Clinicians' power in the inpatient care of anorexia nervosa Assignment

INTRODUCTION & BACKGROUND

Anorexia Nervosa (AN) is associated with lower quality of life (Hay et  al.,  2023) and has the highest mortality rate of any mental illness (Arcelus et al., 2011). According to the DSM-5-TR, AN is characterised by “persistent energy intake restriction; intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain; and a disturbance in self-perceived weight or shape” (American Psychiatric Association,  2022). Numerous psychotherapies are used in the treatment of AN, and the intensity of treatment is determined with consideration for psychiatric acuity and clinical status (Muratore & Attia,  2021). People who are medically compromised with life-threatening AN are cared for in the inpatient setting. In hospital, clinicians (primarily nurses and physicians) are responsible for facilitating activities that ensure weight gain whilst managing the risk of refeeding syndrome. Due to the ego-syntonic nature of AN, conflict between consumers and clinicians occurs as the prospect of weight gain threatens their valued thinness (Gregertsen et al., 2017). Without readily established resolution, clinicians caring for people with AN in the inpatient setting are faced with situations that involve imposing sanctions and the temporarysuspension of a consumer's autonomy; clinicians may be required to enforce injunctions to exercise, supervise meals and enforce meal adherence with the potential to impose nasogastric tube insertion and feeding in severe cases (Ramjan & Gill, 2012). In accordance with their duties, clinicians are liable to exercise power and authority at the expense of consumer autonomy (Zugai et al., 2019).

Inpatient mental healthcare involves an asymmetrical distribution of power and control with consumers in a position of relative vulnerability (Zugai,  2022), and care activities that involve the application of real or threatened force are by definition coercive (O'Brien & Golding,  2003). The concept of coercion includes measures that limit patient autonomy and freedom through physical force as well as measures that involve persuasion or inducement. Experiences of coercion are common in inpatient AN care, as treatment is often provided on an involuntary basis, with involuntary treatment occurring in 13%–44% of admissions for AN (Clausen,  2020). Involuntary treatment is justified on legal and ethical grounds by the lifethreatening implications of the starvation state and the consumer's impaired capacity for autonomy from severe mental illness (Atti et  al.,  2021; Zugai,  2022). The substantial harms associated with coercion are well established; consumers perceive coercive events as punitive and humiliating, and coercion disrupts care and the therapeutic relationship/therapeutic alliance (Hawsawi et al., 2020; Paradis-Gagné et al., 2021). Seed et al. (2016) reports that consumers treated on an involuntary basis for AN have reported experiences of feeling punished, fearful and feeling uncared for.

The clearly established harms of coercion and the frequent use of force in the care of inpatient AN tempt an a priori indictment of inpatient treatment. However, despite the routine use of force in AN care, consumers with AN have also reported an appreciation of care that is ostensibly coercive in nature. In numerous qualitative investigations, consumers have expressed appreciation of care that diminished their own autonomy, in recognition that they were themselves unable to facilitate their own recovery (Neiderman et al., 2001; Offord et al., 2006; Smith et al., 2016; Tierney, 2008; Westwood & Kendal, 2012; Zugai et al., 2013). Furthermore, the restrictive and structured environment of the inpatient setting provides consumers with a safe space to relinquish control of the eating disorder and supported engagement in treatment (Rankin et  al.,  2023). Upon reflection of their experiences, some consumers reconcile and establish justification for the temporary suspension of their autonomy. It is well established that the asymmetry of power in mental healthcare has a dual potential for healing or harm (Zugai,  2022), however the consumer perspective of the power asymmetry is under-established, and the maleficence and beneficence of the asymmetry of power is yet to be thoroughly demarcated.

This study was an exploration of consumers' views of clinicians' position and use of power in inpatient care for AN. By understanding consumers' perceptions of clinicians' power, strategies for diminishing harms associated with the use of power may be developed and implemented. The aim of this study was to investigate the consumer perspective of clinicians' power in the inpatient care of AN, establishing insight into the beneficence and maleficence of the power asymmetry.

METHODS 

Design

A qualitative descriptive design (Doyle et al., 2020) was adopted for this study based on the need to explore the perceptions and experiences of people with AN in an understudied area of research. This design not only recognises the subjectivity and uniqueness of individual experiences, it presents narratives in an authentic and meaningful manner remaining close to the phenomenon being studied (Doyle et  al.,  2020). The narratives can then be compared to uncover patterns that relate to individuals' emic perspective and present them in a manner that aligns with the research question (Bradshaw et al., 2017).The specific qualitative method of analysis utilised in this study was a thematic analysis, conducted in accordance with the guidelines stipulated by Braun and Clarke  (2006), and in conjunction with their more recently published recommendations detailing the reflexive approach (Braun & Clarke, 2019). The COREQ checklist was used to ensure accuracy and completeness of reporting (Tong et al., 2007).

Procedure and participants

This study relied on non-probability, purposive sampling of people who had experienced inpatient care for the treatment of AN; participants were required to have experienced hospitalisation specifically for the treatment of AN in a unit with an eating disorders program. Participants were required to either be recovered by their own estimation, or their care was limited to outpatient management. All participants were at least 18years of age and were able to speak and understand English. Participants needed to be in Australia to participate. People dependent on inpatient care were excluded from this study.

Participants were recruited from social media communities. With permission from the online moderators, an announcement was posted on two online pages that were support groups specifically for people with eating disorders in Australia. The post outlined the general aims and requirements of the study and invited community members to consider participation. The principal investigator's (PI) email address was included for potential participants to make contact. Upon expression of interest, potential participants were provided with an information sheet which provided greater detail about the study, the research team, reasons for the study and the nature of participation. The information sheet indicated that the interviews would focus on their relationships with clinicians and how weight gain was ensured. Participation was voluntary and participants could withdraw from the study at any time. During the course of data collection, no potential participants were excluded and no potential participants changed their mind about participation.

Data collection

Recruitment and data collection occurred from October to December 2022 in Australia. The PI conducted all interviews. Semi-structured interviews were conducted on a secure cloud-based conferencing service at a mutually agreeable time. Prior to commencing the interview, permission was sought to record the interview. Before recording, participants were asked to turn off their webcam to protect their identity, eliminating the possibility of a visual recording. Participants were then asked a set of prescribed screening questions to ensure their suitability for inclusion in the study. The screening questions determined if they were old enough to consent, whether they had experienced hospitalisation specifically for AN, recovery status, and if they felt comfortable with discussing their experiences in hospital. Participants were then asked to provide verbal consent to participate. Interview recordings were password protected, stored directly in Cloudstor hosted by AARNET. No repeat interviews were conducted.

The interview schedule prompted participants to describe their experiences that involved clinicians utilising their position of power. For example, ‘During your time in hospital, were you ever pressured or forced to eat? If so, can you tell me about those experiences?’, and, ‘During those times when you were forced to eat or when you experienced consequences for exercising, how did it make you feel at the time it was happening?’, and, ‘Thinking back on those experiences, do you feel differently about it now, compared to when it was happening in hospital?’. Being a semi-structured interview, the questions varied according to the specific circumstances and experiences reported by the participant. After provisional review of the transcripts, the authors determined that 10 interviews (the entire dataset) were sufficient for the aims of the study, with no new themes emerging. This number of interviews is consistent with other qualitative investigations of comparable focus and methodology (Hem et al., 2018). Transcripts were not returned to participants.

Analysis

The analysis was manually conducted by the listed authors. All listed authors are PhD qualified with substantial experience in qualitative research. The PI is a man, the other investigators are women. JZ and LR are fulltime nursing academics, and KG is a consumer representative with an extensive track record of advocacy group leadership. Interview recordings were transcribed for analysis purposes. Data were analysed through a thematic analysis approach whereby recurring themes that addressed the research aim were accorded significance and reported. Data analysis was conducted with a six-step approach, as prescribed by Braun and Clarke  (2006) (Table 1). This process relied on coding as a valid means of securing validity and reliability of qualitative research findings (Morse, 2015). Consistent with Braun and Clarke  (2019), themes were representative of the patterns of shared meaning within the participants' narratives. The results were determined in consultation with all listed authors, participant checking was not conducted. In reporting the results, quotes from participants were used for their descriptive merit, establishing rich insight into consumer perspectives. Quotes are attributed to pseudonyms.

Ethics

Approval to conduct this study was obtained from a university human research ethics committee (EC00418: 2022- 120S). Prior to transmission to a transcription service, identifiable data from the audio recordings were deleted, and the transcripts used in analysis were non-identifiable. The privacy policy of the transcription service utilised was compliant with Australian Privacy Act 1988 and the Guidelines on Privacy in the Private Health Sector issued by the Federal Privacy Commissioner under the National Health Act 1953 (Pacific Transcription, 2023). The identity of participants were coded and only the PI was aware of the true identities of participants. The investigators did not have a pre-existing relationship with any of the participants. Procedures for management of distress were developed prior to data collection, though none were required. Interview recordings and transcripts will be stored for 5years post publication and subsequently permanently deleted.

RESULTS

All participants in this study (n=10) were adult women. Interviews lasted 40minutes on average, with a total of 6h and 45min of audio material generated. Participants reported substantial lengths of inpatient admission, and some reported having over a year of cumulative inpatient experience.