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18. Caring for adolescent females with anorexia nervosa: registered nurses' perspective, Journal of Advanced Nursing

(C) 2000 Blackwell Science Ltd.

Volume 32(1), July 2000, pp 139-147

Caring for adolescent females with anorexia nervosa: registered nurses'
perspective
[Issues and Innovations in Nursing Practice]

King, Susan J. RN BN(Hons) MRCNA; Turner, de Sales RN MN BA BEd FRCNA
Lecturer, Deakin University (King)
Principal Lecturer, Deakin University, Burwood, Victoria, Australia (Turner)
Accepted for publication 21 January 2000
Correspondence: Susan J. King, School of Nursing, Melbourne Campus, Deakin
University, 221 Burwood Hwy, Burwood, Victoria 3125, Australia.
E-mail: sking@deakin.edu.au

---------------------------------------------------------------------------

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.

----------------------------------------------

INTRODUCTION

The transfer of registered nurse education to the higher education sector was
completed in Australia in 1993 (Steering Committee National Review of Nurse
Education in the Higher Education Sector 1994). As a consequence of this move,
all registered nurses are now educated within the university setting and
graduates normally commence a 1-year full-time graduate nurse programme in a
hospital during their first year of registration. The aim of this year is to
integrate the new graduate into the world of nursing and to consolidate
knowledge and skills attained through their study at university. Simultaneously,
some graduates also commence an honour's programme to be completed over a 1- or
2-year period within a university, as did the researcher. The purpose of this
programme is to enable students to conduct research under supervision, in a
topic that is of interest to them and has relevance to the nursing profession.

During the author's graduate year, her first nursing experience was in a major
public hospital where she cared for adolescent females diagnosed with anorexia
nervosa. It was here that she became aware of inconsistent feelings of
self-worth as a nurse. Anorexic patients in her care refused to eat regardless
of how much encouragement was given to them; she was uncertain of how to
converse with these patients, and at times felt uncomfortable when enforcing
protocols of care. She wondered how other registered nurses reacted in similar
situations and what their experiences were like. Thus, this phenomenological
project was conceived to explore the lived experiences of registered nurses
caring for female adolescent anorexics and to fulfil the requirement for the
Bachelor of Nursing (Honours) degree.

Phenomenology as a philosophy and methodology was selected to enable participants
in this study to describe and explore their lived experience from their unique
perspective, that is, what it was like to be in their world. The philosophy of
Edmund Husserl (1973) and the procedural steps of analysis developed by Colaizzi
(1978) were used as the basis for investigating and extracting the essence of
their lived experiences. Data were gathered via in-depth interviews with five
registered nurses who cared for adolescent females diagnosed with anorexia
nervosa. Outcomes of this study described what it was like to care for anorexic
individuals within general hospital settings, from the perspective of registered
nurse carers.

LITERATURE REVIEW

Adolescence is a transitional phase of human development, a time of change, of
developing a positive self-image and gaining independence (Cantwell 1976, Allen
1994, Woolfield 1994). In particular, adolescence has been described as a '...
very tender, sensitive time of life...' (Cantwell 1976 p. 4), and a phase that
presents the adolescent with '... a special burden, challenge and an opportunity...'
(Coleman 1980 p. 178). Adolescents are often unsure of how others perceive them
and develop an image of themselves from their own interpretations of what other
people think of them (Cantwell 1976). Consistent negative feedback given to an
adolescent impinges on the formation of a healthy self-image (Cantwell 1976).
Further, aberrant behaviours such as anorexia nervosa may emerge, as a cry for
help or for attention from family members (Slee 1993, Rosen 1996).

Towards thinness

In Australian society, there is a trend towards thinness (Nowak et al. 1996).
There is a growing 'weight loss culture' among Australian adolescents,
especially in those who are not overweight (Nowak et al. 1996). Female
adolescents are especially reported to be dissatisfied with their body image and
use extreme weight loss behaviours in an effort to attain thinness (Paxton et
al. 1991, Maude et al. 1993). Concerns are raised that the media has contributed
to the image of a slim figure being the socially acceptable feminine ideal
(Wiseman et al. 1992, Paxton & Sculthorpe 1991). Studies also indicate that
Australian adolescents develop strong beliefs concerning dieting and weight
reduction, which are nurtured in the family unit before reaching high school
(Paxton et al. 1991).

Eating disorders

Two major eating disorders are anorexia nervosa and bulimia nervosa. Both
reflect extreme and fanatical attempts on the part of individuals to reduce
their weight and are classified as psychiatric disorders (Davison & Neale 1990).
Bulimia nervosa is marked by binge eating in response to fear, uncertainty and
insecurity with compensatory vomiting, diuretic and/or laxative usage to remove
or expel food from the body (Rosen 1996). Anorexia nervosa, a condition found
most commonly in females (Akridge 1989, Biley 1989, Palmer 1990, Slee 1993,
Chassler 1994, Commonwealth Department of Human Services & Health 1995, Rosen
1996), is identified with an intense fear of becoming obese and refusal to eat
sufficient food to gain or maintain a normal body weight although hungry
(Davison & Neale 1990).

The aetiology of anorexia nervosa has no definite framework, but many theories
arise from biological, psychoanalytical and behavioural paradigms. Studies
reveal that the typical female adolescent diagnosed with anorexia nervosa has
extreme low self-esteem, feels ineffective, comes from a family with high
expectations, is an overachiever and perfectionist, with some interest in the
arts. Typically she is self-disciplined to the point of obsession and may be
depressed. Depression is identified as either a symptom of anorexia due to
malnutrition or a psychological disorder (Rosen 1996).

Research on anorexia nervosa focuses on: anorexia as a psychiatric illness (Hsu
et al. 1992, Herpertz-Dahlmann & Remschmidt 1993, Toro et al. 1995); anorexia
from sociological (Garrett 1995, 1994, 1992) and psychoanalytical perspectives
(Chassler 1994); recovery of the anorexic (Larson & Johnson 1981, Theander
1985); and the perspective of anorexic patients (Santopinto 1989, McMillan 1994,
Jones & Crawford 1995). With respect to registered nurses, a number of studies
have proposed how they should care for anorexics (Amara & Cerrato 1996, McNamara
1982, Lilly & Saunders 1987, Muscari 1988, Akridge 1989, Kenny 1991).

In addressing the care of anorexic patients in general or psychiatric hospitals,
most literature focuses on psychological points of view and on psychiatric
hospital care (Parkin 1995, Biley 1989, Palmer 1990). A dearth of literature
exists concerning admission of anorexic patients to general hospitals. Common to
the literature are suggestions that caring for anorexics presents unique
challenges to caregivers. However, there is a paucity of literature on the lived
experience of registered nurses caring for adolescent females specifically
diagnosed with anorexia nervosa. Thus the research reported here expands on the
body of knowledge available to address this complex issue.

Treatment regimens for anorexia nervosa

Individuals diagnosed with anorexia nervosa are treated in a variety of practice
settings. Treatment is lengthy and complex depending on the regime focus of the
particular institution. Different protocols are highlighted by various
researchers (Lilly & Saunders 1987, Comerci 1988, Palmer 1990, Guirguis 1994,
Parkin 1995, Amara & Cerrato 1996, Rosen 1996). All include a variety of
management strategies such as aggressive medical management, individual and
family psychotherapy, behaviour therapy and food intake management. Most
importantly, treatment is aimed at an interdisciplinary approach involving '...
medical supervision, nutritional counseling, and mental health intervention...'
(Rosen 1996 p. 105).

Caring for an anorexic patient as an inpatient is particularly challenging for
nursing staff, as they have the greatest contact with patients (McNamara 1982,
Kenny 1991). The distorted view anorexics have of themselves and the world
persuades them to resist food at all costs (Misik 1981). This resistance can be
interpreted as non-compliant behaviour, that is, behaviour that does not '...
coincide with medical or health advice...' (Cameron 1996 p. 244). A person's
self-perception of their health/illness has a significant bearing on their
compliance level (Wichowski & Kubsch 1997). Individuals typically deny that they
have a problem and do not follow advice (Misik 1981).

For effectiveness and compliance with protocols of care (Muscari 1988, Cameron
1996), it is essential for nursing staff to establish a therapeutic relationship
with their patient based on '... trust, consistency, acceptance of the person
but not the condition, and empathy...' (Kenny 1991 pp. 667-668). In recent
times, Guirguis (1994) has proposed specialized units for eating disorders,
which provide improved methods of caring for anorexics in environments with
structure and predictability, as well as support for families.

THE STUDY

This study described the lived experience of registered nurses working within
general hospitals in Victoria, Australia, who cared for adolescent anorexic
females. The researcher utilized bracketing as a method to suspend prior beliefs
and understanding of the phenomenon being explored to achieve 'unclouded sight'
during the study's undertaking (Husserl 1973). Bracketing strategies included
suspension of the literature review until after analysis of data had occurred as
well as undertaking an audio-taped exegesis of own understandings prior to
commencement of the study. Throughout this study, the researcher deliberately
pushed reflective and intruding thoughts and self-opinions out of her mind.
Further, the researcher utilized reflective writing as a means of emptying her
mind prior to interviewing each participant as well as between analysis of each
participant's text.

Every effort was made deliberately to suspend discussion of the study with
colleagues and friends. Additionally the researcher removed herself from 'hands
on' practice of caring for anorexics during the course of this research. The
extent to which these strategies were successful in enabling the researcher to
bracket is the subject of another paper. Suffice it to say that during the
course of this study the researcher found it necessary to return to these
strategies over and over again in order to enable her to remain faithful to the
philosophy and methodology of Husserlian phenomenology, which was the chosen
framework for the conduct of this study.

Ethical considerations

The main ethical concerns for qualitative research are related to (a) the
suitability and rigour of the research project and (b) the possible impact on
the participants of the methods utilized in the research project (National
Health & Medical Research Council 1994). Ethics approval was obtained and all
participants gave informed written consent.

Techniques implemented to satisfy ethical considerations included developing a
decision trail (Sandelowski 1993, 1986, Rose et al. 1995) and using a snowball
technique (Goodman 1961) to identify participants known and unknown to the
researcher.

Participants' confidentiality and anonymity were maintained by using pseudonyms.
During interviews participants were encouraged not to name patients in their
care. If they did so inadvertently, names were deleted during transcription, as
was other defining information. Further, demographic data on participants were
stored separately from audio-tapes, diskettes and transcribed data of the
project.

The participants

The participants in this study were five female registered nurses who did not
have psychiatric nursing or mental health qualifications. They were employed,
either full- or part-time, within adolescent wards of large public hospitals in
Victoria, and had cared for anorexic female patients in the previous 6 months.
Two participants had limited experience of working within mental health
settings. Three participants had postgraduate certificates in different nursing
specialties. Only one participant had their own children. Their cultural
backgrounds were Anglo-Celtic, European and Eastern. Each provided a unique
insight into nursing care and in particular into caring for adolescent females
diagnosed with anorexia nervosa.

Data collection and analysis

Audio-taped in-depth interviews occurred either in the participant's or
researcher's home at mutually acceptable dates and times. An opening request of
'Please could you describe what it is like to care for adolescent females
diagnosed with anorexia nervosa' was used. Probes and nudging (Minichiello et
al. 1995) were used to encourage each participant to expand on their story.
Audio-tapes were transcribed verbatim and analysis was undertaken using
Colaizzi's (1978) procedural steps.

FINDINGS

After extensive analysis and reflection, six themes of meaning emerged. They
were: (a) personal core values of nurses; (b) core values challenged; (c)
emotional turmoil; (d) frustration; (e) turning points; and (f) resolution.

Personal core values of nurses

Participants believed in and based their nursing care on values that formed the
core of they care of all patients. Equality of care, trust, privacy, being
non-judgemental, maintaining confidentiality, assuring patients' rights and
advocacy, were all values asserted by the participants. As stated by Ann:

... patients should be treated all the same, all children should be treated
equally... [In] caring for the children, give them support emotionally,
physically, mentally

Rebecca said:

I like to think that you can trust any kid regardless whether they're an
anorexic or not.

These values enabled the participants to focus and reflect on their nursing
care. Their words mirrored their values as an active positive guide by which
they determined and assured correct ways to care for all patients.

Core values challenged

Over time, caring for anorexics became a challenge. The participants discovered
their patients were deceitful and untruthful and they expressed disbelief at
their behaviours. Further, the participants revealed discontent at not being
true to their core values. Being non-judgemental of anorexic patients became
difficult, because they believed they were not trustworthy. They labelled them,
using derogatory terms, and revealed that subsequent care of other anorexics was
clouded with this acquired distrust. Being suspicious and untrusting were new
behaviours adopted in caring for these patients. Thus the values of equality of
care, trust and being non-judgemental were challenged.

Participants became more aware and sensitized to 'seeing' what their patients
were actually doing so trust became ambivalent. They discussed their discovery
of deceit, lies and sneaky behaviour. As revealed by Rebecca:

I like to think that I can trust them and I find that you can't... you tend to
be a bit cynical... And I guess, because I've seen so many of them sabotage
their meals... I find I don't trust them as easy; I don't give them as much
freedom in choice... I tend to go and double check... even to the simple thing
of have they had their phone call today? If they say no they haven't, I don't
trust them because I know that before they've said 'no I haven't' they've been
given an extra phone call.

Henrietta said:

They would openly admit to me that yes, they were sharing ideas... using
laxatives, the wet toilet paper up the vagina... for your weight, and how to
mimic... the peeing down in the toilet...

The participants revealed that they were unable to trust any anorexic patient
because of what they had erstwhile experienced. Thus, their perception that
their patients were deceitful and lied marred their belief in their core nursing
values.

Emotional turmoil

Many emotions percolated within the participants, who ultimately translated
their inability to nurture a trusting relationship with their patients as an
indictment of their nursing care. Their belief in themselves wavered. As Rebecca
recounted:

It makes me feel... I'm a bit of a failure because I like to think that you can
build up that trusting relationship. But when you first of all go in there with
doubts that you have [trust] - I feel like I'm a failure.

Joanne and Ann said:

... we all were going home feeling terribly inadequate because we thought we
were doing a good job...

... my heart just doesn't warm to them any more... Disgusting - sad you know,
that's not a nurse.

Core values that incorporated trust, honesty and being non-judgemental were
lost, replaced by an inner turmoil of emotions of sadness, anger and being
disheartened.

Frustration

An all encompassing emotion expressed in a myriad of forms and contexts was
frustration. The perception of repetitious and obstructive behaviours became
annoying and frustrating, as expressed by Ann:

You think you've done a good job in getting them up to a healthy weight and good
at getting them to eat a healthy diet. And then... within weeks, they'll just
lose the weight and just come back, and keep coming back and keep coming back.

The participants voiced metaphors of sabotage, sergeant majors and fighting to
describe their experiences. This developed into a subliminal notion of 'us
against them' - of who was going to 'win' the battle of protocol compliance.
Joanne recalled:

... we were just like sergeant majors, we thought we were. Standing over them
telling them what to do. They were 16- and 17-year-old girls that we had [to]
treat like 4- and 5-year-olds...

... we could not get through to them. They never trusted us enough to confide in
us... all of us were really, really tired of... fighting with these girls...

The constant warring frustrated the participants. Being watchful and wary
exhausted their energies.

Turning points

Living with frustration overwhelmed the participants. They reached a point where
they had had enough. The warring, frustration, being hurt and lack of success
eroded their resilience so much that they could not cope with the situation any
more and 'turned off'. They distanced themselves from their patients, spent less
time with them, and switched off to protect themselves. As Sabrina revealed:

Actually I've got to admit though, I hadn't looked after her terribly much...I've
chosen not to... because at the time I thought I really don't need to go through
this again... So I've backed down... which is a bit awful. A bit of self-protection
I guess... but I think I was a bit hurt...

Joanne said:

So now I just look after them like any other patient, no special treatment
really... just stick to the rules and maintain the care... I've just switched
off.

However, for some participants, their experience provided an impetus to search
for alternative ways of caring or seeing the situation. Ann relayed:

... what I learnt from one of the parents was that don't hone in on the body,
the body image.

... I felt that we needed some sort of programme for these anorexics where we
could eventually get them to do exercises.... to body build and to make them
feel good for themselves... that they can also become involved... in the
hydrotherapy once they became medically stable...also some sort of therapy...
like art... a lot of these girls are artistic... and I think they could sort of
expand and try and let their feelings out...

Resolution

Participants began to question their attitudes towards the care of anorexics as
they realized that the quality of their care was not the reason why their
patients did not attain wellness. They began to stand back and view the
situation objectively, as a whole, and not as a separate incidence in the fabric
of the girls' lives. As Rebecca identified:

Everyone rebels in adolescence... they come to hospital... a nurse... gives them
a set of guidelines. Adolescents... the majority of them don't like them
[rules]. They want to have their own ideals, their own beliefs and do things
their own ways... deceiving is part of adolescence... unfortunately with
anorexia, deceiving is detrimental to their health... deceiving to them is not
deceiving, it's only deceiving in my eyes...

Concurrently, the participants began to express some elements of satisfaction.
Sabrina declared:

You can put frustrating, in capital letters. And... it can be pleasurable. When
they reach the bottom of the barrel and start coming up and you see them
blossom. And I do, I really do enjoy that and get a buzz out of that. And to see
them get the shine back in their hair and shine in their eyes and a bit of
fidelity about them. That's great.

Ultimately the participants acknowledged that caring for adolescent female
anorexics was a learning experience. Joanne summarized as follows:

... a good learning experience for me. I've become more open in my thoughts...
and gained a lot of knowledge... and interactions, I think... they have helped
me to look at adolescence in every aspect, so to speak... I just feel like I've
got rich in knowledge... It has just taught me... to interact with them better
in regards to their feelings... emotions and frustrations, anger. Just treat
them like any other patient now.

Ann revealed:

Yeah, looking back, eh. That's... part of your life in nursing and it's an
experience, and... you've learnt from it.

Reflecting on their experiences of caring for anorexics enabled the participants
to develop different perspectives about their care.

Succinct statement of the phenomenon

To appreciate the wholeness of caring for adolescent females diagnosed with
anorexia nervosa, together with its rich and complex meanings, all of the
emergent themes were interwoven to produce a succinct statement of the
phenomenon.

The phenomenon of caring for adolescent females diagnosed with anorexia nervosa
on an adolescent ward in a general hospital, was a journey of frustration. A
turmoil of emotions were experienced by participants who cared for these
individuals, which inevitably eroded their resolve of maintaining core nursing
values. This degradation of their values caused much angst, ultimately causing
them to lose faith in themselves as nurses. The feeling of failure and loss of
faith was the nadir of despair in the experience of caring for the girls. This
negative self-image impelled them to change their focus and redirect their
efforts to understand the reality of the predicament of the anorexics. This
became the pivot for altering attitudes and building resolutions that enabled
them to care for their patients. Reflection on the emotional journey of
understanding revealed a recognition that this was the reality of nursing.

DISCUSSION

Within the literature, core nursing values are widely described (Lillibridge &
Biro 1995, Nolan 1995, Watt 1995, Cameron 1996, Skretkowicz 1992, Watson 1985a,
1985b, Benner & Wrubel 1989, Morse et al. 1990, Gaut 1991, Kenny 1991, Knowlden
1991, Gardner & Wheeler 1981, Leininger 1981, Ray 1981). These authors explore
notions of caring and the nurse-patient therapeutic relationship from different
perspectives, placing emphasis on the importance of caring for patients and
optimizing patient wellness. Initially, the participants in this study embraced
values to guide their practice. They espoused beliefs in equality of care, being
non-judgemental, assuring patients' rights and forming relationships based on
trust.

However, over time and through experience of caring for anorexics, which they
described as a journey, their values were eroded causing them to become
suspicious, untrusting, judgemental and uncaring. Within the literature it is
revealed that maintenance of optimal or idealized relationships is difficult
when caring for anorexics, as these patients present unique and challenging care
needs (McNamara 1982, Kenny 1991, McMillan 1994, Jones & Crawford 1995). Various
authors support a belief that obstructive behaviours of anorexics make it
difficult to develop and maintain a therapeutic relationship (Cameron 1996,
Misik 1981, Kenny 1991), revealing that ongoing fights for control of care
regimens do occur between patients and nurses (Jones & Crawford 1995, McMillan
1994).

The naivety and lack of knowledge displayed by these participants in caring for
anorexic patients is somewhat surprising given that the literature identifies
unique difficulties registered nurses face in caring for patients with anorexia.
The participants in this study did not, however, have formal educational
qualifications in mental health or psychiatric nursing, nor did they voice
awareness of theoretical constructs underpinning the care of anorexic patients.
This suggests that their knowledge base for practice was insufficient and gives
rise to a belief that regular care and support programmes coupled with on-going
education should have been readily available within the hospitals in which they
were employed.

A number of studies propose how registered nurses should care for anorexics
(McNamara 1982, Lilly & Saunders 1987, Kenny 1991, Amara & Cerrato 1996) and
there is frank discussion of nurses needing to change their personal care
philosophy in opposition to their own beliefs and values (Akridge 1989, Muscari
1988). This literature suggests that there are real differences between the
idealized and actual world of nursing practice, which parallel the experiences
of the participants of this study. The participants struggled to reconcile their
ideals to the reality of practice. Nolan (1995 p. 14) discusses role and
personal expectations, revealing how nurses enter the profession with preconceived
ideas of what nursing will be like. She identifies that the traditional service
role of nursing includes ideals but concludes that as nurses juggle to integrate
their ideals with the reality of practice they may become 'weary, wary' and
experience a sense of unfulfilled professionalism.

The literature reveals that it is normal for adolescents to assert themselves,
make choices and take control of their lives, enabling them to develop a
positive self-image and their own identity (Cantwell 1976, Connell 1976, Murray
& Zentner 1989, Woolfield 1994). However, most participants of this study did
not acknowledge that behaviours such as lying, manipulation and deceit may be a
normal part of adolescent growth and development. Rather, they associated these
behaviours with non-compliance and regarded them only as manifestations of
anorexia nervosa. Further they saw these behaviours as direct affronts to their
professional identity, perhaps because they regarded their struggles as
confirmation of their belief that they were a failure as a nurse.

An additional factor that initially contributed to the participants' frustration
was a requirement to work within rigidly defined protocols of care that were the
antithesis of the values they initially espoused. Because they did not develop
the protocols and could not always see their usefulness, they began to obstruct
and/or dismiss them. When faced with caring for anorexics the participants
became aware of differences between their ideals and the realities of nursing.
Some authors speak of this in terms of the theory practice gap (Street 1990)
whilst others acknowledge it as practice within the 'swampy lowlands' (Schon
1983, p. 42).

Over time the participants of this study, who sensed a loss of their core
values, felt pain. A sense of fulfilment could not be experienced until they
distanced themselves and viewed the reality of the anorexics from outside the
circle of their interactions. This is in contrast to the literature concerning
authentic caring relationships, which acknowledges that a caring relationship
with trust is necessary for positive intrinsic rewards for nurses (Ray 1981).

An assumption of Leininger (1981 p. 11) about human caring is that '... there
can be no curing without caring, but there may be caring without curing...'. The
participants believed that it did not matter how much care they gave to the
anorexics, it would not entice them to wellness. That is, there was caring
without curing. This is not a reflection of failing to care enough, but a
reality of human caring as experienced by the participants of this study. It is
therefore important to note that although the participants of this study felt
their nursing care had 'failed', care without cure is a valid experience of
nursing.

CONCLUSION

This qualitative study distilled the essence of what it was like to care for
adolescent female anorexics in public hospitals from the perspective of
registered nurses, who described their experience as a journey. This journey was
bumpy and emotional, filled with some highs and many lows. Initially participants
believed in and asserted their personal core values of nursing care. Over time
and through experiences, they realized that caring for anorexic patients
challenged their values as they understood them. The participants experienced
the anorexics' behaviours as an affront to their personal integrity, leading to
disenchantment with their nursing practice.

Many emotions percolated within the inner beings of the participants. After a
period of time, the participants realized that they had to develop alternate
strategies to enable them to cope with the unique needs of anorexic patients.
They had to distance themselves to see that anorexics are sick people, but sick
in a different sense to what they originally thought or had previously
experienced. The journey of experiencing care of the adolescent anorexic was
never completed. As registered nurses, the participants stepped in and out of
interacting with them. When caring became overwhelming, they distanced
themselves to regroup and reassess their values to enable them to care for other
anorexic patients in the future.

Arising out of this study was an awareness of a strong need: for education
programmes to be put in place to support registered nurses caring for adolescent
anorexics; for new care regimens to be developed which incorporate new ways of
thinking; and for opportunities for nurses to have greater involvement in
assessing and restructuring care protocols for anorexics. Studies are needed
that highlight the relationship of adolescence to the diagnosis of anorexia
nervosa to yield new ways of caring.

Acknowledgements

The researcher is indebted to the participants of this study who, through
revealing their stories of care experiences, helped her to make sense of her own
caring patterns, thoughts, feelings and emotions. Without their contribution and
openness, the lived experience of registered nurses caring for anorexic
adolescent females would still remain an elusive and unexpressed phenomenon.

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