Understanding the therapeutic alliance between nurses and consumers with anorexia nervosa in the context of the inpatient setting : a mixed methods study

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Introduction and Aims: The evidence informing the treatment of anorexia nervosa is limited. It is established that consumers with AN value professional interpersonal relationships with nurses, finding these relationships meaningful and therapeutic. A therapeutic alliance is associated with enhanced outcomes, and may be a promising aspect of the treatment for AN. However, therapeutic alliance is not well understood in the context of the inpatient setting. The aim of this research was to establish a greater understanding of the nature of the therapeutic alliance between nurses and consumers with anorexia nervosa, within the context of the inpatient setting. Method: This study employed a mixed methods approach, two phase explanatory sequential design. The initial phase consisted of a quantitative investigation, involving both consumers and nurses in surveys. Surveys measured the perceived degree of alliance, and investigated other elements of ward context. The subsequent qualitative phase involved semi-structured interviews with both nurses and consumers. Interviews were focused on the relationships between nurses and consumers and the implications of ward context on those relationships. Interviews also developed a qualitative understanding for interpreting the quantitative findings. Results: Consumers reported a relatively low perceived alliance with nurses, a relatively low perceived satisfaction with care, and a severe degree of eating disorder psychopathology. Nurses reported good attitudes towards consumers with acute mental illness. Consumers and nurses had a diverging perception of the alliance, as nurses perceived a higher strength of alliance compared to consumers. The interviews revealed that the alliance was valued and had positive environmental implications. However, anorexia nervosa as an illness was detrimental to the relationships between nurses and consumers. In developing a therapeutic alliance, nurses and consumers actively separated from the destructive implications of anorexia nervosa. Nurses’ use of authority was influential over the development of the alliance. Multiple contextual factors within the ward influenced the therapeutic alliance between nurses and consumers. Discussion and Conclusion: The way that nurses utilised their position of power determined the quality of the therapeutic alliance. A successful therapeutic separation and mutuality was dependent on confidence in the understanding that the orientation of power was employed to credit and protect the consumer. A balance of ‘love and limits’ developed a therapeutic separation, which preceded the mutuality of a therapeutic alliance. Contextual factors within the inpatient setting can be modified to enhance the capacity for nurses to develop therapeutic alliances with consumers.
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