g.. . .being with the ward manager and the hospital manager personality disorder. knowledge
were made to feel disliked by staff.). (p. 72) and they all decided that I wasnt mentally ill. (p. Ah its not as bad as
undeserving of inpatient On the wards they have sworn at me. 262) schizophrenia.
care. One described the They think youre so bad that they can . . .They make it feel like its your fault for taking
attitudes of nursing staff swear at you if you dont get along with up that bed.
thus: them. (p. 72) . . .youre wasting a bed because youve got a
Yeah the attitudes can personality disorder.
be quite difficult I was wasting their time, using the bed that
because they cant somebody else would need. (p. 229230)
place you, its not like
Im a schizo-
phrenic. . .. (p. 397)

First order themes

Fallon (2003) Gregory (2010) Nehls (1999) Rogers & Dunne (2011)

When they were pre- [Service users] felt unhelpful services did A participant described her interpretation of the Theres a lot of people that dont understand PD. Staff know- Staff attitudes
sented with deeply dis- not. . .try to understand them especially underlying philosophy of a brief hospital treatment They put it down to youre just playing up, youre ledge and and
turbing emotional when services were busy (e.g. on inpatient program: theyre [mental health profes- being a pain in the bum. (p. 229) understanding knowledge
problems nurses usually wards). They think oh let her shuffle up sionals]. . .more interesting in protecting the. . .self- of BPD
dealt with this by advis- and down the [ward] corridor because as destructive [behaviour], but not paying attention to
ing the person to seek long as she is locked in why should we the causing of it. (p. 290)
out expert help, for care? (p. 69)
example by contacting
their psychologist. (p.
397)
Improved consistency
of care was identified
with. . .the education of
ward staff on psychiatric
wards by key inform-
ants. . .such as psycholo-
gists or psychiatrists.
(p. 397398).

(continued )
BPD - acute psychiatric inpatient experiences
7
 8

Table 3. Continued

First order themes

Helleman et al. (2014b) Koekkoek et al. (2010) Nehls (1994)

Most of the patients highly valued being able to take a step back The admission ward. . .is a space where they can This group of clients also used the hospital as a Time-out Admission as
from daily life during a brief admission to get some rest, take time off from their daily problems and place to rest. . .One client said: a refuge
distraction. . .Getting a lot of sleep and rest is perceived as helpful responsibilities. (p. 131) It was just a time out. Its nice;. . .You got
to recovery. Getting away from the busy responsibilities of daily life somebody else to take care of your meals, some-
A. Stapleton & N. Wright

for a short period and having less disturbance were found to help body else to take care of your meds, and you dont
patients relax. (p. 447) have to worry about that. (p. 5)

First order themes

Helleman et al. (2014b) Nehls (1994)

Patients tried to prevent negative outcomes, such as self-harm or When the risk of suicide became too high, clients viewed the hospital as a place to keep themselves safe. Safety Admission as
suicide. Tension and emotions can be reduced with a brief admission. One client expressed: I feel a tremendous relief when I get on the unit and turn in my pocket knife and the a refuge
(p. 446) extra pills I have. (p. 5)
You feel safe when youre in the clinic. . . (p. 447)
The availability of a brief admission in times of crisis, also gave
patients a sense of security. (p. 447)

First order themes

Helleman et al. (2014b) Koekkoek et al. (2010) Nehls (1999)

The most important short-term goal reported for the brief admission
was to overcome a crisis without loss of control. (p. 446)
The goal [of brief admission] is, of course, to prevent
worsening. . .The brief admission can stop the slippery slope. (p.
446)
The structure of a ward with its planned coffee breaks and meal times
can help patients regain control of their lives. (p. 447)
Another important positive element is the control . . .brief hospital treatment plans were experienced Control Admission as
participants have over their own treatment. . .Even as simply providing a safe, controlled environment. refuge
though [the brief admission] is still highly struc- (p. 290)
tured, participants do perceive it as under their
control. Because when I say I dont want to, I dont
go. Then it is over, period. (p. 131132)
When at home, the foresight of being re-admitted
within a few weeks facilitates participants to deal
with a crisis. (p. 132)

First order themes

Fallon (2003) Gregory (2010) Horn et al. (2007) Rogers & Dunne (2011)

Where participants had Most participants felt that being dis- . . .I got kicked out (inpatient ward). . .I got 3 days As soon as I said to them I wanted to leave thats Discharge Admission
been hospitalised for charged led to individuals feeling rejected to find myself somewhere to live, get out,. . .I had an what we worked towards and I was out within a process and discharge
self-harm behaviours especially when treatment endings were interview with the ward manager and the hospital month. (p. 229) journey
and now wanted dis- not handled appropriately by services as manager, and they all decided that I wasnt mentally Suddenly I went into ward round and they was
charge from hospital was commonly found on inpatient wards. ill. (p. 262) like oh youre discharged, and this was after being
but agreed to a period (p. 67) on one to one obs. (p. 229)

(continued )
J Ment Health, Early Online: 115
of leave prior to dis- I had leave which slowly increased, until the point
charge [they] felt that I went home for a week and I was discharged
included in the deci- when that week went okay. (p. 229)
sion-making process. It was a very slow process, and it did help, cause
(p. 398) it wasnt such a big reality shock when I got out and
I was on my own. (p. 229)
When I was discharged the last time now, I was
made homeless. (p. 229)
I mean I forgot how to cook and everything, and I
DOI: 10.1080/09638237.2017.1340594

had three young children and when they discharged

me I just didnt know where to begin. (p. 229)

First order themes

Gregory (2010) Nehls (1994) Rogers & Dunne (2011)

It was like a vicious circle. . .I was just in and out of hospital This group of clients acknowledged that one can It would be the odd weekend here, the odd Dependency Admission
but at least in hospital I felt cared for. (p. 70) like the hospital too much and become weekend there. (p. 229) and discharge
addicted. (p. 5) journey
being in the hospital became. . .my whole world
practically. (p. 7)
I really did get so wrapped up in the hospitals that
I didnt have another life, and that was not what I
wanted. (p. 7)

First order themes

Fallon (2003) Rogers & Dunne (2011)

They felt angry at restrictions on their liberty, such as being placed Theyll end up sectioning me just because Ive tried to leave, cause they dont let you out. (p. 229) Use of the Admission
on sections of the mental health act or being prevented from leaving You say you want to come out they say oh no, you cant. Were gonna section you. (p. 229) Mental and discharge
hospital. (p. 397) I had an interview with the psychiatrist, who said I could stay voluntarily or hed put me under section. Health Act journey
(p. 229) 1983
I didnt wanna go there, but he said if I didnt hed have to think about sectioning me. (p. 229)
The other thing that they need to change is that when they say erm you can go in voluntary or we can
section you they need to change that word cause its not voluntary. (p. 229)
BPD - acute psychiatric inpatient experiences
9
10 A. Stapleton & N. Wright
Opportunities for talking with staff appeared to provide
emotional support to people with BPD. Therefore, a lack of
such opportunities was emotionally detrimental and meant
that the admission was less positive:
It can be very frustrating. I felt so alone. I thought the
staff would check on me, but they left me all alone. The
panic didnt become less. I didnt get any structure,
support, or feedback. (Helleman et al., 2014b, p. 447)
Being listened to was another element perceived as an
important part of admission and was reported in six studies
(Fallon, 2003; Gregory, 2010; Helleman et al., 2014b;
Koekkoek et al., 2010; Nehls, 1994, 1999). Admission was
described as unhelpful when participants did not feel listened
to and this was attributed to inpatient wards being too
busy (Gregory, 2010). However, many participants valued
being listened to by professionals, including mental health
nurses, during times of emotional distress and felt that this
was sufficient without the need for expert therapy (Fallon,
2003).
A participant described what mattered to her when she
was contemplating suicide: . . .caring sensitive persons
who just listen and hear and respond from inside. . .maybe
youre inexperienced. . .but I as a consumer dont care
about that. . .. (Nehls, 1999, p. 290)
Contact with fellow inpatients was described as a useful
and helpful part of admission in three of the studies
(Helleman et al., 2014b; Koekkoek et al., 2010; Rogers &
Dunne, 2011) and a first-hand account (Desmond, 2004).
Describing her time spent on a psychiatric ward, Desmond
(2004, p. 5) states she made a lot of friends in hospital and
that she and other inpatients were bonded together through
[their] collective pain. In the studies, contact with people
with similar difficulties was experienced as a good source of
emotional support:
Contact with fellow BPD patients [provides] emotional
support that is hard to find in non-BPD patients.
(Koekkoek et al., 2010, p. 131)
The experience of having contact and shared understand-
ing with both staff and fellow inpatients is described in the
following extract of being hospitalised with BPD:
In 2001, when the country grieved the tragedy of 9/11, I
sat in a hospital day room with three over-medicated
women. . .The orderlies, the nurses. . .all seemed to finally
share what Id been feeling all along, as though the entire
nation and my interior world had something to finally
agree on. (Van Gelder, 2008, p. 247)
In summary, contact with staff and fellow patients was
the most common theme found in data from the primary
studies as well as first-hand accounts. The importance and
expectation of talking to and being listened to by staff during
inpatient admission are highlighted, along with the benefits of
having contact with fellow inpatients. The experience of
J Ment Health, Early Online: 115
admission was described as less positive and unhelpful when
there were no opportunities for contact with staff.
Theme 2: staff attitudes and knowledge
Two second order themes staff attitudes towards BPD and
staff knowledge and understanding of BPD contributed to
the generation of the third order theme staff attitudes and
knowledge. Data relating to this theme were found in five
studies (Fallon, 2003; Gregory, 2010; Horn et al., 2007;
Nehls, 1999; Rogers & Dunne, 2011). Many participants in
the studies described the negative attitudes of acute psychi-
atric ward staff towards people with BPD; for instance, some
reported that staff unfavourably compared them to people who
were experiencing mental illnesses such as schizophrenia:
Ah its not as bad as schizophrenia. (Rogers & Dunne,
2011, p. 229)
What is more, many participants reported feeling as though
staff thought that people with BPD did not warrant care and
that they were wasting a bed (Rogers & Dunne, 2011, p.
230). Such perceptions led people with BPD to feel
undeserving of inpatient care (Fallon, 2003, p. 397).
Some participants also perceived staff as having a lack of
knowledge and understanding of BPD, particularly of the
reasons for the behaviours which people with BPD may display:
Theres a lot of people that dont understand PD. They
put it down to youre just playing up, youre being a pain
in the bum. (Rogers & Dunne, 2011, p. 229)
Other perceptions of staff included a lack of desire to
understand BPD. Whilst talking about the care received
during a BAI, one participant described how she felt about
care which prioritises risk management:
Theyre [mental health professionals]. . .more interested
in protecting the. . .self-destructive [behaviour], but not
paying attention to the causing of it. (Nehls, 1999, p. 290)
Mental health nurses were also viewed as avoiding
opportunities to engage in helping people with BPD when
they referred them to more specialist clinicians:
When they were presented with deeply disturbing emo-
tional problems nurses usually dealt with this by advising
the person to seek out expert help, for example by
contacting their psychologist. (Fallon, 2003, p. 397)
However, it was also noted that greater consistency in care
was experienced where acute psychiatric ward staff had been
educated by more experienced informants, such as psycholo-
gists, about behaviour in relation to [people with BPDs]
personal histories, especially how their personalities and
behaviour had been influenced by abusive events (Fallon,
2003, p. 398).
In summary, acute psychiatric ward staff have been
perceived as lacking knowledge of BPD and as having
negative attitudes towards people with this diagnosis. More
specialist mental health clinicians such as psychologists were
DOI: 10.1080/09638237.2017.1340594
viewed as having greater knowledge and understanding of
BPD than nurses on the wards. As inpatients, many people
with BPD described being met with negative and discrimin-
atory attitudes of staff which led to some feeling rejected and
undeserving of care.
Theme 3: admission as a refuge
The theme of admission as a refuge reflects the more
positive aspects of admission to an acute psychiatric ward that
people with BPD experienced. The second order themes
time-out, safety seeking and control contributed to the involved joint decision making and the use of Section 17
generation of this theme. Time-out was identified as a theme
by the authors of three studies (Helleman et al., 2014b;
Koekkoek, et al., 2010; Nehls, 1994). Admission to an acute
psychiatric ward was viewed by some participants as
providing time-out from daily life by providing rest, sleep
and diminished responsibility:
. . .the admission ward. . .is a space where they can take
time off from their daily problems and responsibilities.
(Koekkoek, et al., 2010, p. 131)
The second order theme safety was found in three of the
studies (Helleman et al., 2014b; Nehls, 1994; Rogers &
Dunne, 2011). Admission to an acute psychiatric ward was
reported as helpful for providing practical and psychological
safety for people with BPD who were experiencing a crisis:
When the risk of suicide became too high, clients viewed
the hospital as a place to keep themselves safe. One client
expressed: I feel a tremendous relief when I get on the
unit and turn in my pocket knife and the extra pills I
have. (Nehls, 1994, p. 5) reported as a positive experience that people with BPD can
The usefulness of psychiatric hospital admission in
maintaining or regaining control is also perceived as import-
ant for people with BPD in overcoming a crisis (Helleman
et al., 2014b; Koekkoek et al., 2010; Nehls, 1999). Control
was also described in relation to the ward environment and the
effects of the BAI, for example:
The structure of a ward with its planned coffee breaks and
meal times can help patients regain control of their lives.
(Helleman et al., 2014b, p. 447)
Another important positive element [of the BAI] is the
control participants have over their own treatment.
(Koekkoek et al., 2010, p. 131132)
Awareness of the availability of hospital admission was
also perceived as enabling maintenance of control in
managing a crisis at home:
When at home, the foresight of being re-admitted within a
few weeks facilitates participants to deal with a crisis.
(Koekkoek et al., 2010, p. 132)
To summarise, admission to acute psychiatric wards was
experienced by many people with BPD as a refuge;
BPD - acute psychiatric inpatient experiences 11
particularly by those who have used the BAI. The importance
of having time-out from daily life, as well as opportunities to
seek safety and rediscover or maintain control during a crisis
were highlighted as important elements.
Theme 4: admission and discharge journey
The second order themes discharge process, dependency and
use of the MHA contributed to the generation of the third
order theme admission and discharge journey. Experiences of
the discharge process were varied; positive experiences
leave for those detained under the MHA prior to discharge
(Fallon, 2003; Rogers & Dunne, 2011). Comparatively, nega-
tive experiences were described as being rushed (Horn et al.,
2007; Rogers & Dunne, 2011), with people feeling rejected
(Gregory, 2010) and unprepared for life back in the community
(Rogers & Dunne, 2011), for example:
I mean I forgot how to cook and everything, and I had
three young children and when they discharged me I just
didnt know where to begin. (Rogers & Dunne, 2011, p.
229)
Dependency on hospitalisation was experienced as a key
element of the admission and discharge journey by partici-
pants in three of the studies (Gregory, 2010; Nehls, 1994;
Rogers & Dunne, 2011) and one first-hand account (Williams,
1998). Participants reported the experience of being regularly
discharged and readmitted to acute psychiatric wards, a
process which has been described using the term revolving
door (Desmond, 2004, p. 5; Rogers & Dunne, 2011, p. 229).
The theme of dependency was revealed where admission was
become addicted to (Nehls, 1994, p. 5). Dependency on
admission also appeared to be associated with participants
feeling cared for in hospital:
I was just in and out of hospital but at least in hospital I
felt cared for. (Gregory, 2010, p. 70)
When my doctor wouldnt hospitalise me, I accused him
of not caring. (Williams, 1998, p. 174)
Comparatively, Williams (1998, p. 174) criticises hospi-
talisation as a treatment approach for people with BPD and
states that it activates needy feelings and perpetuates the
patients sick self-image in her own eyes and those of staff.
Indeed, Williams (1998, p. 174) describes her personal
experience of psychiatric hospital admission as thus:
My self-destructive episodes one leading right into
another came out only after my first and subsequent
hospital admissions, after I learned the system was usually
obligated to respond. . .It prevented me from having to
make a choice to get well or even finding out that I wasnt
as helpless as I believed myself to be.
Williams (1998, p. 174) goes on to argue that repeated
hospitalisation denies people with BPD the autonomy to
12 A. Stapleton & N. Wright
realise their recovery and describes reminding herself of her
ever-growing time out of hospital as a major motivation in
pursuing her own recovery.
The experience of being detained under a section of the
MHA in an acute psychiatric ward was reported by partici-
pants in two of the studies (Fallon, 2003; Rogers & Dunne,
2011). In Fallons (2003) study, participants felt angry at
restrictions of their liberty when sectioning powers were used
to detain them. Also, some participants experienced being
coerced into staying on the ward voluntarily to avoid being
detained on a section:
I had an interview with the psychiatrist, who said I could
stay voluntarily or hed put me under section. (Rogers &
Dunne, 2011, p. 229)
In summary, an array of experiences of the discharge
process was described, ranging from collaborative and
effective, to rushed and rejecting. Also evident in the data
were the feelings of dependency on hospitalisation which
were evoked by the experience of cyclical readmission. What
is more, many people with BPD reported negative feelings
and experiences in relation to use of the MHA to detain them
on acute psychiatric inpatient wards.
Discussion
The findings from the present meta-synthesis suggest that
people with BPD have both positive and negative experiences
of admission to acute psychiatric wards. This echoes findings
from previous research exploring the acute psychiatric care
experiences of people with mental health diagnoses other than
BPD (Quirk & Lelliott, 2001; Walsh & Boyle, 2009). The
finding that people with BPD perceived staff to have negative
attitudes towards them supports existing research (Bodner
et al., 2011; Deans & Meocevic, 2006; Markham, 2003;
Markham & Trower, 2003; Morris et al., 2014; NIMHE,
2003; Weight & Kendal, 2011; Westwood & Baker, 2010).
However, it should be noted that the majority of perceptions
of negative staff attitudes were reported by participants in
Rogers & Dunnes (2011) study whose data collection
technique was a focus group attended by just ten of a total
of 65 service users invited from a community personality
disorder service. It is therefore possible that only those whose
experiences had been negative were more likely to participate
as they felt compelled to express their concerns.
The findings from this meta-synthesis counter the assump-
tion that mental health professionals have greater empathy for
the people they support and are unlikely to engage in
stigmatising behaviour (Bates & Stickley, 2013). According to
social learning theories, people form attitudes based on what
they learn from others (Bernstein et al., 2006); thus it could be
argued that negative attitudes towards people with BPD held
by staff in mental health services are perpetuated as staff
model the feelings, beliefs and behaviours they have learned
from one another. Attitudinal change can result from
providing people with information which they can process
and critically analyse (Bernstein et al., 2006). It is likely,
therefore, that some negative attitudes held by staff about
BPD stem from a lack of knowledge about the condition.
J Ment Health, Early Online: 115
Indeed, participants in the present meta-synthesis also
perceived ward staff as having a lack of knowledge and
understanding of BPD, thus highlighting a need for additional
training for staff working on acute psychiatric wards to
increase knowledge about how to support people with BPD.
The NCCMH (2009) highlights the value of specialist
personality disorder services in delivering support, training
and advice to secondary mental health services such as acute
inpatient wards. Research indicates that health professionals
are interested in further training in order to improve their
knowledge and understanding of BPD (Bodner et al., 2011;
Cleary et al., 2002; James & Cowman, 2007). In order to work
effectively with this client group, NICE (2009) guidance
states that professionals should be aware of the likelihood that
many people with BPD will have had past experiences of
rejection, abuse and trauma, and encountered stigma
associated with self-harm.
In the wider political context, tackling negative staff
attitudes towards BPD would assist in achieving an objective
of the Department of Healths (2011) No Health Without
Mental Health policy for fewer people to experience stigma
and discrimination. A review evaluating the effects of the
Time to Change campaign against stigma and discrimin-
ation towards people with mental health problems found a
lack of improvement in the amount of discrimination
experienced by service users from healthcare professionals
(Henderson & Thornicroft, 2013). Corrigan (2000) highlights
that people who are labelled with a mental health problem can
continue to be stigmatised even when they do not display
behaviours which are attributed to the diagnosis. This is
supported by evidence that people with BPD have been
rejected from services, including inpatient wards, merely
upon receiving their diagnosis (Horn et al., 2007; Morris
et al., 2014). Advocating a person-centred approach, Rogers
(1957) states that knowledge of a persons diagnosis is not
necessary in order to facilitate therapeutic engagement.
Although some people find diagnosis helpful, mental health
labels promote practice within the medical model (Scott,
2010) which has traditionally dominated acute psychiatric
inpatient care (Baguley et al., 2007).
In spite of the aforementioned criticisms of acute psychi-
atric care for people with BPD, this meta-synthesis also
highlights positive elements of ward admission, such as the
opportunity for time-out from daily life. This supports
findings from previous research that acute psychiatric wards
are perceived by service users as a sanctuary and distraction
from the outside world (Walsh & Boyle, 2009). Interestingly,
however, data from this theme came only from those studies
which explored the BAI. As noted by Koekkoek et al. (2010),
only participants who were happy with the BAI may have
agreed to participate. Whats more, the rationales for these
studies may have lead the researchers to be biased in their
reporting of the results; for example, Helleman et al.s
(2014b) rationale was the literature gap in patients percep-
tions of what makes a brief admission effective; thus, they
may have ignored data which highlighted how the BAI is
ineffective. Also, it is unclear how much the interviewers in
these studies guided participants to provide positive feedback
as the keywords used in the interview schedules which guided
the semi-structured interviews were not stated (Helleman
DOI: 10.1080/09638237.2017.1340594
et al., 2014b; Koekkoek et al., 2010). In addition to time-out
from daily life, the themes of safety and control were also
only found in those studies exploring the BAI. This suggests
that the BAI enables acute psychiatric wards to effectively
fulfil their purpose of providing a safe space during a crisis
(CAAPC, 2015) as well as ultimately offering people with
BPD a sense of control over their recovery.
Another important finding that emerged from the study
was that people with BPD feel dependent on inpatient wards.
Fagin (2004) suggests that ward staff should be prepared for
people with BPD being regularly readmitted and that they
should adopt a historical perspective to reflect upon how the
person has changed over time. Enhancing hope amongst staff
about the potential for future change may enable them to
engage with people with BPD in a more recovery-oriented
way. Jones et al. (2010) also point out that many people
admitted to psychiatric wards find it difficult to let go of the
safety they experience as inpatients. This could explain the
finding in the present study that many people with BPD found
the discharge process stressful. As highlighted by Fagin
(2004), the Care Programme Approach is a useful tool for
enabling discussion of boundaries, expectations and respon-
sibilities of all involved in the care of the person with BPD to
ensure a more effective discharge and reducing feelings of
dependency on inpatient admission. Williams (1998) argu-
ment in her lived experience article, that hospitalisation is
counter-productive in the psychological recovery of people
with BPD, contradicts the theme of dependency found in the
primary studies. However, given that Williams (1998)
outlines her position of no longer being symptomatic of
BPD, this adds weight to the finding that the symptomatology
of BPD fosters a feeling of dependency on inpatient wards.
Most people in England receive acute psychiatric care on a
voluntary basis (CAAPC, 2015); however, the present
findings support previous research that some people in the
UK experience being threatened with detention under the
MHA in order to prevent them from leaving hospital (Gilburt
et al., 2008). The MHA Code of Practice (Department of
Health, 2015, p. 116) states that: the threat of detention must
not be used to coerce a patient to consent to admission to
hospital or to treatment. As well as being morally concern-
ing, this practice may further undermine the ability of people
with BPD to take care of themselves (NCCMH, 2009). Such
de facto detention could be attributed to defensive practice
whereby clinicians prioritise self-protection from blame over
the patients best interests (Mullen et al., 2008). Doctors have
reported feeling pressurised into practicing defensive medi-
cine on acute psychiatric inpatient wards and feel that this is
unacceptable and non-therapeutic for service users (CAAPC,
2015, p. 13).
Contact with ward staff, including talking and being
listened to, was highlighted as an important and expected
part of admission by people with BPD. However, the present
studys finding that people with BPD sometimes experienced
a lack of contact with ward staff supports existing research
on service user experiences of acute psychiatric care (Walsh
& Boyle, 2009). In the present meta-synthesis, this was
attributed to staff being too busy or uninterested in
supporting people with BPD. Being listened to by nurses
was reported as sufficient (Nehls, 1999); however, it was
BPD - acute psychiatric inpatient experiences 13
also perceived that nurses may refer people with BPD to
experts because they felt they lacked the knowledge for
effective therapeutic engagement (Fallon, 2003). These
findings suggest that acts of compassion by nurses, such
as finding more time to listen (Morris et al., 2014), could
greatly improve the experiences of people with BPD on
acute inpatient wards. In a wider context, the findings
support the Royal College of Nursings (2014) assertion that
a shortage of mental health nurses in the UK is detrimental
to service users care experiences. The finding that contact
with fellow patients is a positive experience of acute
inpatient ward admission supports existing research
(Gilburt et al., 2008; Jones et al., 2010; Quirk & Lelliott,
2001) and suggests that empathy and mutual understanding
between inpatients is important, particularly where there is a
lack of opportunities for contact with staff.
When considering the limitations of the present study, it is
pertinent to acknowledge that a criticism of the meta-
synthesis methodology is that the integrity of primary
qualitative research is destroyed once it is summarised
(Sandelowski et al., 1997). Despite this, as the scope of the
findings from meta-syntheses is wider than that of single
qualitative studies, they are likely to be more generalisable to
the phenomenon being studied (Zimmer, 2006).
Furthermore, as two of the reviewed studies were carried
out in The Netherlands and two in the USA, generalisations
about the provision of acute psychiatric care for people with
BPD in the UK are made cautiously. Although some findings
were comparable across the three countries in which the
reviewed primary studies were carried out, more negative
experiences appeared to be reported in the UK studies.
However, this may have been influenced by the fact that the
non-UK studies explored experiences of the BAI rather than
unplanned admissions. To further explore the efficacy of the
BAI, future research should specifically compare experiences
of people with BPD using the BAI compared with unplanned
admissions.
It is also noteworthy that all of the reviewed studies based
their findings on participants retrospective ratings of their
experiences in acute psychiatric wards. This may have lead to
a potential recall bias whereby participants recollection of
past events is distorted (Hassan, 2005). Interestingly, research
suggests that people with BPD may be more susceptible to a
recall bias of negative rather than positive emotions (Ebner-
Priemer et al., 2006). Future research could therefore focus on
exploring the experiences of people with BPD during their
admission to acute psychiatric wards.
Conclusions
The findings from this meta-synthesis have highlighted
positive and negative elements of acute psychiatric inpatient
care experienced by people with BPD. Although some
findings were comparable across the three countries, less
positive experiences appeared to be reported in those studies
carried out in the UK in which participants had unplanned
admissions rather than the BAI. Of significance was the
perception of negative staff attitudes towards people with
BPD as this finding supports existing literature and highlights
the importance of the education and training of staff.
14 A. Stapleton & N. Wright
Overall, the findings are informative for the development
of a care pathway for people with BPD as they suggest that,
despite the dependency on hospitalisation that some partici-
pants reported, acute psychiatric inpatient care is perceived by
service users themselves to have an important role in crisis
management. However, changes to acute psychiatric inpatient
service provision and mental health nursing practice are still
required in order to further improve the experiences of care
for people with BPD.
Declaration of interest
The authors declare no conflicts of interest. The authors alone
are responsible for the content and writing of this article.
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