A positive nurse-patient relationship is vital in anorexia recovery but can be difficult to form for many reasons.
In this article…
- The characteristics of anorexia nervosa
- How the disorder affects patients’ thought processes
- Why nurses may have negative attitudes towards patients with the disorder
Aja Louise Murray is a student in the psychology department, University of Edinburgh; Kate Crawford is community psychiatric nurse; Karen McKenzie is consultant clinical psychologist; George Murray is consultant clinical psychologist; all at the Andrew Lang Unit, child and adolescent mental health services, NHS Borders, Selkirk, Scotland.
Murray AL et al (2011) How to develop patient trust in anorexia treatment. Nursing Times; 107: 3, early on-line publication.
Keywords Anorexia nervosa, Eating disorder, Nurse-patient relationship
- This article has been double-blind peer reviewed
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5 key points
1 - Health damaging behaviours associated with anorexia nervosa can be fatal or
lead to serious complications
2 - Positive nurse-patient relationships are crucial if treatment is to be effective
3 - Many patients are cared for by nurses without specialist knowledge of the condition
4 - Nurses should seek to overcome negative attitudes to patients with AN by understanding the complexities of the disorder
5 - Nurses should express acceptance, hopefulness and availability to AN patients
Anorexia nervosa is a serious and commonly fatal psychological condition. It is essential that nurses develop positive relationships with patients to enable successful treatment. However, these relationships are often difficult to form. This article discusses how the features of anorexia affect creating and sustaining effective nurse-patient relationships.
Developing trusting relationships with patients is fundamental to nursing practice - particularly in mental healthcare. However, this can be hard to achieve with some patients, such as those with anorexia nervosa (AN)a rare but serious psychological disorder.
The National Institute for Health and Clinical Excellence (NICE, 2004) acknowledges that treating patients with AN can be challenging, particularly because many are ambivalent about treatment.
Although only 0.3-0.7% of the population experience AN, it has a major impact (Kaye et al, 2000) on the physical and psychological wellbeing of those who do, and on carers, who may blame themselves for contributing to it (Whitney et al, 2005).
As well as the primary effects of AN, patients may also experience secondary effects such as a negative impact on social relationships, education, work, leisure and daily living skills (NICE, 2004). The disorder can be expensive to treat, often requiring hospitalisation (Crow and Nyman, 2004).
The American Psychiatric Association (2000) says AN is characterised by a refusal to maintain an appropriate body weight, achieved by severe calorific restriction.
People are considered to have the condition if their weight is less than 85% of the norm for their height. To achieve this low weight, patients may engage in potentially health damaging behaviours such as vomiting, purging with laxatives, excessive exercise and restricting food intake.
As a result, AN can have serious complications, such as electrolyte imbalances, renal failure, arrhythmias and amenorrhoea (the absence of menstrual bleeding) (NICE, 2004; APA, 2000; Sullivan, 1995). It is one of the most commonly fatal psychological disorders, resulting in death in around 10% of cases (Sullivan, 1995).
Anorexia almost invariably begins with weight loss through dieting, precipitated by body dissatisfaction (Attia and Walsh, 2009). This can derive from many sources, but is commonly a result of teasing by peers or parents, exposure to thinness ideals, or modelling of parental behaviour (Polivy and Herman, 2002).
Patients can experience extreme dissatisfaction, which may relate to a distorted view of their own and the ideal body size (Kaye et al, 2000). Many meet the diagnostic criteria for body dysmorphic disorder, which is characterised by a distorted and distressing perception of a body part or the entire body (APA, 2000).
Recognising this may help nurses to understand the distress patients with AN experience, and to adopt a sympathetic attitude. Glauert et al (2009) pointed out that less severe body dissatisfaction is extremely common, and nurses can reflect on this when attempting to relate to patients with AN. It is also important that nurses consider the difference between normal body dissatisfaction and the intense pathological dissatisfaction often felt by patients with AN.
Other psychological characteristics set patients with AN apart from people with non-pathological body dissatisfaction.
Perfectionism, sociotropy (dependency and a need to please) and narcissism all correlate with AN, suggesting patients find the mismatch between their extreme body ideals and their own perceived body intolerable (Cassin and von Ranson, 2005).
Consistent with this idea is the sense that others are demanding perfection (externally derived perfectionism). This perception diminishes with treatment, but the demand for perfection from oneself (internally derived perfectionism) does not (Cassin and von Ranson, 2005).
This indicates that what may differentiate those at risk of AN who develop the disorder from those who do not is whether they internalise the thin ideal.
Glauert et al’s (2009) findings support this hypothesis. They showed images of bodies of different sizes to female students aged 16-31, and found some women were far more sensitive to being exposed to images of thin bodies than others and more likely to see them as normal or ideal.
Nurses who are aware of the distress AN patients may be experiencing have the best chance of developing and maintaining a positive relationship with them.
To understand the complexity of AN, it is important to recognise it cannot be solely explained in terms of body or weight issues. It is often a coping strategy in response to stressors or negative emotions.
Patients often show a restricted range of emotions, difficulty in identifying these emotions and inadequate problem-solving skills, which make it difficult for them to develop positive relationships with carers. They may also use eating or exercise as a means of managing negative moods (Lobera et al, 2009).
This theory is supported by AN’s high comorbidity with substance misuse - an externalising disorder - and mood and anxiety disorders, which are characterised by negative emotion and a lack of positive emotion (Polivy and Herman, 2002).
Factors that generate stress and negative emotion, such as childhood sexual abuse or a dysfunctional family environment, increase vulnerability to AN (Polivy and Herman, 2002).
People who are predisposed to negative emotion, such as those who score highly on a measure of neuroticism (MacLaren and Best, 2009) or suffer from borderline personality disorder (Paris, 2009), are overrepresented in the AN statistics.
Nurse-patient relationships in AN
Engaging in a therapeutic relationship with patients is vital to the success of any psychological therapy (NICE, 2004).
AN patients see a strong therapeutic relationship as central to their care, so those providing care should be understanding and non-judgemental (Van Ommen et al, 2009; Tierney, 2008). This is consistent with the Nursing and Midwifery Council (2008) code, which says “the people in your care must be able to trust you with their health and wellbeing”.
A positive nurse-patient relationship can help increase self-esteem in patients with AN, which increases the chance of treatment being successful (Karpowicz et al, 2009; George, 1997). Snell et al (2010) said nurses see themselves as having a key role in negotiating relationships between patients and fellow team members.
Barriers to a positive relationship
The care of patients with AN is complex, and a number of factors can undermine the potential for a positive relationship between nurse and patient.
Patients often lack insight into their disorder, failing to grasp its serious nature. It is common for them to actively resist treatment (Attia and Walsh, 2009; Tan et al, 2007). They are likely to have little flexibility in thinking (Vanderlinden, 2008), which makes it extremely difficult to tackle resistance through persuasion.
In some cases, force-feeding may be necessary to keep patients alive (Thiels, 2008) but this can damage self-worth and trust in carers.
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