Love and Limits
Like any healthcare setting, the rules in place within mental health wards are to maintain the safety of patients and staff. However, mental health nursing is a delicate balancing act between enforcing these rules and providing a supportive, caring environment that empowers patients to make choices that support recovery.
In his recent study, Dr Joel Zugai interviewed inpatients with anorexia nervosa and their nurses to understand the therapeutic alliance between mental health nursing staff and patients.
“In a strong and beneficial relationship, nurses cared for patients with compassion and sensitivity while maintaining a clear distinction between the patient as an individual and anorexia nervosa as an illness,” noted Dr Zugai.
Anorexia nervosa is an ego-syntonic mental disorder and often becomes incorporated into the patient’s identity. The first point of call for care is to detach the illness from the individual. Once the illness is recognised as its own entity, nurses can help patients to identify behaviours driven by the illness, empowering them to make healthy decisions. In this way, nurses are caring for an individual and fighting an illness that resides within the same body.
“There’s me, and then there’s the eating disorder. The eating disorder hates it here. The eating disorder doesn’t want to stay here. Until I can consciously make decisions without the eating disorder, like, getting its hands in there, I have to stay here…” (Michelle*, inpatient)
In relation to weight gain, patients are deliberately deprived of decision-making power leaving the nurses to make decisions for their patients. As a result, nurses need to be mindful of how they use their authority.
Both nurses and patients described practical nursing as involving a “motherly” role adoption, says Dr Zugai.
Motherly nurses are valued because they have effectively wielded their power so that they are seen in a position of authority while making it clear that they care for the patient and are interested in them.
Nurses who were non-judgemental and empathic were able to form bonds with their patients, wherein the patient felt comfortable to talk to their nurse about the issues they were facing in hospital. However, this compassion was only useful when it aligned with respect for the nurses' authority. Nurses gained respect by enforcing limitations that were fair and rationalised to ensure the safety of patients and staff.
“Young nurses struggle with this as they are more inclined to form relationships with patients that are similar to friendships. However, power between friends is fairly equal, and thus nurses are unable to operate from a position of authority,” comments Dr Joel Zugai.
Dr Zugai’s study shows that effective nursing care for inpatients with anorexia nervosa requires a delicate application of the ‘love and limits’ approach. This approach allows nurses to reassure patients of their worth, while applying the rules of the ward programme consistently. When the nurse and the patient mutually identify the distinct difference between the individual and the illness, they are able to work collaboratively in recovery from anorexia nervosa.
*Names have been changed to protect the identity of individuals involved in this study.