Posted: February 16th, 2022

Dynamics of mental healthcare in the most restrictive alternative





Case Study After Placement


















Assessing needs and planning care with a service user who has a lived experience with a specific mental health condition


            In order to keep themselves and their patients safe, all nurses in the mental health sector care must be trained in risk assessment and management (Stevens et al., 2018, p 1170). Risk Assessment and Management within the context of Mental Health Nursing delves into topics such as strategies for avoiding risk situations, risk definitions, risk assessment techniques and tools, suicide, forensic aspects of risk, self-harm, victimology, neglect, the risk to others, substance misuse, ethical considerations and risk to self (Kinman, and Teoh, 2018, p 01). A mental health assessment results provide a doctor with a clear picture of the patient’s reasoning, thinking, feeling, and memory. To evaluate your emotional well-being, you will be asked a series of questions throughout the mental health exam. Ms Catherine, a service user who has experienced BPD, is the centre of this article’s assessment and care. This essay’s key topics are the evaluation of needs and the planning of care for a person with a lived experience of borderline personality disorder (BPD). Total adherence to the provision of 2018 nmc code 2018 regarding maintaining privacy is highly upheld in this case analysis (Green, Tinker and Manthorpe, 2018, p 01). The chapters on effective nursing and midwifery care, where the code emphasises the utilisation of services at the centre of care, are given special attention in the code. The major themes of focus include prioritising the people, effective practice, preserving safety, and promoting professionalism and trust-building. 


            My personal experiences with Ms Catherine, a 68-year old retired civil servant having a BPD condition, highlights critical characteristics of the user and the observations made during the period of care provision. I noted that most of the BPD conditions are terrified of abandonment or insecurity, and they may find it difficult to tolerate being alone. While at St. Andrews University Hospital, Ms Catherin could not be engaged in any meaningful and lasting relationships. She exhibited symptoms of improper anger, impulsiveness, and frequent mood swings that may push others away. The BPD usually appears in early adulthood, and it appears to develop worse in young adulthood before gradually improving with age. 

            Approximately 10% to 15% of patients in outpatient clinical settings and 15% to 20% of patients in inpatient psychiatric settings are regarded to meet the diagnostic criteria for BPD. BPD diagnosis criteria include suicidal or self-harming behaviour, which I learned may be difficult to manage and recover from in many situations, with rates of suicide among persons diagnosed with BPD ranging from 8% to 10%. (White and Brooker, 2020, p 1-3). A pattern of unstable and intense interpersonal relationships and emotional instability, self-mutilation, and poor impulse control have always been seen among BPD service-users. As a junior professional, I found it difficult to treat, communicate with and empathise with these service users, possibly because BPD behaviours have the potential of causing a negative impact on interpersonal interactions, especially relationships with the nursing staff.


Assessing the needs of the service user

            The status of persons with borderline personality disorders (BPD) is critical in assessing the requirements of service users. Psychotherapy and hospitalisation were two of the most pressing issues that Ms Catherine had to deal with. An important characteristic of those with borderline personality disorder (BPD) is that they may experience mood fluctuations and lack confidence in their own abilities and their role in society. Because of this, their ideas and interests might change at a moment’s notice. Those with borderline personality disorder tend to perceive things in black and white terms, all good or negative. Their impressions of other people might likewise shift swiftly. People may go from being friends to enemies or even traitors in the blink of an eye. Borderline personality disorder (BPD) makes it difficult to maintain deep personal relationships, particularly with those closest to the sufferer (Kinman and Teoh, 2018, p 01). Those who are close to a person who has bipolar disorder may experience a variety of distressing symptoms, including mood swings, anger outbursts, and anxiety about being abandoned. Relationships with persons who have BPD are typically described as an emotional roller coaster with no clear end in sight by partners and family members. (Gale et al., 2016, p 1046). People with borderline personality disorder are also prone to seeing things in black-and-white terms, such as everything is either good or terrible. They, too, may change their views about others at any time. People who are considered friends one day may suddenly be seen as foes the next. Emotional swings may lead to dissatisfactory relationships.

             The nursing assessment involves a systematic and continuous process of gathering data, sorting, analysing, and structuring the data, as well as the documentation and sharing of that data (O’Shea et al., 2016, p 150). The formulation and implementation of a patient-centred care plan based on evidence-based practices are made possible by the integration of creativity and critical thinking skills across the whole nursing process. With precision education, therapy is tailored to an individual’s cultural, physiologic, and spiritual needs rather than a one-size-fits-all approach that often fails. The nursing evaluation includes acquiring information about the patient’s psychological, socioeconomic, physiological, and spiritual needs. In order for a patient to be properly evaluated, this is the first stage in the process. Another crucial part of the process is collecting data, both subjectively and objectively (Hird, 2017, p 1561). Every stage in the nursing process would be guided by the accuracy and relevancy of particular clinical procedures. Preliminary information is gathered by observation, which includes both subjective and objective data, such as a patient’s medical and surgical history and his or her social and psychological background, on to diagnosis, which requires the use of clinical judgment to formulate nursing diagnoses and determine what could be wrong with the patient (Agnol et al., 2019, p 40).

Additionally, a care strategy must be developed, which includes objectives, treatments, and possible outcomes. After completing the job or implementing the intervention, you’ll need to activate and implement your plan. The next phase is observation, which is used to determine whether or not the intervention was effective.

            The purpose of the initial nurse assessment is always focused on the determination of the assessment parameters and responsibilities necessary to plan and deliver appropriate, tailored patient care. This includes an appropriate degree of care to ensure that there is the satisfaction of the demands of the client or patient in a linguistically and culturally competent manner (Cheung and Yip, 2017, p 02). Evaluating the patient’s response to care and support from the community is also part of the pre-admission assessment. Once admitted, you will be assessed and reassessed. Finally, the last strategy is to discharge a strategy that is safe. After all, the information has been considered, and the patient is admitted, and the patient comes on the unit, or their status is converted to inpatient, they are given a medical history and a physical examination (Romeu‐Labayen et al., 2020, p 868). The information gathered should be recorded on the Nursing Admission Assessment Sheet, which may differ slightly depending on the facility. All information gathered should be included. The nurse performing the assessment must document and sign the assessment, either in writing or electronically.

            Morality and appropriate conduct are at the heart of ethics, yet they are not necessarily mandatory for a person to follow. Although they are not ideal conditions for a physician to adhere to, they are required under medical ethics. The legal elements of patient care are controlled by country-specific regulations, which are in turn guided by medical ethics. Medical ethics and the laws of the nation are considered when an Indian psychiatrist is accused of misconduct. The patient-physician interaction is governed by confidentiality’s moral and ethical sanctity, particularly in mental health (Agnol et al., 2019, p 40). Psychiatrists play a major role here. However, in therapeutic settings, patients with mental illness (P.W.M.I.) have the option of waiving this confidentiality agreement. 

                        In terms of service user engagement, there are a number of key attributes of service user engagements that were highlighted. Firstly, there is a person-centred approach whereby in a person-centred approach, the focus is on the individual (Fan and Lyu, 2021, p 155). Care planning, medication and other forms of therapeutic intervention, evaluation, and risk analysis have all been identified as possible applications for informed decision-making (Danivas et al., 2016, p 150). It is important for informed decision-making to have proper knowledge, shared information, and a wide range of treatment and care alternatives available. Users of mental health care services need advocacy, it was discovered. There’s a chance that professional lobbying on behalf of service consumers may fail at some point and that citizens’ or self-advocacy are crucial since they don’t have a conflict of interest with the service providers they represent.

            In terms of receiving views of the service user and their feedback, quality of life is valued more by service users than by mental health experts as an outcome metric (Cheung and Yip, 2017, p 01) It was noted that the service user can influence so many areas like government agencies, civil services, legislature, public servant, and expert and lobby groups through reports and briefings, in the provision of informal mechanisms and evidence, that working in close partnership was also emphasised. Some of the studies have shown that there is need for effective working partnership between the service users and the healthcare professionals. 

            The principle of recovery in the recovery-oriented mental health practices are focused on a number of areas of focus that forms the basis of the recovery process. These include the uniqueness of the individual service user. Users are encouraged to realise that recovery results are distinctive and unique to each individual and extend beyond the only focus on health to include an emphasis on social involvement and the quality of life. When moving towards recovery, practitioners become agents of hope to the service users and for everyone’s recovery and who value each service user’s individuality, expertise, personality and individual self-worth and significance of their experiences (Agnol et al., 2019, p 40). Again, for an effective recovery process, practitioners would focus on services that help citizens, social integration, and inclusion by helping them overcome social, political, and economic hurdles. To ensure individualised, person-centred treatment plans, the systems used must foster a culture of self-determination, participation in decision-making, and a willingness to take calculated risks. A significant premium will be placed on improving access to, maintaining continuity of care for, engaging patients in treatment, and implementing programs driven by those patients themselves.

            Many interpersonal skills were used to demonstrate the ability to provide mental health treatment from a person-centred viewpoint and improved outcomes for the service user in this case (White and Brooker, 2020, p 02). Studies like Agnol et al. (2019, p 40) have shown that people who have utilised mental health services cherish the opportunity to relate their story and, more crucially, being heard. Other skills include the ability to paraphrase all the communications from the service user. This helps in decoding the information shared to elicit the appropriate action. Again, developing summary skills is very instrumental in ensuring that only precise and main points were noted in any engagement with the service users. Proper understanding of non-verbal communication is very helpful in the analysis of actions and moves made by the service users (Romeu‐Labayen et al., 2020, p 868). This is very helpful in ensuring that the information is properly decoded and the most appropriate responses are given. 


Planning care for the service user for service users with BPD

This clinical guideline elaborates on these findings and offers recommendations for service design and organisation for individuals with a borderline personality disorder. The evaluable evidence was thoroughly examined. Service providers and practitioners will be provided with the most up-to-date information about borderline personality disorder therapy as it is available so that they may choose what sort of services optimise effectiveness and safety while minimising damage. BPD therapy should be recognised as a valid use of healthcare services by health practitioners at all healthcare system levels and in all types of healthcare institutions, including general practices and emergency departments.

A person’s BPD should never be used as an excuse to deny them health treatment. Respectful, kind, sympathetic, consistent, and dependable health providers should work with patients who have BPD. Listening carefully, taking the other person’s sentiments seriously, and communicating properly are all vital when someone is expressing their ideas and feelings. If a patient with BPD is agitated or letting their emotions get the better of them, healthcare professionals should remain calm and nonjudgmental. Health care providers should be aware that people with BPD are more prone to feelings of rejection and abandonment when treatment ends or they no longer see the same person. The person should be made aware of these changes before they are implemented. Trauma-informed treatment is essential for people with BPD, who may have been subjected to significant stressors in the past or in their daily life. Assessing a person’s level of trauma should be done with caution and in the appropriate context. It is not appropriate to obtain information on a patient’s past trauma history during a crisis. When people with BPD share past trauma, health care practitioners should verify their experience and respond with empathy. A person with bipolar disorder (BPD) may only be told about their family’s past trauma if they give their permission. As a result, many people with BPD seek treatment to help them better understand and cope with their condition. Individualised treatment plans (Template 1) for people with BPD should be developed with their involvement. The person’s family or spouse should be engaged in developing the management plan if it is in their best interest and they have given their consent.

If persons with BPD self-harm or attempt suicide on a frequent basis, their routine health care provider should evaluate their risk. Health care providers must have an in-depth understanding of the patient over time in order to assess when the patient is at high risk of suicide and whether long-term BPD treatment should be continued or special emergency care should be provided to keep them safe at all times. Suicidal thoughts are less likely to recur when people’s well-being is improved. Healthcare practitioners should focus on the ‘here and now’ while treating someone with BPD in crisis. Longer-term treatment with the person’s BPD-treating psychiatrist (for example) may be more effective at addressing problems that need more in-depth discussion (for example, earlier experiences or relationship troubles). Even in the midst of a crisis, health care providers should strive to keep their patients involved in their own search for solutions.

The bulk of a person’s BPD therapy should be delivered at a mental health facility in their local neighbourhood. Severe and long-lasting BPD should be referred to an appropriate BPD service. Those who are at danger of suicide or major self-harm should be admitted to a hospital or other inpatient facility, but this should not be a long-term treatment option for those with BPD. Hospital stays should be limited and focused on attaining certain goals agreed upon by the patient and their healthcare professionals, such as recuperation or treatment. Long-term hospital admissions for persons with BPD should typically be avoided by health providers. If a person with BPD has to go to the E.R. because they’ve self-harmed or are unable to manage their emotions, staff should arrange for mental health treatment to begin while their physical needs are being met. Emergency department workers should treat patients who have injured themselves with professionalism and compassion. Each health care provider should appoint a key contact person for a person with BPD who gets treatment from more than one health service and is responsible for coordinating the patient’s care across those providers. All health care providers engaged in the patient’s care should be informed of the management plan, which should include a concise crisis plan. The plan should also be updated on a regular basis. People with BPD who often go to the E.R. or their regular care physician for help during a crisis should discuss their crisis plan with these health care professionals as well. A general training program that fosters empathy, respect, and the execution of the principles of management of individuals with BPD for all employees who come into touch with service users with this condition is required in order to effectively apply I.C.P.s for BPD.

These principles apply to all interactions between service users and staff, and it is the obligation of both staff and service users to uphold them. Improving mental health care by including the people who will use it and encouraging them to participate actively in treatment are two of the most prevalent approaches. Many persons who have experienced mental health issues themselves offer a unique viewpoint that might be helpful to both the individual and those who provide mental health assistance. Mental health nurses commonly treat patients with borderline personality disorder in both the hospital and the community. It is believed that between 3% and 4% of the population has BPD, making it the most prevalent personality disorder. BPD is more common than schizophrenia or bipolar disorder, according to research conducted throughout the world. Few studies have examined the sympathetic relationships between psychiatric nurses and patients with bipolar disorder. One study found that nurses had lower empathy scores than psychiatric and psychological professionals for persons with BPD. Nurses, as compared to other mental health professionals, are seen to be the least sympathetic by BPD patients. Nursing staff responses to patients with BPD, as well as BPD service consumers’ characteristics and assumptions, have been extensively studied.

Psychodynamic case formulation looks at how the patient’s symptoms first occurred and is a valuable guideline for physicians since it looks at object connections, ego strength, mental capability, and fundamental conflict, prepares therapy, and predicts prognosis. Symptoms of borderline personality disorder (BPD) include a dramatic life experience, impulsivity, interpersonal issues, and mood and behavior instability. The clinical presentation and therapeutic response of the disease are influenced by these unstable and diverse symptoms. People with BPD have strong transference and countertransference reactions, and they are often labeled as “difficult patients” by healthcare providers and nurses who spend the most time with them in inpatient settings. As a result, psychodynamic formulation is very important and effective in BPD situations in order to better understand the patient and manage treatment procedures.

Criteria for compliance with Regulations in planning care

            Healthcare and nursing rules must be followed to the letter. Regulation 15 stipulates that each resident of an authorised institution must have an Individual Care and Treatment Plan (I.C.P.). In addition to having an I.C.P. in place, every authorised center resident must also be reviewed against nine separate criteria for each I.C.P. (Griffith, 2018, p 01). Scholars consider mental health nursing plan as a multifaceted role that provides practical and social support in addition to more formal psychological therapy. Some of the most common complaints and observations made by the service users in the U.K. include inadequate information, poor inter-professional communication, and a lack of possibilities for collaborative treatment are among the complaints made by service users (Lepping et al., 2013, p 543). Notably, many international researches like Graney et al. (2020, p 1046); and Ogunlesi and Ogunwale (2018, p 35) believe that BPD is more common than either schizophrenia or bipolar disorder in the general population.

Criterion 1: I.C.P. in place (Interim)

            Criteria 1 necessitates the implementation of a comprehensive evaluation, admission, and discharge planning process. As soon as the service user is admitted to the authorised facility, they must have an interim care plan in place. On the basis of admissions and risk evaluations, this plan should be implemented.


Assessment: On entrance to the authorised facility, the service user should immediately undertake a comprehensive assessment of their talents, problems and concerns. The admitting doctor should conduct an interview with the service user, preferably with the admitting nurse present.

On admission: To address the service user’s immediate requirements, the admitting doctor and nurse must fill out an interim care plan. When the MDT members meet with the service user, they may add to or amend the interim care plan.

Discharge planning done as part of the assessment process: The MDT should begin the process of discharge planning as soon as possible after admission, in collaboration with the service user’s family/advocate and the service provider.

Criterion 2: MDT ICP in place within 7 days

A full MDT ICP must be in place during and after the 7-day period following hospitalisation. This applies to all certified acute and long-term care facilities.

In this case, a classical example is given of a service user who maintained that she possesses extraordinary abilities and can read people’s minds and feelings, her next-door neighbour, she believes, will be her future husband (Romeu‐Labayen et al., 2020, p 868).   This is not recorded using the description of ‘Relapse of psychotic symptoms.

Criterion 3: Involvement of service user

Care planning necessitates the participation of service users. Wherever possible, the MDT and the people responsible in receiving care should be encouraged to work together.

In this case, Recovery terminology such as ‘co-production’ need to be used more often.

Criterion 4: Review and development of MDT Input

An individual’s care plan must include all necessary treatment and care as defined by Mental Health Act 2001 (Approved Centers) Regulations 2006, Regulation 15, as well as all necessary resources and the resident’s relevant objectives that are in accordance with best practices (Griffith, 2018, p 01).

In this case, the MDT review involves the process of evaluation of the I.C.P.

Criterion 5: Setting appropriate goals to be used by the resident

Approved Centers under the Mental Health Act 2001 (Approved Centers), Regulations 2006, Regulation 15, it is stated that; 

The individual care plan shall specify the treatment and care required which shall be in accordance with best practice, shall identify necessary resources and shall specify appropriate goals for the resident.” (Romeu‐Labayen et al., 2020, p 868).

In this scenario, it is noteworthy that the I.C.P. should include co-creation and documentation of important objectives for the service user.

It would be tough to come up with appropriate goals for the challenges, issues, or needs of the service users. 

Criterion 6: Treatment and care towards meeting goals

A service user’s stated demands and obstacles need that the care, treatment, or interventions be tailored to meet those needs. A basis for this may be found in the Mental Health Act 2001 (Approved Centers) Regulations 2006, Section 15; 

The individual care plan shall specify the treatment and care required which shall be in accordance with best practice.”

Criterion 7: Resources towards care provision

The Mental Health Act 2001 (Approved Centers) Regulations 2006 Regulation 15, which states that;

The individual care plan shall specify the treatment and care required which shall be in accordance with best practice, shall identify necessary resources.” (Romeu‐Labayen et al., 2020, p 867).

Notably, the materials accessible to the MDT as a whole as well as the service user assist us in putting the interventions in place.

Criterion 8: Any acute episode needs to be reviewed after seven days and routine care after six months

Pre-planned I.C.P. evaluation in partnership with service users is essential for this procedure. When clinically necessary, an unplanned review of a patient’s treatment plan may also be required.

Criterion 9: Documentation

The I.C.P. must be documented in a collection of documents. This includes goals, treatment procedures, care provision, and resources required. It also includes allotted space/sections for reviews. There is a need for clear clinical file records that are identifiable and uninterrupted.

Criterion 10: Education requirement (for children)

As part of the MDT ICP, adult inpatient units should include education requirements for children. Children may be considered to be inpatients within the adult unit for an extended amount of time. 


            It was the goal of this article to examine and arrange care for a person with Bipolar illness. This essay’s primary topic is on how to diagnose and arrange for the treatment of someone who has a personal history of borderline personality disorder (BPD). Nurses must be aware of the hazards that threaten them and their patients in order to maintain a safe working environment, and risk assessment and management are critical components of care for people with mental illnesses. It is important to note that in this example, personal experiences with a BPD patient and observations made over the course of therapy are highlighted. In this instance, the BPD patient need both counseling and institutionalisation to meet his or her basic requirements. During the planning process, it was established that strict adherence to healthcare and nursing requirements as required. Individual Care and Treatment Plans (I.C.T.P.s) are required under Regulation 15 for all residents of licensed facilities (I.C.P.). All residents at recognised centers must have an Individualised Care Plan (I.C.P.), and each I.C.P. must be reviewed on nine distinct criteria.













References list

Agnol, E.C.D., Meazza, S.G., Guimarães, A.N., Vendruscolo, C. and Testoni, A.K., 2019. Nursing care for people with borderline personality disorder in the Freirean perspective. Revista gaucha de enfermagem40.

Cheung, T. and Yip, P.S., 2017. Workplace violence towards nurses in Hong Kong: prevalence and correlates. B.M.C. public health17(1), pp.1-10.

Divas, V., Lepping, P., Punitharani, S., Gowrishree, H., Ashwini, K., Raveesh, B.N. and Palmstierna, T., 2016. Observational study of aggressive behavior and coercion on an Indian acute ward. Asian journal of psychiatry22, pp.150-156.

Gale, N.K., Thomas, G.M., Thwaites, R., Greenfield, S. and Brown, P., 2016. Towards a sociology of risk work: A narrative review and synthesis. Sociology Compass10(11), pp.1046-1071.

Graney, J., Hunt, I.M., Quinlivan, L., Rodway, C., Turnbull, P., Gianatsi, M., Appleby, L. and Kapur, N., 2020. Suicide risk assessment in U.K. mental health services: a national mixed-methods study. The Lancet Psychiatry7(12), pp.1046-1053.

Green, C.E.D.A., Tinker, A. and Manthorpe, J., 2018. Respecting care home residents’ right to privacy: what is the evidence of good practice? Working with Older People.

Griffith, R., 2018. District nurses must guard against inappropriately accessing patient records. British journal of community nursing23(7), pp.355-357.

Hird, M., 2017. Service user involvement in mental health assessment: comparing people’s experiences of mental health triage assessments with theoretical perspectives on user involvement. The international journal of psychiatric nursing research13(1), pp.1561-1577.

Kinman, G. and Teoh, K., 2018. What could make a difference to the mental health of U.K. doctors? A review of the research evidence.

Lepping, P., Lanka, S.V., Turner, J., Stanaway, S.E. and Krishna, M., 2013. Percentage prevalence of patient and visitor violence against staff in high-risk U.K. medical wards. Clinical medicine13(6), p.543.

O’Shea, L.E., Picchioni, M.M. and Dickens, G.L., 2016. The predictive validity of the Short-Term Assessment of Risk and Treatability (START) for multiple adverse outcomes in a secure psychiatric inpatient setting. Assessment23(2), pp.150-162.

Ogunlesi, A.O. and Ogunwale, A., 2018. Correctional psychiatry in Nigeria: Dynamics of mental healthcare in the most restrictive alternative. BJPsych International15(2), pp.35-38.

References list

Romeu‐Labayen, M., Rigol Cuadra, M.A., Galbany‐Estragués, P., Blanco Corbel, S., Giralt Palou, R.M. and Tort‐Nasarre, G., 2020. Borderline personality disorder in a community setting: service users’ experiences of the therapeutic relationship with mental health nurses. International journal of mental health nursing29(5), pp.868-877.

Stevens, J., Butterfield, C., Whittington, A. and Holttum, S., 2018. Evaluation of arts-based courses within a U.K. recovery college for people with mental health challenges. International journal of environmental research and public health15(6), p.1170.

White, E. and Brooker, C., 2020. Mental health nursing: is Rome burning? British Journal of Mental Health Nursing9(2), pp.1-11.


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