Rejection--a neglected phenomenon in psychiatric nursing

The basically asymmetric character of the 'psychotic patient-psychiatric nurse' relationship constitutes an ethical challenge for the nurse. One aspect of this relationship is that nurses must constantly self-consciously control their behaviour towards the patient. There is some evidence that the patient sometimes feels offended because of his perception that the nurse rejects him. The purpose of this article is to examine the role rejection plays in the 'psychotic patient-psychiatric nurse' relationship and ethical implications this might have for the field of psychiatric nursing. This study is conducted using an ethnographic research design that includes participant observation and narrative interviews of nurses working on an acute ward of a psychiatric hospital. One case is analysed and discussed in depth through the philosophical insights (particularly 'the ethical demand') of the Danish moral philosopher K.E. Løgstrup. The psychotic patient, being vulnerable, dependent, and trusting, confronts the psychiatric nurse with a constant 'ethical demand' to take care of him. The patient's trust, and his fight to maintain his dignity, creates a risk of being rejected. The nurse, by resorting to the tactic of 'impersonal professional routine', which does not define the relationship as a personal encounter, creates boundaries between herself and the patient. The nurse's withdrawal from the patient's perception of reality is experienced by the patient as rejection and hence an offence of his dignity. The nurse's rejection of the patient has two causes: external factors--for example inadequate staffing--cause the nurse to be unable to live up to the professional ideal of 'welcoming' the patient; internal factors--for example the profession's understanding of itself--create an unclear understanding of the nurse's role and responsibilities. It is necessary to work with both the external and internal factors to improve psychiatric nursing.