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Eating disorders: why do nurses choose this field?

VOL: 97, ISSUE: 46, PAGE NO: 37

Shelagh Wright, RMN, Dip Family Therapy, is a family therapist at Huntercombe Manor Hospital, Maidenhead, Berkshire

We all know that the NHS is in crisis when it comes to recruiting and retaining staff. Unacceptable stress levels and lack of appreciation are contributing to the exodus. It is recognised that more attention needs to be paid to the well-being of nurses, in particular newly qualified nurses who are just beginning to develop their careers. To do this it would be useful to know what attracts recruits into nursing, and how they feel about themselves and their chosen profession. The following study aimed to answer these questions within the context of eating disorder services.

We all know that the NHS is in crisis when it comes to recruiting and retaining staff. Unacceptable stress levels and lack of appreciation are contributing to the exodus. It is recognised that more attention needs to be paid to the well-being of nurses, in particular newly qualified nurses who are just beginning to develop their careers. To do this it would be useful to know what attracts recruits into nursing, and how they feel about themselves and their chosen profession. The following study aimed to answer these questions within the context of eating disorder services.

Recruiting staff for specialist eating disorders posts is extremely difficult. Advertisements for generic mental health nursing posts generate a greater response than advertisements specifically for eating disorder services. When candidates are given the option of a generic post or an eating disorder post, they tend to prefer the generic post. Most of the specialist eating disorder posts are taken up by newly qualified nurses.

This poses something of a problem: having predominantly newly qualified nurses within a specialist service means that there is a lack of general psychiatric experience to draw on, and a lack of experienced staff to act as role models.

Feedback from nursing colleagues suggests that the difficulty recruiting experienced staff to a specialty is linked with nurses' anxieties about:

- Not having the skills required to function in the specialty setting;

- The grade associated with the specialist post, which may not reflect the level of generic experience already gained.

Newly qualified nurses are often advised to gain experience in acute care. The newly qualified psychiatric nurse will often meet people with eating disorders in an acute psychiatric setting and this can often influence the nurse's view of treating eating disorders. Having gathered some experience, skills, and confidence, the nurse may then decide to specialise in eating disorders.

The problem is that moving on to the next stage of their career is unlikely to bring with it a promotion. Junior positions within a specialist setting are usually graded the same as junior positions within a generic setting, so for many nurses it would mean a sideways career step.

The study
The study examined three areas:

- Nurses' reluctance to apply for specialist eating disorders posts and whether this is linked to their level of self-esteem and/or their general attitudes and beliefs about people with mental illnesses, particularly people with eating disorders;

- Nurses' anxieties about whether they have the necessary skills for the job;

- The grade associated with the post.

Nurses working in general, psychiatric and specialist eating disorders settings were surveyed using a nursing profile questionnaire (self-designed), a standardised body image questionnaire (Probst et al, 1995), and an attitude questionnaire, 'Attributions of responsibility for anorexia nervosa', from an unpublished thesis.

To ensure that the study included nurses from a variety of settings that could potentially treat people with an eating disorder, questionnaire packs were sent to: members of the RCN special interest group for eating disorders; delegates attending a conference on nursing patients with eating disorders; and two senior nurses in general medicine who were asked to encourage colleagues to participate. From a total of 227 questionnaire packs, 98 were returned (a 43% response rate).

The results of the questionnaires were compared, looking for a correlation between nurses' attitudes towards people with eating disorders, their decision to work in this clinical area, and their attitudes toward their own bodies.

Self-esteem and body image
Nurses who had chosen to work with people with eating disorders were found to have a significantly higher level of body dissatisfaction than those who had chosen not to work with this client group. The nurses who chose to work in the field also believed that the patients did not want to be ill. Nurses who had had an eating disorder themselves were not more likely to choose to work in this field.

Anxieties about skills
The results showed that nurses who are working with people who have an eating disorder are more likely to seek or be offered additional training for that work. In addition, working with people who have an eating disorder requires additional training irrespective of the nurse's basic training. It was also suggested that with additional training the nurse is less likely to blame the patient for his/her illness.

Grading issues
The results addressing this issue were qualitative. The main reasons respondents gave for not choosing to work with people with eating disorders were related to money and career progression.

Discussion
The results indicate that nurses working with people who have eating disorders do have issues about their own body image but that personal experience of eating disorders may be irrelevant. People who work in this field may become more aware of issues about their own body image by the very nature of the work.

However, a significant number of respondents who were not working with people with eating disorders believed that people with anorexia nervosa want to be ill.

The results suggest that training is the crucial point at which to effect a change in attitude towards people with eating disorders, as well as to equip nurses with a better understanding of what skills are required to work with this client group.

The need to incorporate some self-awareness and personal as well as professional development in the nurses' training is also apparent. The value placed on these skills is probably harder to change, as this would naturally mean a higher cost being attached to the nurse possessing the skills.

The answer to the question 'Why do nurses choose to work with people who have eating disorders?' may well lie in theories of attribution.

Wortman (1975) reported that people make causal attributions to enhance their feelings of control over their environment. Attribution of responsibility for illness is used to indicate the extent to which a person has used his/her ability to become ill. A study by Ickes and Kidd (1976) showed that the person who is seen to be responsible for their health problem is less likely to be offered help.

Translated into the nurse-patient relationship, this theory would mean that the nurse would have to view the patient with the eating disorder as not being responsible for developing their disorder.

In the same study, Ickes and Kidd suggested that the carer has to believe that she has the ability to help the patients achieve a positive outcome, but the person she is helping is unable to believe this.

So the nurse who chooses to work with people with eating disorders not only has to believe that the patient is not responsible for the development of their illness and cannot recover without help, but also that he/she can make recovery possible.

The results of this study suggest that:

- Nurses who have issues about their own body image are more likely to choose to work with people with eating disorders. This might suggest that they would have some level of understanding about body image problems and believe that their intervention could make a difference to the patient;

- Nurses who choose to work with people with eating disorders are more likely to have had additional training for the post. This could suggest recognition of the additional skills required for such work;

- Nurses who choose to work with people with eating disorders do not believe that patients with anorexia nervosa want to be ill.

Conclusion
The results of this study are by no means representative of nurses generally, but they do provide a snapshot of one group of nurses who have made a positive choice to work with people with eating disorders. The implications of the results are:

- It is perhaps unnecessary to exclude people who have had personal experience of an eating disorder from nurse training, which has been one of the consequences of the Clothier report following the Beverly Allitt inquiry;

- Nursing education needs to pay attention to nurses' own body image issues, and their personal as well as professional development. The nursing profession needs to value itself enough to dispel the myth that all nurses are angels and present the more accurate image of nurses as ordinary people;

- Changes to basic nursing education are necessary. For example, there should be modules on eating disorders and how they relate to the present sociocultural environment. The fact that eating disorders predominantly affect young women should also be discussed, especially in the context of nursing as a mainly female profession. An elective training module or short training course for students who want a placement with an eating disorders service would be useful.

- The experience and training required to work successfully with people with eating disorders needs to be recognised and valued as a specialty, both by nurses seeking employment and by employers recruiting nurses to work in this area.

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