Therapeutic alliance, anorexia nervosa and the inpatient setting: A mixed methods study.

AIMS: The aim of this study was to understand the context of the inpatient setting for the treatment of anorexia nervosa and the implications for the therapeutic alliance between nurses and consumers. BACKGROUND: The nature of the therapeutic alliance is dependent on the contextual factors that influence interactions. The inpatient setting for the treatment of anorexia nervosa is one such setting where the therapeutic alliance is operative, yet challenging and poorly understood. DESIGN: A two-phase explanatory sequential design was employed. Descriptive statistics from phase one informed phase two interviews. Phase two data were analysed through thematic analysis. METHODS: A convenience sample of nurses and consumers were recruited from six wards, in five hospitals. Phase one involved the completion of a survey (N = 128) that measured the strength of the therapeutic alliance, as well as other elements of ward context. Phase two interviews (N = 54) were focused on the therapeutic alliance between nurses and consumers and the implications of the inpatient setting. Data collection occurred between May 2014 - February 2015. RESULTS: Anorexia nervosa as an illness carries destructive implications for the quality of the therapeutic alliance. Nurses' intimate position in the inpatient setting and interpersonal capacity is influential in overcoming the obstacles that impede the therapeutic alliance. CONCLUSION: Nurses' capacity for developing therapeutic alliances is in part dependent on a supportive ward organization and the adequacy of resources to permit meaningful interactions with consumers with anorexia nervosa. Understanding the contextual factors specific to the inpatient setting enhances nurses' ability to develop therapeutic alliances.

The nature of the therapeutic alliance between nurses and consumers with Anorexia Nervosa in the inpatient setting: A mixed-methods study.

AIMS AND OBJECTIVES: To develop a greater understanding of the nature of the inpatient therapeutic alliance between nurses and consumers with Anorexia Nervosa (AN). BACKGROUND: Consumers with AN value interpersonal relationships with nurses, finding these relationships meaningful and therapeutic. It is established that the therapeutic alliance enhances outcomes for consumers with AN. However, establishing the therapeutic alliance in the inpatient setting is considered challenging. DESIGN: This study employed a two-phase mixed-method explanatory sequential design. An initial quantitative survey, phase one, was followed by the collection and analysis of qualitative data, phase two. METHODS: Phase one employed validated survey instruments, measuring the perceived degree of therapeutic alliance and elements of ward milieu. Phase two involved semi-structured interviews that focused on therapeutic relationships between nurses and consumers, with specific exploration of the results from phase one. Data collection commenced May 2014 and concluded February 2015. RESULTS: The therapeutic alliance involved interpersonal engagement and a balanced application of authority. In a therapeutic alliance, nurses cared for consumers with interpersonal finesse, whilst maintaining clear distinction between the consumer as an individual and AN as an illness. Nurses also developed a therapeutic alliance by occupying their position of power with consistent yet individualised expectations and by maintaining appropriate professional boundaries. CONCLUSIONS: The therapeutic alliance between nurses and consumers with AN is not developed through negotiation of equal partners. Rather, the therapeutic alliance is dependent on nurses' capacity to maintain their position of power, whilst demonstrating their trustworthiness to the consumer. In trusting nurses, consumers felt safer in investing in a new concept of well-being. RELEVANCE TO CLINICAL PRACTICE: By understanding the nature of the therapeutic alliance as it is described in this study, nurses have an enhanced capacity to develop effective therapeutic alliances with consumers. A maternalistic nursing style emerged as a viable approach.