Abstract Risk is one of the most complex and anxiety-provoking issues faced by mental health nurses, with huge potential for not only helping but also significantly harming service users. Often considered narrowly in terms of violence and suicide, risk is best thought of more broadly as the potential of losing something of value. ‘How-to’ guides to risk may be fruitless when human beings are so complex, thus this chapter defines risk, identifies core foundational principles and relational practice required when working with service users, and presents models and discussion to aid critical thinking and reflection. The action/consequences model offers a thinking aid for decision making, considering how containing risk and tolerating risk can have a variety of outcomes, each of which can help or harm.

This paper explores competing meanings which may arise through receiving a diagnosis of "borderline personality disorder," discussing how this may impact a person's treatment and their sense of self. This paper is informed by qualitative case study research, which utilized interviews to explore experiences of crisis and crisis intervention for people diagnosed with borderline personality disorder, their family and friends, and professionals who work with them. Utilizing this qualitative research data, alongside wider literature, the conceptualization of "borderline personality disorder" and the actual and potential real-world consequences of receiving this label are explored. Potential meanings are mapped onto a "black hole" model where potential competing meanings exist in the same place at the same time, and harm a persons sense of self. "Borderline personality disorder" is the most controversial personality disorder diagnosis. People may conceptualize their distress through four different labels for borderline personality disorder, be seen as "not real mental illness," "borderline of what?", not personality disorder, only personality disorder, and too unstable for therapy. Spaghettification, a term from astrophysics, is used as a metaphor to explain how a persons sense of self can fragment as they are pulled into the confusion of this black hole.

In this comment piece, the author uses the analogy of jelly to understand the complexity of working with the risk of suicide ethically and effectively, including the impact of acts or omissions of mental health service interventions. The article explores the dilemma of how to contain risk, emphasising that while recognition of the complexity is important, perfection is impossible when working with the risk of suicide.

The aim of this paper is to identify barriers to quality mental health nurse education in the United Kingdom and show these through the sharing of personal experiences of working as a mental health nurse academic. Since the Nursing and Midwifery Council introduced their 'future nurse' education standards in 2018, mental health content for mental health nurses has been argued to have been marginalised. The sense of a diluted mental health nurse education was supported by an open letter, signed by over 100 mental health nurses, with representation across 33 universities. Nonetheless, the approach taken by the NMC has been defended. Meanwhile, mental health nurse academics all over the United Kingdom are having varying experiences, some of incredible discomfort and invalidation. The movement 'mental health deserves better' arose through many of these mental health nurses feeling they had no representation or channel to voice their concerns. This is a personal position paper which outlines barriers to autonomy for mental health nurse academics, and shares personal opinion on experiences which have impacted the ability to deliver a depth of knowledge, skill and critical thinking to students, impacting the quality of new mental health nurse graduates. The issue is discussed using contemporary literature to support lines of argument, which are augmented by personal experiences of working in nurse education. There are complex interconnected issues within nurse education which can hinder the autonomy of mental health nursing to decide its own future. This paper recounts a personal journey. Often we cannot understand the failings of a system until we try to navigate it from the inside.

The following speech was read verbatim, to open the matter for discussion on the future nurse standards, at the Royal College of Nursing Congress in Glasgow on 9 June 2022.

This article aims to draw attention to increasing genericism in nurse education in the United Kingdom, which sees less specialist mental health education for mental health nursing students and offers opposition to such direction. In 2018, the Nursing and Midwifery Council produced the 'Future Nurse' standards which directed changes to pre-registration nurse education. This led to dissatisfaction from many mental health nurses, specifically regarding reduced mental health content for students studying mental health nursing. Concerns have been raised through public forum and evolved into a grassroots national movement 'Mental Health Deserves Better' (#MHDeservesBetter). This is a position paper which presents the perspective of many mental health nurse academics working at universities within the United Kingdom. Mental health nurse academics collaborated to develop ideas and articulate arguments and perspectives which present a strong position on the requirement for specialist pre-registration mental health nurse education. The key themes explored are; a conflict of ideologies in nursing, no parity of esteem, physical health care needs to be contextualized, the unique nature of mental health nursing, ethical tensions and values conflict, implications for practice, necessary improvements overlooked and the dangers of honesty and academic 'freedom'. The paper concludes by asserting a strong position on the need for a change of direction away from genericism and calls on mental health nurses to rise from the ashes to advocate for a quality education necessary to ensure quality care delivery. The quality of mental health care provided by mental health nurses has many influences, yet the foundation offered through pre-registration education is one of the most valuable. If the education of mental health nurses does not attend to the distinct and unique role of the mental health nurse, standards of mental health care may diminish without assertive action from mental health nurses and allies.

Professional self-disclosure can be defined as a clinician revealing personal information about themselves to the person they are caring for. This article provides reflections from clinicians working in child and adolescent mental health services (CAMHS) and their navigation of professional self-disclosure during the coronavirus disease 2019 pandemic. The reflections focus on the use of self-disclosure in supportive relationships with foster carers. Drawing on the authors’ practice experiences as clinicians in specialist CAMHS settings, the article considers changes in the way that self-disclosure was approached following the shift to remote care delivery during the pandemic. The authors suggest that remote working involves a potentially increased scope for inappropriate use of self-disclosure and outline the implications for mental health nurses working with foster carers.

Many mental health nurses and academics believe that the Nursing and Midwifery Council's standards of proficiency for registered nurses, published in 2018, have negatively affected mental health nurse education in the UK. Serious concerns had been raised before the implementation of these standards, but warnings were not heeded and many people think that the 'dilution' of mental health nurse education that they once feared has now become reality. This article presents some of the arguments made by mental health nurses and academics against a generic approach to education, or genericism. The authors suggest that there is now a debate about these issues in the profession, as demonstrated by the emergence of a grassroots movement called Mental Health Deserves Better, and that mental health nurses need to resist the loss of specialist education and look towards the future of the profession.

Mental health nursing students experience education from both academic institutions and on clinical placements, yet there often remains a divide in understandings and attitudes between the two. This editorial provides personal and professional comment on this issue, and identifies it as something which must be addressed in order that we promote rather than hinder the development of our profession.

The Nursing and Midwifery Council's (NMC) Standards of Proficiency for Registered Nurses have noble aims and yet their impact has been an assault on mental health nursing as a specialism.

Purpose The use of long-term anti-psychotic medication for borderline personality disorder contravenes prescribing guidelines in the UK. There is evidence to suggest clozapine can be beneficial yet anecdotally it is prescribed almost exclusively in locked settings. A single study suggests a substantial proportion of psychiatrists disapprove of this practice. The purpose of this paper is to articulate concerns about the use of clozapine for “BPD” that are absent from current literature. Design/methodology/approach This paper summarises the reflections and experiences of the authors lived experience, academic and clinical backgrounds. Findings The published literature is uniformly positive when describing the prescription of clozapine for those diagnosed with BPD; however, this in no way reflects the experience of the authors. There is no body of material reflecting a study showing that a substantial number of psychiatrists have issues with this practice. Research limitations/implications While it is a fact that there is a discrepancy between psychiatrists attitudes towards clozapine prescription for “BPD” and the published literature, the described concerns in this paper are based solely on the authors’ experiences and observations. Practical implications Those seeking literature to articulate concerns about the use of clozapine with this population will likely be disheartened by the paucity of published literature. Originality/value To the best of the authors’ knowledge, this paper is the first to raise substantial concerns about the use of clozapine for those diagnosed with “BPD” and the circumstances in which it is prescribed.

Self-disclosure can be valuable in therapeutic relationships, although practitioners may feel apprehension around boundaries and worry what may be appropriate. This article asserts the importance of critical thinking around self-disclosure, emphasising that while there is no clear ‘right and wrong’, what is necessary in professional practice is to carefully consider its purposeful use. Discussion using evidence and clinical examples is framed within a model that may be used to aid reflection on the use of self-disclosure within the therapeutic relationship. Self-disclosure is a grey area, but its use in mental health nursing can be invaluable.

WHAT IS KNOWN ON THE SUBJECT?: People diagnosed with "BPD" often experience crisis and use services "BPD" is a controversial diagnosis, and the experience of crisis and crisis intervention is not well understood WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: People diagnosed with "BPD" have different experiences of crisis, and using the diagnosis alone as a basis for deciding care and treatment is not appropriate There are many human factors which can influence how professionals deliver care to people diagnosed with "BPD" WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The education of staff, views on responsibility, team conflicts and access to clinical supervision can have an impact on how care is delivered, and should be addressed by organizations providing crisis care. Access to care often occurs when a person is self-harming or suicidal, but does not address underlying distress. Crisis care should go beyond managing behaviour and address any underlying needs. ABSTRACT: Introduction "Borderline personality disorder" ("BPD") is associated with frequent use of crisis intervention services. However, no robust evidence base supports specific interventions, and people's experiences are not well understood. Aim To explore the experiences of stakeholders involved in the crisis care of people diagnosed with "BPD." Method Integrative review with nine databases searched January 2000 to November 2017. The search filtered 3,169 titles and abstracts with 46 full-text articles appraised and included. Results Four themes were constructed from thematic analysis: crisis as a recurrent multidimensional cycle, variations and dynamics impacting on crisis intervention, impact of interpersonal dynamics and communication on crisis, and balancing decision-making and responsibility in managing crisis. Discussion Crisis is a multidimensional subjective experience, which also contributes to distress for family carers and professionals. Crisis interventions had limited and subjective benefit. They are influenced by accessibility of services, different understandings of "BPD" and human dynamics in complex decision-making, and can be experienced as helpful or harmful. Implications for practice Subjectivity of crisis experiences shows limitations of the diagnostic model of "BPD," emphasizing that interventions should remain person-centred. While thresholds for intervention are often met after self-harm or suicidality, professionals should review approaches to care and support people with underlying distress.

People with personality disorder diagnoses have been described as a challenging group to work with, and this has led to negative perceptions and stigmatisation of the clinical label. A hypothesis that these negative perceptions are rooted in a lack of empathy, directly related to a lack of understanding of the lived experience of these conditions, led to the development of a teaching session using experiential learning. The session used simulation to allow students to adopt the role of a person diagnosed with a personality disorder and interact in a facilitated scenario. A qualitative and phenomenological design saw the perceptions of four student nurses captured through a focus group and interview. Students described the teaching session as beneficial in having improved their empathy and increased their understanding of the experience of people living with personality disorder diagnoses, allowing them the understanding to be able to challenge stigma, giving them a desire to role model good practice to others and increasing their confidence in working with people with personality disorder diagnoses. This has clear implications for practice through increasing understanding and reducing the potential for negative perceptions, thus potentially improving the experience of mental health care for people with personality disorders.

Patients with borderline personality disorder are frequent users of inpatient mental health units, with inpatient crisis intervention often used based on the risk of suicide. However, this can present an ethical dilemma for nursing and medical staff, with these clinician responses shifting between the moral principles of beneficence and non-maleficence, dependent on the outcomes of the actions of containing or tolerating risk. This article examines the use of crisis intervention through moral duties, intentions and consequences, culminating in an action/consequence model of risk management, used to explore potential outcomes. This model may be useful in measuring adherence and violation of the principles of beneficence and non-maleficence and therefore an aid to clinical decision making.