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.