Presentation by Dr Sheila Mortimer Jones - Staff Perspectives of the Innovative Open Borders Program. Presented at the Western Australian Mental Health Conference 2019

1. Staff Perspectives of the Innovative Open Borders Programme
Dr Sheila Mortimer-Jones
Dr Ahmed Munib
Professor Paul Morrison
Ms Amanda Hellewell
Assoc. Professor Francesco Paolucci
Professor Catherine Hungerford
Ms Jumiati Sinwan
Mrs Sonia Neale

3. Residential facility
• Managed and staffed by nurses 24 hours
• No doctors on site
• Buy food, cook and do laundry
• Communal meals twice a week

4. Relapse Prevention
• Requires extra support there
may be a decline in
functioning due to stressors
Stepdown
• Prepare for discharge home
following hospital admission
Step-up
• The consumer has become
unwell and requires extra
support. Would otherwise be
admitted to hospital
Open Borders Program
• Offered to consumers with
BPD who meet set criteria
• Brief stay 3-7 days
• 24 hours phone coaching
• Modified DBT
• Self-referral
Residential Facility
• Public state-wide
• 10-bedded residential
• Shared bedrooms
• Staffed 24 hours by
nurses
• Available to all mental
health consumers
regardless of diagnosis
who are actively managed
by a mental health service

5. Costs
 Cost of one bed day in an acute mental health facility is
$1300
 Cost of one ED attendance $600
 Other costs:
 1:1 special observations
 Emergency call outs
 One bed day in HRS approx $400

6. Open Borders programme
 To be accepted onto the programme:
 Diagnosis Borderline Personality Disorder
 5 or more presentations/admissions 12 months
 Or one long admission
 Heavy users of the system
 Same criteria for admission to HRS except
 Can self-refer
 Additional 24 hour phone support

7. Open Borders -Aim
 Break the cycle of hospital admission
 Reduce rates of self harm
 Support recovery journey
 Self referral
 Avoids escalating behaviours which can arise when a client tries to gain
admission to hospital – increasing self harm and suicidality
 Discharge date set on admission
 Early discharge encouraged

8. Admissions
 These are either prearranged or crisis driven
 Prearranged – short periods of respite – 3-7 days.
Ranging from every two months down to every two weeks,
depending on the support needs of the client
 Crisis driven – Client can simply phone up the service
and request to come in. If a bed is available that will be
facilitated. Client is encouraged to act early to avoid crisis
rather than wait

9. OB programme
 DBT focused
 Validation of emotional responses
 Mindfulness groups
 Building a life worth living
 Monthly meetings as a group with clinical
psychologist
 to increase understanding of BPD and skills in
managing/changing behaviours

10. OB programme
 Reviewing crises to work out what went wrong and
how the situation could be better dealt with in the
future
 Reduced focus on medications
 Explicit focus on borderline personality disorder and
its symptoms

11. OB programme
 Avoidance of terms such as “being unwell”
 can have the effect of relieving the client of responsibility
 Reduced focus on risk
 Increased focus on coping
 Self ownership of progress
 Instil sense of pride
 Phone coaching service
 Plan – research effectiveness of the programme

12. Evaluation
 Recorded semi structured interviews
 Staff and clients
 Experienced Mental Health Nurse
 Helen Fisher RN

13. Analysis
 Staff – 9/10 particpants
 Clients – 8/8 particpants
 Thematic analysis
 Small meaning units
 Categories
 Themes

14. Staff perspectives Findings
 Themes
 Benefits of the programme
 Challenges
 Emotional impact
 Client outcomes
 Effect of the physical environment

15. Benefits
 Flexibility to spend time with clients
 Tailoring care
 “you are in a great position in that you can just sit there with a
client and really nut out what is the absolute best thing for them”
 “This is like, I’m going to tailor this very much to you. I’m going to
make this fit for you”
 Home away from home
 “there’s a more friendly, village, communal type of feeling amongst
the clients and the place”
 “they’re also around other clients with similar mental health issues
as them…...so they have…they can make friends..there’s a social
setting for them.. and… have a sense of belonging”

16. Benefits
Empowerment
 “this business of people being encouraged to take control of
their own treatment, organise your own admissions, seek out
and use the support that’s available for them rather than being
a passive recipient is the key”
 Small supportive team approach
 “they’ve got somebody .... who knows them ….. they don’t have to tell
their life story every single time”

17. Emotional impact
 Rollercoaster of emotions
 “it’s kind of emotionally draining and then mentally
challenging but you enjoy it and you do see those glimmers of
people moving forward”
 “sometimes it’s great, sometimes it’s overwhelming and
sometimes it’s just exhausting”
 Rewarding
 “from the hospital environment to here…… it’s a lot more
rewarding because you just see the clients come through get a
lot more out of this service than they would if they went to the
hospital … it’s just a different way of nursing….a different
treatment setting that I find.. it’s lot more effective”

18. Emotional impact
 Demanding, intensive work
 “and they are very common themes, suicidal stuff..so you
might be listening to 3, 4 people who are staying here, who are
suicidal. Really… full on stuff”
 “sometimes you’re listening to..one person with problems,
then another person’s problems..and you’re just soaking it all
up..”

19. Challenges
 Lack of resources
 “we need equipment, we need arts supplies, we need all that sort of
stuff”
 “even if they just want to paint for example or just do art and craft,
we often …. we struggle to get the money at the moment for that “
 Heavy responsibility
 “when pushed comes to shove, you are actually…you are actually IT”
 “It’s not like a ward, where you’ve got two, three, four other people to
work with um, and help guide…. you’ve got an RN after hours left on
their own to make some tricky decisions”
 “Sometimes you are on your own here……so you have to make all the
decisions and you have to….. make the right calls… . and decide things
yourself..”

20. Client outcomes - staff
 Positive growth
 “and they come alive..like they used to use self-harm…now they use
alternative strategies… they doing other things..so they’re still in the
system but they’ve changed a lot …and they’ve grown”
 Caring for others
 “and it gives people ..the opportunity to do something for others
when they say, ‘Oh no, me and such and such will prepare the
communal meal’ and that comes with a whole bunch of benefits aside
from just keeping yourself busy, it comes with benefit of other people
saying, ‘Hey that meal was really good, thanks very much.’ It’s a real
boost to people’s self-esteem. It’s simply the opportunity for helping
other people …”

21. Client outcomes - clients
 They’re all, if you need them they are there. I’ve never
had that, never in my life. Never! C3
 ... come the end of this month …...it would have been an
entire year where I have not had a hospital admission….
Which is epic for me C1
 And the place is relaxed and pretty chilled … it’s not
clinical and it’s not…. as artificial. C1
 I used to think black and white thinking and now I think
I try to think more positively than negatively. Hampton
Road has basically saved my life. C3
 Pills don’t work, I reckon I could do without pills…(in the
Open Borders program) they medicate, but not as much.
I’m happy, smile, laugh C3

22. Client outcomes - Clients
 “I’m here today because they cared enough to want
me to hang around” C2
 “I’m growing, I’m finding myself more now… I’m
dealing better with the Borderline Personality
Disorder and the people are really nice here, you
know. They’re friendly and there’s no nastiness in
here ... “C8

23. The residential building
 Structural limitations
 “they haven’t got their own bedroom or their own ensuite or anything
like that.. and so it’s a bit like the backpackers… so yeah I mean that
would have been ideal wouldn’t it ..to have…a little bit more space”
 “Some people find the environment fine, shared bedrooms, shared
bathrooms…but it’s not what other people expect in the 21st
century….”
 “Shared bedrooms, as much as people moan and groan about that,
and as much as a pain in the bum it is sometimes, it has huge
benefits you know in that, if you’ve got people in single bedrooms,
they just isolate, they can be doing anything in there, and just
knowing that, like you see some people just being in proximity to
another human sometimes is therapy on its own.”

24. Summary - staff
 Observed positive client outcomes
 Caring, sense of achievement, positive growth
 Residential facility
 Old world charm – communal feel
 Mixed - Some benefits to shared rooms
 More activity rooms/resources/garden area required
 Responsibility
 High level, recognition could be improved
 Small team approach crucial
 Welcoming clients, knowing clients, supportive team
 Clinical supervision
 Needs further work and formalisation

25. Summary - clients
 Being empowered in decision making
 Relaxed atmosphere – “staff are chilled”
 Learning practical strategies
 Increased quality of life
 Feeling a sense of achievement
 Flexibility of staff to spend time with us
 Being welcomed
 Being known

26. Conclusion
 Empowerment & Self-determination
 Small supportive team approach
 Experienced and confident nursing staff
 Nursing led
 Flexibility in a residential setting
 Staff and client perspectives of the Open Borders
programme for people with borderline personality
disorder (2019) International Journal of Mental Health Nursing

27. Acknowledgments
 Rhys Jones RN
 Clive Bachelor RN
 Helen Fisher RN