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Florence Nightingale School of Nursing and Midwifery

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T29324

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Module LeaderDIANE TOFTS

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Module Code5KNIP527

Module TitleSTUDENT LED PROJECT

Title of AssignmentVIDEO ON ANOREXIA

Submission Date29/05/2014

Word Count2000

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This essay aims to show the rationale behind my student project, which is a trigger video (Ber & Alroy 2001) aimed to promote reflection and discussion about Anorexia Nervosa (AN). I will be exploring the negative effects that stigma has on the therapeutic nurse-patient relationship and the advantages of using video as an educational tool to inform healthcare professionals about AN and thereby, reduce stigmatizing attitudes. Throughout this essay I will be using the term nurse but it can be replaced by any other healthcare professional dealing with the patient, such as physiotherapists, healthcare assistants and dentists.

Anorexia is a complex illness, with no definitive cause but is thought to be a mixture of biological, psychological, social, spiritual and political factors involved (King & Turner 2000, Matusek & Knudson 2009, Vitousek et al. 1998). Anorexia Nervosa is defined as syndrome in which the individual maintains a low weight as a result of a preoccupation with body image, construed either as a fear of fatness or a pursuit of thinness (National Collaborating Centre for Mental Health 2004).

Although its prevalence is low at 0.03% of the population, Anorexia Nervosa has the highest mortality rate of any psychiatric condition (Birmingham et al. 2010). In addition, due to the ego-syntonic nature of AN, patients often resist treatment which can be extremely distressing and challenging for healthcare professionals (Crisp 1997, Bell 2003, King & Turner 2000, Bamford & Mountford 2012, Vitousek et al. 1998).

The therapeutic alliance or therapeutic relationship is a phenomenon frequently highlighted in literature as being the corner-stone of mental health nursing care to facilitate recovery. This literature also identifies key characteristics the nurse requires in order to develop the therapeutic relationship which are: trust, non-judgmental attitudes, acceptance, genuineness and consistency (Peplau 1952, Ironbar & Hooper 1989, Martin 1987, McQueen 2000, Murray & Huelskoetter 1990).

The need for a therapeutic nurse-patient relationship is paramount to a persons recovery from AN (Crisp 1980, George 1997, Pereira et al 2006). A positive attitude of the nurse towards a patient with AN is crucial to allow the therapeutic relationship to develop (George 1997, Henry et al. 1993). This is highlighted in the views of patients with AN, given in qualitative studies. The major theme to emerge is the importance of positive therapeutic relationships developing, especially with their key nurse (Sly et al. 2014). The therapeutic relationship is commonly regarded as a bond that develops over time however, the patients initial perceptions of this relationship can be a significant predictor of weight gain and treatment outcome (Bourion-Bedes et al. 2012, Sly et al. 2014).

Despite this research, in practice, nurses have reported difficulties in creating these therapeutic relationships, due to barriers ranging from: a lack of patient collaboration; patients resistant to treatment; a lack of therapeutic nursing skills or knowledge about the illness (Deering 1987, Ramjan 2004). The ego-syntonic nature of AN is thought to be the reason the patient often withdraws from the nurse-patient relationship (Vitousek et al. 1998). Denial of problems related to AN, which is inherent in the disorder, is a symptom which can prove challenging to nurses. However, research has shown that this denial tends to stop when therapeutic relationships are established (Crisp 1980).

Discussing the complexities of what is required to establish a therapeutic alliance with a patient with AN is outside the scope of this essay. Instead, the focus will be on one barrier to therapeutic alliances that is commonly expressed in research - a lack of nursing education about the complexity of the illness, which leads to stereotyping, labelling, stigmatising and negative attitudes towards the patients as nurses struggle to understand the disorder (Garrett 1991, King & Turner 2000, Ramjan 2000).

Stigma exists when a discrediting attribute or mark that someone has, or is believed to have, marks them as different and causes them to be denigrated (Goffman 1963, Hayward & Bright 1997, Major OBrien 2005, Park et. al 2013). There is extensive literature on the topic of stigma towards mental illness but only a few about eating disorders (Crisafulli et al. 2008). In a population based survey in the UK, 33% believed that individuals are solely to blame for their illness and 35% believed that they could pull themselves together if they wanted to (Crisp 2005). These beliefs also held by many healthcare professionals, with one study revealing 59.4% of medical and nursing staff at a general hospital stating that patients with AN were responsible for their condition (Fleming & Szmukler 1992). Other studies have also shown that many nurses have the attitude that patients with AN are able to fix themselves (Ramjan 2004)

AN is frequently associated with low self-esteem and it could be argued that this is linked to the common comorbidity of AN and depression (Eckert et al. 1982, Huon & Brown 1984, Rastam 1992, Williams et al. 1990, Williams et al. 1993, Zerbe et al. 1993). Self-stigma is when a person cognitively and emotionally accepts the negative stereotypes assigned to them about mental illness. This causes them to denigrate themselves due to belief that they are of less value than others because of their diagnosis (Bilton et. al 1996, Rusch 2005). Due to the common link between low self-esteem and AN, it is crucial that nurses are aware of self-stigma when treating patients.

I believe there is a great need for nurses, who treat individuals with AN, to receive some educational input regarding the disorder, which is regularly mentioned in the literature (Fleming & Szmukler 1992, Garrett 1991, George 1996, King & Turner 2000). This education should target the common misconceptions of AN, that reduce the quality of care given, primarily that people are to blame for their illness and can pull themselves together if they want to (Crisp et. al 2000, Ramjan 2004). Evidence shows that interpersonal contact with stigmatized individuals correlates to more positive attitudes towards that group, from others (Corrigan et. al 2001, Couture & Penn 2003, Link & Cullen 1986, Penn & Nowlin-Drummond 2001, Pettigrew & Tropp 2006). In the case of nurses, this results in a significant increase in the likelihood of the development of therapeutic relationships.

Before deciding on the educational tool to use, the barriers to nursing education need to be thought through. The most obvious one is the lack of protected time nurses have to explore evidence-based research. There is sometimes a lack of willingness on the nurses part, but if they are willing, opportunities to participate in courses on mental illness or have direct contact with patients who conduct live teaching sessions are not always available (Penn et al. 2003). Tools to reduce psychiatric stigma are limited those that are available are often unable to be accessed by a large number of individuals, in a cost-effective manner (Penn et al. 2003).

Watching a five minute video, allows nurses to schedule time for the intervention as they know how long the video will take. Also, a video generally requires far less time than reading evidence-based literature on the topic (Dave & Tandon 2011). In addition, if the video were to be posted online, this allows healthcare professionals quick and easy access to it, which is increasingly cost-effective.

Video can be used to foster appropriate attitudes and combat subtle prejudices (Raingruber 2003). It allows individuals to deal openly with their beliefs and attitudes, even if they may be stigmatizing, allowing them to critically evaluate and reflect on them. In addition, videos allow teachers to provide feedback without the potential of embarrassment. There is a risk, if the patient is present, that they may be offended if nurses dealing openly with stigmatizing attitudes (Ber & Alroy 2001).

Healthcare educators, in recent times, have started using films and videos as a curricular tool, as it is important to find new and creative ways to stimulate, motivate and increase learning for student nurses (Alexander 2005, Higgins & Lantz 1997). This has been labelled cinemeducation (Alexander et. al 1994) and provides a useful counterweight to traditional didactic ways of teaching. Nursing education should not solely be a fact-loading process but also facilitate critical thinking and reasoning (Facione et. al 1994). Film and video are entertaining ways of learning, are known to engage attention and are enjoyed by users (Alexander 2005, Dave & Tandon 2011).

Videos have the ability to portray behavioural and mental health themes with both the aspect of realism and an emotional punch (Alexander 2005). They become a window for practitioners to peer into, to see how afflicted individuals experience illness in their day-to-day life (Silenzio et al. 2005). After watching them, videos can easily trigger discussion and reflection and teachers can provide feedback in a supportive, non-judgmental environment (Alexander 2005, Ber & Alroy 2001, Kalra 2012, Kalra 2013, Leelapattana et al. 2007).

Education should seek to examine the learners beliefs and integrate new, more refined ideas into their belief system, thereby facilitating the learning process (Kolb 1984). Kolbs learning cycle (1984) highlights the importance of experience followed by reflection, in order to promote alterations in thinking and behaviour. This is where deep learning occurs. This is exemplified in cinemeducation which allows persons to become emotionally involved in an experience, whilst at the same time, maintain a distance because of the medium. This helps to foster objectivity in the reflection process (Higgins & Dermer 2001, Kalra 2012, Leelapattana et al. 2007). In addition, with videos often offering realistic yet sensitive portrayal of characters, the potential to generate empathy and tap into the viewers emotional intelligence increases (Kalra 2013, Pave & Tandon 2011).Chan et al. (2009) found that educating teenagers in Hong Kong about Schizophrenia with a lecture about stigma coupled with a video showing life experiences of four individuals recovery from schizophrenia, significantly reduced stigmatising attitudes. Clement et al. (2011) found a similar result in the UK with student nurses watching a DVD of mental health service users and their carers talking about their experiences, being as effective in reducing stigma as the live speaking sessions. This reinforces the fact that video can be just as useful as live interpersonal contact with stigmatized individuals. Ber & Alroy (2001) utilise the term trigger videos to describe brief 3-10 minute clips that are used to provide reflection, stimulate discussion and help medical students confront their feelings about aspects of care in the doctor-patient relationship.

In light of the above research, I decided to direct and create my own trigger video for healthcare professionals, in order to stimulate reflection and change stigmatizing attitudes regarding AN. Firstly, I created a script and storyboard, integrating the research about stigma and AN with the personal experiences of a friend who has the illness. A voiceover of my friend provided her point of view and was juxtaposed with a voiceover from myself to provide information. I deliberately endeavoured to utilise the open question What do you see when you look at me? as a repetitive phrase throughout the video, to stimulate reflection of those watching it. (See appendices for a more detailed storyboard).

Crisafulli et al. (2008) created a questionnaire to be given after an educational input regarding AN. This evaluates different facets of participants attitudes towards individuals with AN including their views as to the cause of it. In addition Penn et al. (1994) created a characteristics scale to elicit the views of students about characteristics they associate with schizophrenia. Using these two papers as inspiration, I created two shorter questionnaires, one that could be given before the video and one after to evaluate its effect on stigmatizing attitudes (See appendices for a sample of questionnaires I created).

In conclusion, AN is a complex illness which can often lead to stigmatizing attitudes from the public and healthcare professionals. These attitudes can have a detrimental effect on a persons recovery due to them creating barriers to the formation of therapeutic relationships. This video highlights the experience of one girls, Frances, struggle with AN, however, I believe that showing the commonalities and differences between several peoples struggles would be more effective. This is because people may perceive Frances experience as unique and not applicable to others with Anorexia, so therefore an exception to the stereotype. In addition, I believe this video could not only be utilised by healthcare professionals, but also by family members of those with AN, the general public and students both in school and on healthcare-related courses.

References

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Bamford B.H. & Mountford V.A. (2012) Cognitive behavioural therapy for individuals with longstanding anorexia nervosa: adaptations, clinician survival and system issues. European Eating Disorders Review 20(1), 49-59.

Bell L. (2003) What can we learn from consumer studies and qualitative research in treatment of eating disorders? Eating and Weight Disorders 8(3), 181187.

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Bilton T., Bonnett K., Jones P., Lawson T., Skinner D., Stanworth M. & Webster A. (2002) Introduction to sociology. 4th Ed. Palgrave Macmillan, Basingstoke.

Bourion-Bedes S., Baumann C., Kermarrec S, Ligier F., Feillet F., Bonnemains C.,Guillemin F. & Kabuth B. (2013) Prognostic value of early therapeutic alliance in weight recovery: a prospective cohort of 108 adolescents with Anorexia NervosaJournal of Adolescent Health 52(3), 344350.

Chan J.Y.N, Mak W.W.S. & Law L.S.C (2009) Combining education and video-based contact to reduce stigma of mental illness: The Same or Not the Same anti-stigma program for secondary schools in Hong Kong. Social Science & Medicine 68(8), 15211526

Clement S., van Nieuwenhuizen A., Kassam A., Flach C., Lazarus A., de Castro M., McCrone P., Norman I. and Thornicroft G. (2011) Filmed v. live social contact interventions to reduce stigma: randomised controlled trial 201(1), 57-64.

Corrigan P.W., Green A., Lundin R., Kubiak M.A. & Penn D.L. (2001) Familiarity With and Social Distance From People Who Have Serious Mental Illness. Psychiatric Services 52(7), 953-958.

Couture S.M. & Penn D.L. (2003) Interpersonal contact and the stigma of mental illness: A review of the literature. Journal of Mental Health 12(3), 291-305.

Crisafulli M.A., von Holle A. & Bulik C.M. (2008) Attitudes Towards Anorexia Nervosa: The Impact of Framing on Blame and Stigma. International Journal of Eating Disorders 41(4), 333-339.

Crisp A.H. (1980) Anorexia Nervosa: Let Me Be. Academic Press, London.

Crisp A.H. (1997) Anorexia as a flight from growth: assessment and treatment based upon the model. In Handbook of treatment for eating disorders (Garner D.M & Garfinkel P.E. eds.) pp 248-278.

Crisp, A.H. (2000) Stigmatization of and discrimination against people with eating disorders including a report of two nationwide surveys. European Eating Disorders Review 13(3), 147152.

Crisp A.H. (2005) Stigmatization of the discrimination against people with eating disorders including a report of two nationwide surveys. European Eating Disorders Review 13(3), 147152.

Crisafulli M.A., Holle A.V. & Bulik C.M. (2008) Attitudes towards anorexia nervosa: the impact of framing on blame and stigma. International Journal of Eating Disorders 41(1), 333-339.

Dave S. & Tandon K. (2011) Cinemeducation in psychiatry. Journal of Continuing Professional Development 17(4), 301-308.

David L.P., Chamberlin C., & Mueser K.T. (2003) The Effects of a Documentary Film About Schizophrenia on Psychiatric Stigma 29(2), 383-391.

Deering C.G. (1987) Developing a therapeutic alliance with the anorexia nervosa client. Journal of Psychosocial Nursing 25(1), 1117.

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Garrett C. (1991) Bread and Butter Stuff: Nursing People With Anorexia Nervosa: A Report for CHER (Communication, Health and Education Research Centre), UWS-Nepean. UWS Nepean, Westmead.

George L. (1997) The psychological characteristics of patients suffering from Anorexia Nervosa and the nurses role in creating a therapeutic relationship. Journal of Advanced Nursing 26(5), 899908.

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Hayward P. & Bright J.A. (1997) Stigma and mental illness: a review and critique. Journal of Mental Health 6(4), 345-354.

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Higgins J.A & Dermer S. (2001) The Use of Film in Marriage and FamilyCounselor Education. Counselor Education & Supervision 40(3), 182-192.

Higgins S.S. & Lantz M.L. (1997) An Innovative Approach Using Film and CreativeWriting to Teach Developmental Concepts to Pediatric Nursing Students. Journal of Pediatric Nursing 12(6), 364-366.

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Ironbar N.O. & Hooper A. (1989) Self instruction in mental health nursing. Bailliere Tindall, London.

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Kalra G. (2012) Talking about stigma towards mental health professionals with psychiatry trainees: A movie club approach. Asian Journal of Psychiatry 5(3), 266-268.

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Storyboard

Masking the illness in front of friends and familyRegular body checking is a common behaviour for individuals with Anorexia Nervosa (Hasse et al. 2011, Suda et al. 2013).Black balloons in the background symbolising the constant influence individuals have due to their illness (Anorexia Nervosa) is a theme throughout the video.Correction:The title Anorexia should be corrected to Anorexia Nervosa, with the term Anorexia simply meaning loss of appetite not the diagnosed mental illness.

Feeling alone, with no one to turn to for help, all she can do is cry as she doesnt know what to do.

Trying to run away from the problem or ignoring it.A jump cut to Frances now outdoors in a field. This part of the video, filmed outdoors, aims to be more surreal and symbolic of the internal thoughts and battle in an individuals mind with Anorexia.Many patients describe a constant battle between Anorexia as a friend and an enemy (Colton & Pistrang, 2004, Serpell et al.1999).Letting go of Anorexia One balloon is still left; highlighting that recovery is a lifelong process for most people with Anorexia Nervosa. Recovery does not mean the problem is gone, recovery requires maintenance, follow ups and regular monitoring. I believe this added another dimension to this video. The video reveals the actress in the video has experienced Anorexia Nervosa first hand. Ties well with the repeated question: What do you see when you look at me?

A finale quote, aiming to stimulate further reflection alongside the video

References

Colton A. & Pitstrang N. (2004) Adolescents Experiences of Inpatient Treatment for Anorexia Nervosa. European Eating Disorders Review 12(5), 307316.

Haase A.M., Mountford V. & Waller G. (2002) Associations between body checking and disordered eating behaviours in nonclinical women. International Journal of Eating Disorders 44(5), 465468.

Haase A.M., Mountford V. & Waller G. (2002) Associations between body checking and disordered eating behaviours in nonclinical women. International Journal of Eating Disorders 44(5), 465468.

Serpell L., Treasure J., Teasdale J., & Sullivan V. (1999) Anorexia nervosa: friend or foe? a qualitative analysis of the themes expressed in letters written by anorexia nervosa patients. International Journal of Eating Disorders 25(1), 177186.

Suda M., Brooks S.J., Giampietro V., Friederich H.C., Uher R., Brammer M.J., Williams S.C.R., Campbell I.C. & Treasure J. (2013) Functional neuroanatomy of body checking in people with anorexia nervosa. International Journal of Eating Disorders 46(7), 653662.

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