Effective nursing care of adolescents diagnosed with anorexia nervosa: the patients’ perspective

Aims and objectives. The purpose of this study is to develop – from the patients’ perspective ‐ a tentative theoretical model explaining the effectiveness of inpatient nursing care of adolescents diagnosed with anorexia nervosa. Background. The continuous and direct involvement of nurses with patients is likely to play a significant role in the recovery process of patients with anorexia nervosa. However, only limited evidence is available on what patients with anorexia nervosa themselves consider important and effective in terms of nursing care. Design. The design of this study was qualitative. Methods. A grounded theory approach was applied where 13 adolescents with anorexia nervosa were interviewed to generate data for the model. Results. Participants stated that nurses contributed significantly to their recovery from anorexia nervosa. Three recurring themes emerged from the data: (1) normalisation, (2) structure and (3) responsibility. The focus of nursing care with respect to these themes shifted during the phases of recovery. Conclusions. Based on patients’ experiences a theoretical model is developed describing effective nursing care of adolescents diagnosed with anorexia nervosa. Patients identified the key components of this model as essential to their weight recovery. Relevance to clinical practice. The model may be used to improve the quality of nursing care of adolescents diagnosed with anorexia nervosa through analysis of current practice with respect to the key components of our model. Interventions that are based on these components closely follow the patients’ needs.     

Nurses and the 'therapeutic relationship': Caring for adolescents with anorexia nervosa

BACKGROUND: Research studies suggest that hospital programmes for young people diagnosed with anorexia nervosa have high readmission rates and limited effectiveness. Nurses caring for these adolescents face a particular set of problems in seeking to establish therapeutic relationships. AIM: This paper reports a study with the original aim of providing rich data on the development of therapeutic relationships between adolescents diagnosed with anorexia and paediatric nurses. However, it was discovered that paediatric nurses were struggling to develop therapeutic alliances with these adolescents. The study was then modified to explore the difficulties and obstacles hindering the formation of therapeutic relationships in this context. METHOD: The study used naturalistic inquiry. The 10 participants were Registered Nurses from the acute wards of an Australian children's hospital with at least 2 years' experience of caring for adolescents with anorexia nervosa. The data were collected using semi-structured interviews that were recorded on audiotape and then thematically analysed both manually and with the aid of the NUD*IST computer package. FINDINGS: Participants described how they struggled to develop therapeutic relationships in this clinical environment. Three themes emerged: (1) 'Struggling for understanding' explores the difficulties nurses experienced in coming to terms with the complexities of a diagnosis of anorexia nervosa and its recovery processes. (2) 'Struggling for control' examines the power struggle between nurses and patients and the mutual distrust that often developed between them as a consequence of this struggle. (3) 'Struggling to develop therapeutic relationships' describes the difficulties some nurses had in establishing therapeutic alliances with these adolescents. CONCLUSION: Recommendations are made for improving the nursing component of hospital treatment programmes for adolescents with anorexia nervosa in the direction of more genuinely therapeutic relationships.     

跟踪回访延伸护理在神经性厌食症患者中的应用及效果

目的探讨跟踪回访延伸护理在神经性厌食症(AN)患者中的干预效果。方法以随机数字表法将2016年9月至2017年9月该院收治的80例AN患者分为对照组和试验组,每组40例。对照组给予常规护理,试验组在对照组基础上给予跟踪回访延伸护理,比较两组进食障碍调查问卷(EDE-Q)评分,行为抑制/激活系统量表(BIS/BAS)评分及Frost多维完美主义心理量表(FMPS)评分。结果干预后,两组EDE-Q各维度(限制进食、关注饮食、关注体质量和关注体型)评分均明显下降(P<0.05),且试验组下降幅度大于对照组(P<0.05);两组BIS评分、FMPS评分均明显下降(P<0.05),BAS评分均明显升高(P<0.05),且试验组下降或升高幅度均大于对照组(P<0.05)。结论在AN患者中实施定期跟踪回访延伸护理干预,能有效改善患者饮食状态及心理状态,值得临床推广使用。     

The psychological characteristics of patients suffering from anorexia nervosa and the nurse's role in creating a therapeutic relationship

This paper reviews research on the psychological characteristics of patients suffering from anorexia nervosa and that examining the therapeutic relationship. The former research suggests that anorexic patients possess a psychological profile characterized by: a phobia of weight gain and fear of loss of control; alexithymia and lack of introceptive awareness; mistrust of self and others; cognitive dysfunction; low self-esteem; and often the presence of starvation-induced depression. The latter strongly suggests that in order for a relationship to be therapeutic it needs to be characterized by: empathy; positive regard and acceptance; warmth; commitment; trust; genuineness; and be non-judgemental. The implications of these research findings regarding the nurse's role in forming a therapeutic relationship with anorexic patients is then discussed. It is seen that it is vital that nurses receive adequate education before working with such patients, and that their knowledge is regularly updated. Nurses should receive regular clinical supervision and support, in order to ensure that they are able to provide therapeutic care for such patients.     

Dynamics of nurses’ authority in the inpatient care of adolescent consumers with anorexia nervosa: A qualitative study of nursing perspectives

Nurses caring for adolescent consumers with anorexia nervosa in the inpatient setting are challenged in a unique way, in that they are caring for people with whom they do not have a mutually held concept of well‐being. Their efforts to ensure weight gain are frequently against the wishes of the consumer. This dissonance results in challenging interactions, where nursing care and authority may be undermined. This study investigated the dynamics of nurses’ authority within this context. Interviews with nurses (n = 10) were conducted and analysed through thematic analysis. Nurses reported that consumers, compelled by the psychopathology of anorexia nervosa, often sought to challenge or undermine their authority. Some nurses experienced the opposition and conflict as demoralizing, whereas others were able to maintain confidence in the therapeutic merit of their care. Younger, inexperienced nurses in this study were particularly vulnerable to interactions that mitigated their authority, due to their tendency to engage in friend‐like relationships. Nurses caring for adolescents with anorexia nervosa should be prepared to be confronted by interactions that overtly and surreptitiously undermine their capacity to exercise professional authority. It is important that nurses recognize the importance of maintaining their authority, and how it can be threatened in subtle and unexpected ways.     

Caring for adolescent females with anorexia nervosa: registered nurses' perspective

This phenomenological study was undertaken to explore in depth the experiences of registered nurses caring for adolescent anorexic females within paediatric wards of general hospitals in Victoria, Australia. A qualitative design underpinned by the philosophy of Edmund Husserl was employed for this study. Audio taped in-depth interviews with five registered nurses working within the public health care system were conducted. Using Colaizzi's procedural steps of analysis, six themes of meaning were explicated. They were: (a) personal core values of nurses; (b) core values challenged; (c) emotional turmoil; (d) frustration; (e) turning points; and (f) resolution. These themes, when taken together, described the essence of the journey undertaken by registered nurses who cared for adolescent anorexic females. The findings of this study indicated that there is a need for extensive registered nurse preparation, on-going support, and development of education programmes to enable registered nurses to care for these patients with greater understanding. Further, the participants identified the need for new care regimes and protocols to be developed that incorporated new ways of thinking. They also expressed a desire to be have greater involvement in the planned care of their patients.     

Shape-shifting discourses of anorexia nervosa: reconstituting psychopathology

HARDIN PK. Nursing Inquiry 2003; 10 : 209–217 Shape‐shifting discourses of anorexia nervosa: reconstituting psychopathology This article explores how the circuitous relationship between individuals, the media, and discursive systems replicate and reinforce the act of self‐starvation in young women. Using a feminist poststructuralist methodology, the focus of this article is on how discourses and institutional practices operate to position young women who take up the subject position of wanting to be diagnosed as anorexic. Utilizing data from online accounts and individual interviews, I attend to the ways in which young women are institutionally positioned as ‘anorexics’ and the effects that those positions have on their behaviors, in addition to reinforcing institutional practices that construct anorexia nervosa. Questions addressed through this inquiry are: How do institutional practices create and continue to constitute ‘anorexia nervosa’? How do discourses operate to position young women such that they are either included and/or excluded into the category of ‘anorexia nervosa’? What are the effects and consequences that emanate from these positionings?     

神经性厌食症致多器官功能障碍治疗体会

神经性厌食症（Anorexia Nervosa,AN）是一种常见的身心综合征,它起病于青少年,男女患病率不同,女性终生患病率为0.5%～1%,男性为女性的1/10〔1〕。AN的主要特征是患者因害怕肥胖或有体像障碍而有意地反复或长期节食,导致体重明显低于正常体重标准的下限〔2〕,其症状表现兼具生理和心理两方面：生理上主要为限制或拒绝进食,     

Self‐esteem in patients treated for anorexia nervosa

ABSTRACT: Anorexia nervosa (AN) mainly affects girls or women between 13 and 45 years of age. According to previous studies, one of the reasons for the desire to be thin is low self‐esteem. The purpose of the study was to examine the self‐esteem of 38 female patients with AN between 16 and 25 years of age, before and after 3 months of treatment at a specialist ward for eating disorders in Göteborg, Sweden. A quantitative pre‐ and post‐assessment based on two self‐rating questionnaires, the Rosenberg Self‐Esteem Scale (RSE‐S) and three subscales (weight phobia, body dissatisfaction, and ineffectiveness) of Eating Disorder Inventory‐2 (EDI‐2), together with body mass index (BMI), were used in the study, which was conducted between June 2005 and March 2008. The results reveal that self‐esteem, BMI, weight phobia, and body dissatisfaction improved significantly between pre‐ and post‐treatment. The RSE‐S and EDI‐2 ineffectiveness correlate highly with one another, which lends support to convergent validity, and the internal consistency was high for both the RSE‐S and EDI‐2 ineffectiveness. The results indicate that the treatment was effective, as both patients' self‐esteem and BMI increased after completed treatment, which was the primary goal of the treatment at this ward. Future studies should focus on follow up and the way self‐esteem manifests itself at different points in time within an individual.     

Health care access: a consumer perspective

This article describes the use of action research as an information base for policy formulation by a collaborative partnership in Spokane, Washington. Health and social service providers recognized access to care by uninsured persons as a major community issue. Little was known from the consumers' perspective about factors limiting access. No benchmarks existed against which to measure progress. Investigators collected mailed surveys from 475 residents of six Spokane neighborhoods and 97 persons participated in 12 focus group sessions. Income, education, and ethnicity were primary factors affecting perceptions of degree to which medical, dental, and mental health needs were being met. Many residents were unable to obtain needed health care; low-cost dental and mental health services were named as their highest priorities. Quality of care, relationships with providers, immediacy of access, and cost were important concerns. Major barriers were cost, length of time before one could get an appointment, lack of comfort with providers, and having to miss work for appointments. Consumer input is critical in understanding local issues in health care. Action research that combines qualitative and quantitative data enhanced practice/policy decisions through assuring ownership of the research and immediate use of findings by involved agencies.     

Alteration of the QT rate dependence in anorexia nervosa

Myocardial repolarization has been evaluated in patients with anorexia nervosa (AN) with conflicting results. The authors postulated that dynamic alterations in QT interval adaptation could characterize these patients. This study compared QT dynamicity along RR intervals from 24-hour ECG data of patients with and without AN. Twenty-five patients (23 women) fulfilling the Diagnostic and Statistical Manual (DSM IV) criteria for AN were included in the study. All underwent 24-hour ECG Holter recordings, allowing QT and RR measurements, and heart rate variability (HRV) analysis in free-living conditions. A group of 25 sex- and age-matched healthy subjects served as controls. Compared with controls, AN patients presented with relative bradycardia, more particularly during night periods but neither mean QT nor corrected mean QT length (calculated using Bazett formula) over the 24 hours of monitoring differed. However, QT/RR slope was found significantly enhanced compared with normals (-2.00 +/- 0.53 vs - 1.42 +/- 0.40) (P = 0.006): QT length related to heart rate was found longer for a heart rate <55 beats/min in AN. Mean 24-hours QT length appears unaltered in AN in the absence of electrolytic disorders. However, the QT/RR relationship was enhanced reflecting the specific autonomic imbalance encountered in this population. The clinical implications of such findings need to be discussed since an equivalent enhancement of QT/RR slope has been described after myocardial infarction in patients presenting life-threatening ventricular arrhythmias.     

An angel on my shoulder: a study of relationships between women with anorexia and healthcare professionals

Adults with anorexia are an under-researched group because the usual focus is on adolescents. The relationships that occur between healthcare professionals and adults with anorexia are often challenging, because they do not necessarily agree on the goals of treatment. The therapeutic relationship is widely recognized as crucial to care, even healing and restorative in its own right but problematic in this setting. This is a phenomenological study of how therapeutic relationships are negotiated and maintained in a day care service. Six women with anorexia nervosa and seven of their healthcare professionals were interviewed in the care setting to explore their lived experience of their relationships. Six important themes emerged from the interviews: the authenticity of the relationship, safety, the externalization of the eating disorder, recovery measured in kilos, the power of hope and optimism and the use and acceptance of maternalism in the care setting. Findings suggest that patients appreciated the safety and security of care, but some were using the service as respite rather than recovery. Patients saw goals and tasks related directly to weight gain as irrelevant to their main concerns, but engagement with people who provided a secure, nurturing and maternalistic context for safety and optimism was seen as supportive.     

Women's experiences of bulimia nervosa

AIM: This paper reports a study to interpret and understand bulimia nervosa as women experience it. BACKGROUND: Research into bulimia nervosa has focused on prevalence rates, health complications, comorbidity, neurochemical dysregulation, and cultural influences. Despite a multitude of investigations, little published research appraised bulimic women's personal experiences and understanding of this disorder. Such an understanding would assist health care professionals in providing sensitive, empathetic care. METHOD: The principles of Heideggerian phenomenology guided the study. Participants were 13 actively bulimic women, aged 18-36 years, with lengths of illness from 1 to 23 years. Data were obtained through interviews, personal diaries, and demographic questionnaires. FINDINGS: Participants' narratives revealed four themes that characterized the experience of living with bulimia: isolating self, living in fear, being at war with the mind, and pacifying the brain. The practices bulimic women engage in are carried out in secret, and hence participants experienced isolation. Binge eating and self-induced vomiting are considered abnormal behaviours; therefore, participants believed that they were subjected to negative public perceptions, which led to the experience of living in fear. The women feared being judged if others knew about the disorder. Several feared living without bulimia because it had become a significant part of their identity. In addition, these women were terrified of gaining weight or becoming fat. They experienced an internal struggle with the mind. In order to pacify the inner voice, many fed the compulsion to eat, and this resulted in guilt. The women subsequently balanced the experience by getting rid of fullness and erasing guilt, which was primarily achieved through self-induced vomiting. CONCLUSIONS: Understanding the experience of bulimia for women who suffer from this disorder is important. Bulimia often presents as a chronic and potentially lifelong health issue. Awareness of bulimic women's perspectives could promote a comprehensive appreciation of bulimia, its aetiology, and directions for treatment alternatives.     

Exploring therapeutic engagement with individuals with a diagnosis of personality disorder in acute psychiatric inpatient settings: A nursing team perspective

Individuals with a diagnosis of personality disorder (PD) face negative attitudes and are often deemed harder to care for than individuals with other diagnoses. To improve care and engagement with services, it is essential to understand the ways general psychiatric nursing staff approach this client group. This research aims to examine the ways inpatient psychiatric nursing staff therapeutically engage with individuals with a diagnosis of PD. Focus groups were conducted with Registered Mental Health Nurses (n = 7) and Health Care Assistants (formally known as nursing assistants; n = 12) who care for individuals with a diagnosis of PD in a general psychiatric inpatient setting. A thematic analysis indicated six themes: the right frame of mind, knowing the service user, knowing when to engage, service user input, a unified approach, and structured admissions. The findings highlight what non‐PD specialist inpatient nursing staff do in order to engage therapeutically with this group of service users and areas that require improvement. Supporting good practice could improve staff confidence when caring for this client group, lower stigma around the diagnosis, and promote a more positive experience of care for individuals with a diagnosis of PD who are using general inpatient mental health services.