Ethical Issues.

Ethical approval was obtained from all three sites in 2000, following rigorous completion of the respective ethical approval forms, supplemented with sample consent forms (see appendix 4) and information sheets (see appendix 3) for

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every stage of the research. Although this process was rigorous and daunting, and despite the protracted nature caused by two sites changing their ethics committees in preference to external, neutral local ethics committees which required me to resubmit new applications. Consequently, ethical approval was obtained from the following committees, however to limit deductive disclosure the specific names of the hospitals have been removed,

1. The High Secure Hospital: The North Sefton Local Research Ethics Committee, and the ‘High Secure Hospital’ Research and Development Department.

2. The Medium Secure Hospital: The York Research Ethics Committee, and ‘Medium Secure Hospital’ Clinical Development Forum.

3. The Low Secure Hospital: The Lancashire Care NHS Trust Research Governance Sub-Committee.

Participation in the study was on a voluntary basis, with assurances that participants would be provided with anonymity, opportunities to withdraw at any stage, and that their decisions would not be problematic. Consent forms (see appendix 4) and information sheets (see appendix 3) were provided for every stage of the research. Anonymity was ensured by names being coded, audio tapes and Q-sort statements to be erased/safely disposed of on completion of the study, all data pertaining to the participants was stored in a secure cabinet. Additionally, the whole transcripts are not included within this final document.

Accessing the participants was initially protracted in various ways which I will briefly reflect upon.

5.2.1 The High Secure Hospital: once I had obtained managerial and ethical

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Committee), I found that despite various disruptive influences within the hospital (discussed further in chapter three) the measure of spontaneous support and generosity was very positive. Although, I was conscious of the potential need for cathartic expression in the midst of these difficulties. Despite the fact that I was reasonably well known through my full-time employment over many years within this context, I undertook the process with appropriate sensitivity whilst maintaining a neutral position as possible within the process.

5.2.2 The Medium Secure Hospital was very receptive at every level of

engagement with this research, and encouraged me to present this work to numerous training forums, patient care teams, individual professionals, and directed me to obtain formal agreements from: two clinical development committees, the hospital governance/ethics committee, and the newly created Local Ethics Committee based at York University.

The treatment team within the one specialised ward for patients’ diagnosed with personality disorder were extremely pleasant, motivated and generous with their time and support. Overall, they utilised a broad raft of evidence based therapeutic interventions and encouraged the use of various reflective processes, which was evident through their feedback.

5.2.3 The Low Secure Hospital: prior to successfully approaching this hospital I

had sought to enlist various renowned, low secure environments for the treatment of personality disorder. They are included below because they had the potential for representing a more informed spectrum of diversity within the

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study, which ultimately was excluded and are highlighted below as a potential limitation of the study.

The ‘H’ Clinic, London. I had experienced two informative visits to this clinic, only to eventually discover that there was a moratorium on research proposals due to the overwhelming number currently being undertaken at that time.

The ‘C’ Hospital, London. Following two visits and numerous letters over a period of nine months, to this environment. I discovered that the research coordination had been undertaking significant changes which had resulted in delayed and inconsistent responses, culminating in feedback that there was a gender biased towards female patients to the exclusion of males in their environment, that would invalidate the research due to the significantly lower numbers of men diagnosed with personality disorder.

‘W’ House, Reading. This environment was recommended by the above and represented an excellent 'therapeutic community' with strong links to the 'Therapeutic Community Association,’ and a flattened hierarchy of multidisciplinary staff. Following two visits in which I had been very impressed at every level by the skill, motivation, receptiveness and having undertaken all the requirements of the local ethics committee, I was surprised to learn that two members of the nursing team had felt uncomfortable about potentially undertaking the assessment interview (adult attachment interview) which was going to form part of a previously proposed aspects of the research. Consequently, on this basis, and to my surprise, the therapeutic community team felt that they had no choice but to regrettably withdraw their involvement.

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Although I respected their decision, there did appear to be an irony that their decision emanated from an environment that seemed so strongly founded and promoted the importance of self-reflection within a safe, shared context. However, their response did prompt some self-reflection within myself pertaining to their perception of my boundaries (e.g. my employment in an environment which had been subject to a public enquiry) or was it simply a concern about discussing potential personal vulnerabilities or other unknown issues. Nevertheless, I concluded that after over 20 years of ethically sensitive, boundaried employment as a nurse and psychotherapist bound by sound ethical standards and my adherence to the best ethical and research protocols (eg. provision of a significant amount of information about the subject matter for informed consent, safety, confidentiality and much more) it is perhaps impossible to account for all variables. Unfortunately, at a later stage, I was to discover that the flattened hierarchy still caused interprofessional difficulties between medical professionals, who thought that nursing professionals should acquiesce to what they believed to be best. Consequently, the research appears to have been inadvertently lost within this dynamic.

The Low Secure Hospital, represented an environment which does not specialise in patients’ diagnosed with personality disorder but nevertheless does have considerable involvement with them, both within their in/out-patients’ departments. I undertook four visits to orientate staff at various levels of the research and successfully obtained ethical approval in 2000 once ‘people diagnosed with personality disorder’ were referred to within the documentation as ‘people with relationship difficulties’. The rationale for this modification is that

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although they obviously use this diagnostic label, they felt that it reduces the stigma associated with it. This environment has also been very supportive and receptive throughout this research process.