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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Nurses’ Establishment of Health Promoting Relationships:
A Descriptive Synthesis of Anorexia Nervosa Research</title><author><name sortKey="Salzmann Erikson, Martin" sort="Salzmann Erikson, Martin" uniqKey="Salzmann Erikson M" first="Martin" last="Salzmann-Erikson">Martin Salzmann-Erikson</name><affiliation><nlm:aff id="Aff1">Faculty of Health and Occupational Studies, Department of Health and Caring Sciences, University of Gävle, Gävle, SE-80176 Sverige Sweden</nlm:aff></affiliation></author><author><name sortKey="Dahlen, Jeanette" sort="Dahlen, Jeanette" uniqKey="Dahlen J" first="Jeanette" last="Dahlén">Jeanette Dahlén</name><affiliation><nlm:aff id="Aff2">Child and Adolescent Psychiatry Outpatient Clinic, Stockholm County Council, Stockholm, Sweden, Ersta Sköndal University College, Institution for Caring Science, Stockholm, Sweden</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">28111516</idno><idno type="pmc">5219017</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5219017</idno><idno type="RBID">PMC:5219017</idno><idno type="doi">10.1007/s10826-016-0534-2</idno><date when="2016">2016</date><idno type="wicri:Area/Pmc/Corpus">000040</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000040</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Nurses’ Establishment of Health Promoting Relationships:
A Descriptive Synthesis of Anorexia Nervosa Research</title><author><name sortKey="Salzmann Erikson, Martin" sort="Salzmann Erikson, Martin" uniqKey="Salzmann Erikson M" first="Martin" last="Salzmann-Erikson">Martin Salzmann-Erikson</name><affiliation><nlm:aff id="Aff1">Faculty of Health and Occupational Studies, Department of Health and Caring Sciences, University of Gävle, Gävle, SE-80176 Sverige Sweden</nlm:aff></affiliation></author><author><name sortKey="Dahlen, Jeanette" sort="Dahlen, Jeanette" uniqKey="Dahlen J" first="Jeanette" last="Dahlén">Jeanette Dahlén</name><affiliation><nlm:aff id="Aff2">Child and Adolescent Psychiatry Outpatient Clinic, Stockholm County Council, Stockholm, Sweden, Ersta Sköndal University College, Institution for Caring Science, Stockholm, Sweden</nlm:aff></affiliation></author></analytic><series><title level="j">Journal of Child and Family Studies</title><idno type="ISSN">1062-1024</idno><imprint><date when="2016">2016</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>Qualitative values that address personal and interpersonal dimensions are often overlooked in research that examines mental well-being among young patients with anorexia nervosa. The aim of this review was to identify and describe factors that promote and impede the relationships between nurses and the children, adolescents and young adults who are diagnosed with anorexia nervosa and also to explore and describe how those relationships benefit the patients’ processes toward increased health and well-being. A descriptive literature synthesis was conducted following the four steps as described by Evans. The three databases CINAHL, PsycINFO and PubMed were used to search for qualitative articles. Fourteen articles met the criteria for inclusion and were analysed. Key findings were identified, and categories and themes were formulated and compared across the studies. Four themes are presented in the results: (1) The essentials in a relationship; (2) The person at the centre; (3) The nurses’ attitudes; and (4) Knowledge. In addition to the contribution to the knowledge of how anorexia is manifested, our findings demonstrate the necessity for nurses to be person-centred in their relationships with patients and to have attitudes characterised by presence, genuine commitment and motivation. Nurses are more likely to convey a sense of trust and safety when they communicate with openness and honesty. Our review suggests that the motivation for patients to adhere to treatment is likely to increase when nurses approach patients with these characteristics and attitudes. We argue that the findings are relevant for nurses in their everyday practices.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Anthony, W" uniqKey="Anthony W">W Anthony</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Arcelus, J" uniqKey="Arcelus J">J Arcelus</name></author><author><name sortKey="Mitchell, A" uniqKey="Mitchell A">A Mitchell</name></author><author><name sortKey="Wales, J" uniqKey="Wales J">J Wales</name></author><author><name sortKey="Nielsen, S" uniqKey="Nielsen S">S Nielsen</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Bakker, R" uniqKey="Bakker R">R Bakker</name></author><author><name sortKey="Van Meijel, B" uniqKey="Van Meijel B">B van Meijel</name></author><author><name sortKey="Beukers, L" uniqKey="Beukers L">L Beukers</name></author><author><name sortKey="Van Ommen, J" uniqKey="Van Ommen J">J van 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<front><journal-meta><journal-id journal-id-type="nlm-ta">J Child Fam Stud</journal-id><journal-id journal-id-type="iso-abbrev">J Child Fam Stud</journal-id><journal-title-group><journal-title>Journal of Child and Family Studies</journal-title></journal-title-group><issn pub-type="ppub">1062-1024</issn><publisher><publisher-name>Springer US</publisher-name><publisher-loc>New York</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">28111516</article-id><article-id pub-id-type="pmc">5219017</article-id><article-id pub-id-type="publisher-id">534</article-id><article-id pub-id-type="doi">10.1007/s10826-016-0534-2</article-id><article-categories><subj-group subj-group-type="heading"><subject>Original Paper</subject></subj-group></article-categories><title-group><article-title>Nurses’ Establishment of Health Promoting Relationships:
A Descriptive Synthesis of Anorexia Nervosa Research</article-title></title-group><contrib-group><contrib contrib-type="author" corresp="yes"><contrib-id contrib-id-type="orcid">http://orcid.org/0000-0002-2610-8998</contrib-id><name><surname>Salzmann-Erikson</surname><given-names>Martin</given-names></name><address><phone>+46-707-106999</phone><email>martin.salzmann@hig.se</email></address><xref ref-type="aff" rid="Aff1">1</xref></contrib><contrib contrib-type="author"><name><surname>Dahlén</surname><given-names>Jeanette</given-names></name><xref ref-type="aff" rid="Aff2">2</xref></contrib><aff id="Aff1"><label>1</label>Faculty of Health and Occupational Studies, Department of Health and Caring Sciences, University of Gävle, Gävle, SE-80176 Sverige Sweden</aff><aff id="Aff2"><label>2</label>Child and Adolescent Psychiatry Outpatient Clinic, Stockholm County Council, Stockholm, Sweden, Ersta Sköndal University College, Institution for Caring Science, Stockholm, Sweden</aff></contrib-group><pub-date pub-type="epub"><day>13</day><month>9</month><year>2016</year></pub-date><pub-date pub-type="pmc-release"><day>13</day><month>9</month><year>2016</year></pub-date><pub-date pub-type="ppub"><year>2017</year></pub-date><volume>26</volume><issue>1</issue><fpage>1</fpage><lpage>13</lpage><permissions><copyright-statement>© The Author(s) 2016</copyright-statement><license license-type="OpenAccess"><license-p>This article is distributed under the terms of the Creative Commons Attribution 4.0 International License
(<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/4.0/">http://creativecommons.org/licenses/by/4.0/</ext-link>), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.</license-p></license></permissions><abstract id="Abs1"><p>Qualitative values that address personal and interpersonal dimensions are often overlooked in research that examines mental well-being among young patients with anorexia nervosa. The aim of this review was to identify and describe factors that promote and impede the relationships between nurses and the children, adolescents and young adults who are diagnosed with anorexia nervosa and also to explore and describe how those relationships benefit the patients’ processes toward increased health and well-being. A descriptive literature synthesis was conducted following the four steps as described by Evans. The three databases CINAHL, PsycINFO and PubMed were used to search for qualitative articles. Fourteen articles met the criteria for inclusion and were analysed. Key findings were identified, and categories and themes were formulated and compared across the studies. Four themes are presented in the results: (1) The essentials in a relationship; (2) The person at the centre; (3) The nurses’ attitudes; and (4) Knowledge. In addition to the contribution to the knowledge of how anorexia is manifested, our findings demonstrate the necessity for nurses to be person-centred in their relationships with patients and to have attitudes characterised by presence, genuine commitment and motivation. Nurses are more likely to convey a sense of trust and safety when they communicate with openness and honesty. Our review suggests that the motivation for patients to adhere to treatment is likely to increase when nurses approach patients with these characteristics and attitudes. We argue that the findings are relevant for nurses in their everyday practices.</p></abstract><kwd-group xml:lang="en"><title>Keywords</title><kwd>Anorexia nervosa</kwd><kwd>Literature review</kwd><kwd>Psychiatric nursing</kwd><kwd>Relationship</kwd></kwd-group><custom-meta-group><custom-meta><meta-name>issue-copyright-statement</meta-name><meta-value>© Springer Science+Business Media New York 2017</meta-value></custom-meta></custom-meta-group></article-meta></front><body><sec id="Sec1" sec-type="introduction"><title>Introduction</title><p>Anorexia nervosa (AN) primarily affects adolescent girls and young women and is characterised by excessive dieting, leading to severe weight loss with a pathological fear of becoming fat or unhealthy behaviours that hinder weight gain despite clear indications of remaining underweight. Another aspect of the disease is a distorted body image, affecting ideas about weight and body form, along with a self-image that is overly influenced by these factors (American Psychiatric Association <xref ref-type="bibr" rid="CR1">2013</xref>).</p><p>A longitudinal study from the U.S. showed that the mortality among individuals with AN is significantly higher than that of the general population (Franko et al. <xref ref-type="bibr" rid="CR18">2013</xref>). Two meta-analyses have also shown that AN has the highest mortality among all psychiatric diseases (Arcelus et al. <xref ref-type="bibr" rid="CR3">2011</xref>; Smink et al. <xref ref-type="bibr" rid="CR52">2012</xref>). Causes for death are most often physiological factors, such as undernourishment and cardiovascular collapse (Wilkes and Anderson <xref ref-type="bibr" rid="CR60">2000</xref>), but suicide also occurs often among youth with AN (Papadopoulos et al. <xref ref-type="bibr" rid="CR39">2009</xref>). AN usually debuts during an important and identity-forming time in life when the individuals are between 15–20 years old. The onset has serious consequences for the youth themselves, and it also has extensive consequences for the whole family and their living conditions (Russell <xref ref-type="bibr" rid="CR48">2006</xref>). Reasons for onset are not completely mapped out, but predispositions, such as family, socio-cultural, genetic, biological and individual factors have been identified (Hällström <xref ref-type="bibr" rid="CR23">2010</xref>; Nilsson et al. <xref ref-type="bibr" rid="CR33">2007</xref>). A Danish cohort study that followed over 2300 children and youth for three generations showed that there is a heightened risk for the development of AN within families that have incidences of affective disorders, including anxiety, obsessive-compulsive disorder, personality disorders and substance abuse as well as those with siblings suffering from AN (Steinhausen et al. <xref ref-type="bibr" rid="CR53">2015</xref>).</p><p>Eating disorders are often reported to be difficult to treat, and caring for patients diagnosed with AN is often complex due to low motivation for treatment among the patients (Geller et al. <xref ref-type="bibr" rid="CR19">2001</xref>; Marzola et al. <xref ref-type="bibr" rid="CR29">2012</xref>; Vitousek et al. <xref ref-type="bibr" rid="CR58">1998</xref>). Beyond the fear of gaining weight or losing control (Palmer <xref ref-type="bibr" rid="CR37">2000</xref>), a negative self-image is also said to be characteristic for this patient group, all of which contribute to difficulties in treatment (Björck <xref ref-type="bibr" rid="CR7">2006</xref>). Higher levels of guilt and hate tied to the person as well as lower levels of self-affirmation and self-love are shown in people with AN in comparison with people with other eating disorders. AN is reported to be the eating disorder that is tied most closely with self-control (Björck <xref ref-type="bibr" rid="CR7">2006</xref>).</p><p>One reason that youths with AN are ambivalent and choose to fight treatment of their illness can be the positive effects they experience using the disease and its restrictions as tools for control and handling of emotions-something treatment would prevent (Treasure et al. <xref ref-type="bibr" rid="CR56">1999</xref>; Williams and Reid <xref ref-type="bibr" rid="CR61">2010</xref>). Giving oneself over to treatment is about letting go of control, and therefore complexity in care arises (Palmer <xref ref-type="bibr" rid="CR38">2002</xref>; Paulson Karlsson <xref ref-type="bibr" rid="CR40">2012</xref>). In treatment of patients with high degrees of self-hate, there is a risk that those treating the patient respond to the patient in a negative way. Patients with a high degree of self-hate can provoke hostile reactions from therapists, and low levels of rejection, accusations and belittlement can negatively influence the treatment (Björck <xref ref-type="bibr" rid="CR7">2006</xref>; Kiesler <xref ref-type="bibr" rid="CR27">1996</xref>).</p><p>The establishment of emotional alliances and trusting relationships is essential in psychiatric care (Borg and Kristiansen <xref ref-type="bibr" rid="CR8">2004</xref>; Denhov and Topor <xref ref-type="bibr" rid="CR14">2012</xref>; Peplau <xref ref-type="bibr" rid="CR42">1991</xref>). The relationship between nurses and patients is paramount in psychiatric nursing in order to accomplish a change that will help and direct patients’ processes toward health and recovery (Barker and Buchanan-Barker <xref ref-type="bibr" rid="CR5">2005</xref>; Dahlberg and Segesten <xref ref-type="bibr" rid="CR13">2010</xref>; Shanley and Jubb-Shanley <xref ref-type="bibr" rid="CR50">2007</xref>). In a prospective cohort study of adolescents with AN in France, Bourion-Bedes et al. (<xref ref-type="bibr" rid="CR9">2013</xref>) demonstrated the correlation between AN patients’ perceptions of early therapeutic alliances and shorter times in achieving target weights. Other studies report on the way motivation towards changing eating habits varies among patients with AN (Nordbo et al. <xref ref-type="bibr" rid="CR34">2011</xref>; Vansteenkiste et al. <xref ref-type="bibr" rid="CR57">2005</xref>).</p><p>In order to support progress in the treatment of AN, it is essential to explore and address patients’ expressed motivations at an early stage and throughout the process to help patients maintain a positive attitude toward change (Paulson Karlsson <xref ref-type="bibr" rid="CR40">2012</xref>). According to Pereira et al. (<xref ref-type="bibr" rid="CR43">2006</xref>), difficulties in creating an alliance with adolescents with AN are often due to a strong identification with the disease, low cognitive functioning related to starvation and being in treatment because the parents have demanded it, not because they have decided to seek treatment on their own. Earlier studies also show that parents often feel a stronger alliance with caregivers than the adolescents in treatment do. This had an impact on treatment progress, as patients did not feel secure and felt less positive toward change (Forsberg et al. <xref ref-type="bibr" rid="CR17">2013</xref>; Halvorsen and Heyerdahl <xref ref-type="bibr" rid="CR21">2007</xref>; Isserlin and Couturier <xref ref-type="bibr" rid="CR24">2012</xref>). However, parents’ alliances with caregivers are important for their roles as parents and their further support of their children after discharge (Honey et al. <xref ref-type="bibr" rid="CR22">2007</xref>; Isserlin and Couturier <xref ref-type="bibr" rid="CR24">2012</xref>). According to McCormack and McCance (<xref ref-type="bibr" rid="CR31">2006</xref>), the foundation in person-centred care is comprised of different constructs, and one important construct is the attributes of the nurse, including being professionally competent and interpersonally skilled. The literature generally emphasises what a health-promoting relationship is and how it can influence patients on their path to good health (Dahlberg and Segesten <xref ref-type="bibr" rid="CR13">2010</xref>; McCormack and McCance <xref ref-type="bibr" rid="CR31">2006</xref>; Safran and Muran <xref ref-type="bibr" rid="CR49">2000</xref>). However, there is a lack of clear descriptions of specific factors that contribute to creating this important relationship between nurses and patients with AN.</p><p>To promote the development of the clinical work that aims to reduce suffering during care, reduce the length of care and increase the results of treatment, there is a strong incentive to gather knowledge that identifies the factors that promote a care relationship that supports the patient’s health process. We believe that nurses hold a position in which they are able to impact the quality of care because of their abilities to manage the complexity in their relationships with patients. Hence, we conducted a descriptive literature synthesis in which our aim was to identify and describe factors that promote and impede the relationships between nurses and children, adolescents, and young adult patients with AN. Our aim was to also explore and describe how those relationships benefit the patients’ processes toward increased health and well-being.</p></sec><sec id="Sec2"><title>Method</title><p>In this review we analysed and synthesised original research based on subjective experiences concerning relationships between nurses and patients. This descriptive literature synthesis is grounded in our idea that reality is socially constructed, as opposed to the positivist paradigm. Hence, the focus in this review accounts for ‘studying people in natural settings while engaging in life experiences’, also termed naturalistic enquiry (Lincoln and Guba <xref ref-type="bibr" rid="CR28">1985</xref>). In order to create a systematic structure of the research process we chose to adopt the process for synthesising qualitative data outlined by Evans (<xref ref-type="bibr" rid="CR15">2002</xref>). In summary, Evans identifies the following steps in this process: (1) Gather the sample, (2) Identify the key findings, (3) Categorise themes across studies, and (4) Describe the phenomena.</p><p>Step 1: According to Evans (<xref ref-type="bibr" rid="CR15">2002</xref>) we determined the unit of analysis and which studies to include and exclude. The inclusion criteria were the following: original peer-reviewed articles on qualitative studies, written in English, published between 2004–2014, relevant to the purpose of the review, addressing children, adolescents and young adults (no specific age limits), scored as middle or high quality (evaluating the studies), and with a clear focus on patients diagnosed with AN and nurses’ experiences of caring for patients diagnosed with AN. Next, we determine which databases should be used. In collaboration and discussion with the librarian at the university, three databases were chosen due to their appropriateness in relation to the aim of the review: CINAHL, PsycINFO and PubMed. Search terms varied slightly across the databases. In summary, the following terms were used: CINAHL (search terms as “Subject Headings”: anorexia nervosa, qualitative studies, nursing care, interpersonal relationships, professional-patient relationships, Manual search: anorexia, qualitative, nurse*, relationship*, therapeutic alliance, effective nursing<italic>*</italic>). Six hundred eighty articles were found and all titles were read, out of those, 41 abstracts were read, 22 of the articles were reviewed and finally 12 chosen for inclusion. PsycINFO (search terms as Thesaurus: anorexia nervosa, qualitative research, therapeutic process*, interpersonal relationship*, Manual search: anorexia nervosa, nursing, therapeutic relationship*, alliance, effective nursing, professional relationships*). Three hundred fifty articles were found and all titles were read, out of those, 11 abstracts read, 6 articles reviewed and one chosen for inclusion. PubMed (search terms with MESH: anorexia nervosa, nurse-patient relationship*, professional-patient relationship*, qualitative research). Three hundred fifty four articles were found and all titles were read, out of those, four abstracts were read, one articles were reviewed but no article was chosen for inclusion. In addition, a manual search was conducted based on the reference list in the identified articles; the manual search resulted in one article chosen to be included in the review. See (Supplementary Table 1) for more details about search terms, combinations and number of hits. Since this is a review, permission to include the articles were not required.</p><p>Next, we selected the sample based on the search. First, the titles of the articles were read and determined whether the study suited our review aim. Of those articles that were considered suitable, the whole abstracts were read. A purposeful sample of 30 articles were selected based on how well the results in the included studies answered the research aim. Four articles were excluded, as they were not relevant even though the abstract at first seemed relevant. The remaining 26 articles were quality-valued based on a review template (Supplementary Table 2). The two review templates published in Forsberg and Wengström (<xref ref-type="bibr" rid="CR16">2013</xref>) and in Willman et al. (<xref ref-type="bibr" rid="CR62">2006</xref>) were merged both into one. Hence, it was possible to cover all important aspects when reviewing a research article. In addition, a point system was added to the modified template in order to quantify the quality. The template consisted of 25 questions regarding the quality of the article, covering aim, methodology, results, credibility, clinical relevance and ethical considerations. Each question in the template could be answered with a yes, giving one point and no, giving zero points. The points were summarised for each article, and 0–17 points was considered to indicate low quality, 18–20, middle-range quality and 21–25 points indicated high-quality. Four articles were excluded due to low quality. The review was performed by the second author. After internal discussion between the authors, an additional eight articles were excluded due to low relevancy, as the results in the articles did not provide accurate data to answers to the research aim. The remaining 14 articles, involving a total participant number of 134 patients and 33 nurses, were included for analysis (See Table <xref rid="Tab1" ref-type="table">1</xref>).<table-wrap id="Tab1"><label>Table 1</label><caption><p>Analyses of selected studies</p></caption><table frame="hsides" rules="groups"><thead><tr><th></th><th>Author, year, country</th><th>Title</th><th>Purpose of the study</th><th>Design</th><th>Participants</th><th>Method of analysis</th><th>Main results and quality</th></tr></thead><tbody><tr><td>A</td><td>Ross & Green (<xref ref-type="bibr" rid="CR47">2011</xref>). England.</td><td>Inside the experience of anorexia nervosa: A narrative thematic analysis</td><td>To research if in-patient care is experienced as therapeutic</td><td>Qualitative. Semi-structured interviews.</td><td>2 patients (over 18 years old) that had been sick with AN for over five years, with in-patient experience. Now in specialised day patient clinic.</td><td>Thematic analysis</td><td>Stresses the importance of nurturing relationships in the treatment of chronically ill patients with AN.</td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>High. 22/25</td></tr><tr><td>B</td><td>Van Ommen et al. (<xref ref-type="bibr" rid="CR36">2009</xref>). The Netherlands.</td><td>Effective nursing care of adolescents diagnosed with anorexia nervosa: the patients’ perspective</td><td>To describe effective nursing practices in in-patient care for patients with AN, from a patient’s perspective.</td><td>Qualitative. Semi-structured interviews.</td><td>13 patients (13–17 years old) that were treated in a specialised clinic with out-patient and in-patient care.</td><td>Grounded theory</td><td>Nurses contributed significantly to the recovery from AN through normalisation, structure and responsibility.</td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>High. 22/25.</td></tr><tr><td>C</td><td>Zugai et al. (<xref ref-type="bibr" rid="CR64">2012</xref>). Australia.</td><td>Effective nursing care of adolescents with anorexia nervosa: a consumer perspective</td><td>To describe how nurses enable weight gain and a positive experience for adolescents in treatment for AN, from a patient’s perspective.</td><td>Qualitative. Semi-structured interviews.</td><td>8 patients (12–18 years old) with in-patient experience, but now in specialised day patient clinic.</td><td>Thematic analysis</td><td>Nurses’ characteristics were seen as having a strong influence on patients’ experiences, primarily regarding weight gain, maintaining a therapeutic environment and the relationship between nurses and patients.</td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>High.21/25</td></tr><tr><td>D</td><td>Gulliksen et al. (<xref ref-type="bibr" rid="CR20">2012</xref>). Norway.</td><td>Preferred therapist characteristics in treatment of anorexia nervosa: the patient’s perspective</td><td>To describe which characteristics that patients with AN prefer in therapists.</td><td>Qualitative. Semi-structured interviews.</td><td>38 patients (18–51 years) that were treated as day patients, in-patients and out-patients at specialised clinics as well as general hospitals.</td><td>Thematic analysis</td><td>The care of patients with AN requires a caregiver with the ability to use a complex spectrum of skills. Preferred characteristics and skills included acceptance, vitality, expertise and the understanding to challenge the patient.</td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>High. 21/25.</td></tr><tr><td>E</td><td>Ramjan (<xref ref-type="bibr" rid="CR45">2004</xref>). Australia.</td><td>Nurses and the ‘therapeutic relationship’: caring for adolescents with anorexia nervosa</td><td>To research the difficulties that prevent relationships between nurses and patients with AN.</td><td>Qualitative. Semi-structured interviews.</td><td>10 nurses with at least two years of experience treating patients in in-patient care at a general children’s hospital.</td><td>Thematic analysis</td><td>The main themes in the care of patients with AN were 1) the aim to understand the disease, 2) the pursuit of control and a balance of power with the patient, 3) the desire to build a caring relationship and the difficulty of creating alliances.</td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>High.22/25.</td></tr><tr><td>F</td><td>Offord et al. (<xref ref-type="bibr" rid="CR35">2006</xref>). England.</td><td>Adolescent inpatient treatment for anorexia nervosa: a qualitative study exploring young adults’ retrospective views of treatment and discharge</td><td>To explore young adults’ opinions about previous in-patient care, how these experiences in care impact the need for control and low self-esteem as well as discharge.</td><td>Qualitative. Semi-structured interviews.</td><td>7 patients (16–23 years old) with experience with in-patient care.</td><td>Interpretive phenomenological analysis</td><td>Expressions of the adolescents’ normal development were not noted by the caregivers, which made things more difficult for the patients, and authoritative relationships were thought to contribute to feelings of isolation and inferiority.Medium high. 19/25.</td></tr><tr><td>G</td><td>Jenkins & Ogden (<xref ref-type="bibr" rid="CR25">2011</xref>). England.</td><td>Becoming ‘whole’ again: a qualitative study of women’s views of recovering from anorexia nervosa</td><td>To explore how women experienced their recovery from AN.</td><td>Qualitative. Semi-structured in-depth interviews.</td><td>15 patients, (over 18 years old) in the recovery stage with experience with both in-patient and day patient care.</td><td>Interpretive phenomenological analysis</td><td>The relationships with professionals had an influence on the recovery process, specifically regarding irrational and rational thinking and behaviours</td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>Medium high. 19/25.</td></tr><tr><td>H</td><td>Micevski & McCann (<xref ref-type="bibr" rid="CR32">2005</xref>). Australia.</td><td>Developing interpersonal relationships with adolescents with anorexia nervosa</td><td>To describe how nurses develop therapeutic relationships with adolescents with AN.</td><td>Qualitative. unstructured in-depth interviews.</td><td>10 nurses that treat patients with AN as in-patients in a children’s clinic.</td><td>Grounded theory</td><td>An individual focus and a sense of equality and respect are essential in care and for creating therapeutic relationships with patients with AN.</td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>Medium high. 19/25.</td></tr><tr><td>I</td><td>Bakker et al. (<xref ref-type="bibr" rid="CR4">2011</xref>). The Netherlands.</td><td>Recovery of normal body weight in adolescents with anorexia nervosa: the nurse’s perspective on effective interventions</td><td>To research the most effective aspects in nursing with adolescents with AN regarding weight gain. From a nurse’s perspective.</td><td>Qualitative. Semi-structured in-depth interviews.</td><td>8 nurses & 1 social worker that treat patients between 12–18 years with AN in a specialised clinic.</td><td>Thematic analysis</td><td>The nurses saw themselves as in a key position to support patients in weight gain, and a good therapeutic relationship was the most essential aspect for this.</td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>Medium-high. 18/25.</td></tr><tr><td>J</td><td>Pemperton & Fox (<xref ref-type="bibr" rid="CR41">2011</xref>). England.</td><td>The experience and management of emotions in an inpatient setting for people with anorexia nervosa: a qualitative study</td><td>To describe meaningful factors for caring for and aiding with managing emotions for people with AN in in-patient care.</td><td>Qualitative. Semi-structured interviews.</td><td>8 patients (under 25 years old) from two specialised units with in-patient care.</td><td>Interpretive phenomenological analysis</td><td>Some strategies among health professionals could aid in maintaining the anorexic behaviours in patients, while some anorexic behaviours in patients had negative impacts on the staff and therefore the care.</td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>Medium high. 20/25.</td></tr><tr><td>K</td><td>Sly et al. (<xref ref-type="bibr" rid="CR51">2014</xref>). England.</td><td>Rules of engagement: qualitative experiences of therapeutic alliance when receiving in-patient treatment for anorexia nervosa</td><td>To explore patients’ experiences with developing therapeutic alliances during hospital stays.</td><td>Qualitative. Semi-structured in-depth interviews.</td><td>8 patients (18–34 years old), that were treated in day patient care with earlier experiences with in-patient care.</td><td>Interpretive phenomenological analysis</td><td>Alliances are a main component in the treatment of eating disorders, and they are influenced by trust, safety and a sense of equality.</td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>Medium high. 19/25.</td></tr><tr><td>L</td><td>Wright & Hacking (<xref ref-type="bibr" rid="CR63">2012</xref>). England.</td><td>An angel on my shoulder: a study of relationships between women with anorexia and healthcare professionals</td><td>To describe the experience of the therapeutic relationship between women with AN and their caregivers and to examine the contexts that enable this.</td><td>Qualitative. Semi-structured in-depth interviews.</td><td>6 patients (21–44 years old), as well as their 7 caregivers (1 dietician, 1 therapist, 5 nurses). Patients were treated in day patient care and had been in different treatments for an average of 11 years.</td><td>Thematic analysis</td><td>Six topics that influence the caring relationship were presented: 1) sincerity, 2) safety, 3) the process of the disease, 4) recovery measured in kilograms, 5)hope and optimism, 6) the caregiver’s characteristics in handling patients.</td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>Medium high. 18/25.</td></tr><tr><td>M</td><td>Colton & Pistrang (<xref ref-type="bibr" rid="CR10">2004</xref>). England.</td><td>Adolescents’ experiences of inpatient treatment for anorexia nervosa.</td><td>To describe the experience of in-patient care for adolescents with AN.</td><td>Qualitative. Semi-structured interviews.</td><td>19 patients (12–17 years old), treated at a specialised clinic. Many of the patients had experience with previous stays in in-patient care at specialised clinics and in general hospitals.</td><td>Interpretive phenomenological analysis</td><td>Patients experienced conflicts and dilemmas regarding treatment, insight into the disease and the desire to get well. Key aspects of this were described.</td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>High. 21/25.</td></tr><tr><td>N</td><td>Tierney (<xref ref-type="bibr" rid="CR54">2008</xref>). England.</td><td>The individual within a condition: a qualitative study of young people’s reflections on being treated for anorexia nervosa.</td><td>To explore young people’s experiences of being treated for AN.</td><td>Qualitative. Semi-structured interviews.</td><td>10 patients that were treated for AN as teens (between 11–18 years old). Participants were in different stages of the disease and treatement process but had been in treatment within the last three years.</td><td>Thematic analysis</td><td>Aspects that patients considered important in care were discussed: the balance between the physical and the psychological, certain characteristics in professionals, and the experience of improvement in the process toward better health.</td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>High. 22/25.</td></tr></tbody></table></table-wrap></p><p>Step 2: The analysis procedure described by Evans (<xref ref-type="bibr" rid="CR15">2002</xref>) includes reading and collecting the findings. In order to conduct our inductive analysis, the included articles were read thoroughly, and notes were taken. Both the results in the original studies and conclusions were considered as data. Texts that were relevant to our purpose were coded with different colours, given a code number and pasted into a separate spreadsheet with five columns (Supplementary Table 3). The first column shows the author names, and the key findings are in the second column.</p><p>Step 3: In accordance with Evans’ (<xref ref-type="bibr" rid="CR15">2002</xref>) descriptive synthesis process we reviewed the key findings and compared them with those in the other studies. We condensed the key findings to get a clear picture of the text, and these were written down in the third column, presented in (Supplementary Table 3). The text in the third column was also copied onto post-it notes. The post-it notes were placed on a wall and sorted according to their similarities and differences. This led to the creation of four main themes, which are noted in column four, after each key finding. The next step according to Evans (<xref ref-type="bibr" rid="CR15">2002</xref>) is to search for nuances within the themes. The key findings within each theme were compared with each other. Based on the differences within the themes, we constructed different sub-themes. These were noted after each key finding in column five in the document. In total, we identified ten sub-themes which gave a nuanced and comprehensive understanding of the phenomena. Next, we compared and discussed the key-findings and the themes in order to view the parts in relation to the larger context in which they belonged. The content of the themes was reflected on using further comparisons with the articles’ outcomes and through a review of previously written notes and key findings. When two sub-themes tended to flow into each other, these were merged into one sub-theme.</p><p>Step 4: The fourth and final step in Evans’ (<xref ref-type="bibr" rid="CR15">2002</xref>) synthesis process is to describe the phenomena. With reference to the qualitative studies, each of the four themes and corresponding sub-themes are explained below in the “Results” section.</p></sec><sec id="Sec3" sec-type="results"><title>Results</title><p>The results are presented under the four themes: (1) The essentials in a relationship, including the sub-themes (a) Feelings of solidarity, participation and equality, (b) Openness, integrity and honesty and (c) Trust and safety; (2) The person at the centre, including the sub-themes (a) Seeing the person behind the diagnosis and (b) Balance between the physical and the psychological, (3) The nurses’ attitudes, including the sub-themes (a) Motivation and hope, (b) Maintaining structure, responsibility and normality and (c) Presence and availability; and (4) Knowledge, including the sub-themes (a) Understanding, experience and knowledge and (b) Emotional management and identification.</p><sec id="Sec4"><title>The Essentials in a Relationship</title><p>This theme relates to factors that are the essence for establishing a relationship, as they promote a collaboration between the nurse and the patient and the patient’s health process. This is the overarching theme for the following three sub-themes: feelings of solidarity, participation and equality; openness, integrity and honesty; and trust and safety.</p><sec id="Sec5"><title>Feelings of Solidarity, Participation and Equality</title><p>Equality in the relationship and respect for each other’s positions as nurse and patient along with involvement in care were described as significant for the relationship (Colton and Pistrang <xref ref-type="bibr" rid="CR10">2004</xref>; Gulliksen et al. <xref ref-type="bibr" rid="CR20">2012</xref>; Offord et al. <xref ref-type="bibr" rid="CR35">2006</xref>; van Ommen et al. <xref ref-type="bibr" rid="CR36">2009</xref>; Sly et al. <xref ref-type="bibr" rid="CR51">2014</xref>). Equality in the relationship meant that patients felt that they could express their feelings as well as that the nurses were able to freely express what was expected from the patient. Several studies have further described the importance of nurses actively allowing the patients to be more involved to create an alliance (Colton and Pistrang <xref ref-type="bibr" rid="CR10">2004</xref>; Jenkins and Ogden <xref ref-type="bibr" rid="CR25">2011</xref>; van Ommen et al. <xref ref-type="bibr" rid="CR36">2009</xref>). Colton and Pistrang (<xref ref-type="bibr" rid="CR10">2004</xref>) reported care without involvement, care that was done to or for the patients and not with them, as a negative experience. Furthermore, lack of involvement could lead to resistance and hamper the recovery process and the relationship and could even worsen the illness (Sly et al. <xref ref-type="bibr" rid="CR51">2014</xref>). The nurse’s ability to establish a personal connection in the relationship was described as important in the recovery process and essential for the establishment of a trusting relationship (Ross and Green <xref ref-type="bibr" rid="CR47">2011</xref>; Wright and Hacking <xref ref-type="bibr" rid="CR63">2012</xref>; Zugai et al. <xref ref-type="bibr" rid="CR64">2012</xref>). When nurses provided information about their own personal lives, they conveyed a sense of equality between themselves and the patient, which was considered important in the development of the relationship (Micevski and McCann <xref ref-type="bibr" rid="CR32">2005</xref>). However, the nurses felt that this kind of relationship could negatively affect patients’ willingness to open up if the nurses were too much in focus. Hence, a professional balance regarding the extent to which the nurses should be able to share information about themselves was emphasised.</p></sec><sec id="Sec6"><title>Openness, Integrity and Honesty</title><p>The aspects of openness, integrity and honesty were identified as vital in establishing a relationship (Micevski and McCann <xref ref-type="bibr" rid="CR32">2005</xref>; van Ommen et al. <xref ref-type="bibr" rid="CR36">2009</xref>; Sly et al. <xref ref-type="bibr" rid="CR51">2014</xref>; Wright and Hacking <xref ref-type="bibr" rid="CR63">2012</xref>; Zugai et al. <xref ref-type="bibr" rid="CR64">2012</xref>). A genuine commitment of the nurses, the feeling that they were not just ‘doing a job’, contributed to a sense of safety among the patients (Gulliksen et al. <xref ref-type="bibr" rid="CR20">2012</xref>; Pemperton and Fox <xref ref-type="bibr" rid="CR41">2011</xref>; Wright and Hacking <xref ref-type="bibr" rid="CR63">2012</xref>; Zugai et al. <xref ref-type="bibr" rid="CR64">2012</xref>). In Pemperton and Fox’s (<xref ref-type="bibr" rid="CR41">2011</xref>) study, the author writes that even though nurses showed empathy and a desire to validate the patient’s feelings, it was only when the nurses really showed a genuine commitment that patients felt meaning in care. Such commitment made it possible for the patient to see beyond the role of the nurse only as a professional, which promoted an individual and unique relationship (Pemperton and Fox <xref ref-type="bibr" rid="CR41">2011</xref>; Zugai et al. <xref ref-type="bibr" rid="CR64">2012</xref>). On the contrary, in situations when nurses failed to demonstrate such commitment and genuineness, it resulted in a sense of ‘us versus them’ (Pemperton and Fox <xref ref-type="bibr" rid="CR41">2011</xref>). An open and genuine interest for the patients’ difficulties which was based on patient-focused conversations was highlighted in several studies as important for the relationship (Gulliksen et al. <xref ref-type="bibr" rid="CR20">2012</xref>; Offord et al. <xref ref-type="bibr" rid="CR35">2006</xref>; Sly et al. <xref ref-type="bibr" rid="CR51">2014</xref>). If the patients were able to share their thoughts and feelings with the nurses, the conversation was thought to help the patient forward in the health process (Bakker et al. <xref ref-type="bibr" rid="CR4">2011</xref>).</p></sec><sec id="Sec7"><title>Trust and Safety</title><p>Nurses cited trust as important in the care of people with AN, but also for guiding a change in the patients’ behaviours (van Ommen et al. <xref ref-type="bibr" rid="CR36">2009</xref>; Zugai et al. <xref ref-type="bibr" rid="CR64">2012</xref>). Trust was described as a component of the relationship and could be developed over time (Gulliksen et al. <xref ref-type="bibr" rid="CR20">2012</xref>; Micevski and McCann <xref ref-type="bibr" rid="CR32">2005</xref>). Patients’ feelings of trust in the relationship grew as the nurses demonstrated knowledge of the illness (Ross and Green <xref ref-type="bibr" rid="CR47">2011</xref>). On the contrary, Ramjan (<xref ref-type="bibr" rid="CR45">2004</xref>) described that when nurses lacked knowledge about the illness, this mindset facilitated an overly narrowed focus on the patient’s behaviours, resulting in a power struggle in the relationship. Patients were considered to be manipulative, and nurses felt that patients saw them as enemies with authoritative approaches, and the interventions were considered to be punitive.</p></sec></sec><sec id="Sec8"><title>The Person at the Centre</title><p>This theme rests on the ability for nurses to separate the diagnosis of a patient from them as individuals. Studies suggest that nurses must not prioritise the physical aspects of the illness over the psychological. The two sub-themes are woven to one theme: seeing the person behind the diagnosis and finding a balance between physical and psychological issues.</p><sec id="Sec9"><title>Seeing the Person Behind the Diagnosis</title><p>Several studies emphasised that both nurses and patients found it imperative that nurses clearly distinguish the two-fold view of the patient’s identity, as including both the patient’s diagnosis and the patient as an individual (Colton and Pistrang <xref ref-type="bibr" rid="CR10">2004</xref>; Gulliksen et al. <xref ref-type="bibr" rid="CR20">2012</xref>; Jenkins and Ogden <xref ref-type="bibr" rid="CR25">2011</xref>; Micevski and McCann <xref ref-type="bibr" rid="CR32">2005</xref>; van Ommen et al. <xref ref-type="bibr" rid="CR36">2009</xref>; Ross and Green <xref ref-type="bibr" rid="CR47">2011</xref>; Sly et al. <xref ref-type="bibr" rid="CR51">2014</xref>; Tierney <xref ref-type="bibr" rid="CR54">2008</xref>; Wright and Hacking <xref ref-type="bibr" rid="CR63">2012</xref>). However, this is not always easy, as demonstrated in Ramjans’ (<xref ref-type="bibr" rid="CR45">2004</xref>) study, where nurses expressed negative experiences as they viewed patients with anorexia as manipulative and distrustful. Nurses who behaved in an authoritarian manner and were seen as prejudiced because they put the diagnosis before the individual provoked a feeling of loss of identity, and made the patients feel as ‘just another anorexia case’ (Gulliksen et al. <xref ref-type="bibr" rid="CR20">2012</xref>; Tierney <xref ref-type="bibr" rid="CR54">2008</xref>). This was thought to reinforce the illness and the identity of being anorexic. When nurses were able to express respect for the person behind the illness, it helped the patients to take a more active role in the relationship, and these patients were able to progress toward health (Micevski and McCann <xref ref-type="bibr" rid="CR32">2005</xref>). Sly et al. (<xref ref-type="bibr" rid="CR51">2014</xref>) stressed that a strategy among nurses was to let the patients tell their own stories.</p></sec><sec id="Sec10"><title>The Balance between the Physical and the Psychological</title><p>Several studies stressed the nurses’ inability to pay attention to patients’ needs for psychological support to the same extent as they did to the physical issues. Such a single-minded focus on weight reinforced the feelings among patients of being their diagnosis (Colton and Pistrang <xref ref-type="bibr" rid="CR10">2004</xref>; Jenkins and Ogden <xref ref-type="bibr" rid="CR25">2011</xref>; Offord et al. <xref ref-type="bibr" rid="CR35">2006</xref>; Pemperton and Fox <xref ref-type="bibr" rid="CR41">2011</xref>; Tierney <xref ref-type="bibr" rid="CR54">2008</xref>). The unbalanced focus hampered the relationship as patients perceived that the nurses did not want to be supportive of all their needs but, rather, saw only the goal of the patients reaching a certain weight (Pemperton and Fox <xref ref-type="bibr" rid="CR41">2011</xref>). The feeling of loss of control due to weight gain and lack of psychological support strengthened the anorexic behaviours, thereby working against the patient’s health process (Offord et al. <xref ref-type="bibr" rid="CR35">2006</xref>; Tierney <xref ref-type="bibr" rid="CR54">2008</xref>).</p></sec></sec><sec id="Sec11"><title>Nurses’ Attitudes</title><p>One prominent theme addressed the personae of the nurses and the way nurses approached the patients. These aspects were seen as keys to promoting a relationship and helping patients in their processes of recovery. The nurse was described as a role model regarding establishing norms, responsibilities and structure in the patient’s life. Nurses’ attitudes is the overarching theme for the following three sub-themes: motivation and hope, maintaining structure, responsibility and normality, and presence and availability.</p><sec id="Sec12"><title>Motivation and Hope</title><p>Nurses play an important role in informing and educating the patients about the treatment and therapeutic goals in order to motivate the patients. Bakker et al. (<xref ref-type="bibr" rid="CR4">2011</xref>) emphasises the need for nurses to persuade patients that interventions and restrictions are actions against the illness and not against the patient as a person. In several studies, motivation was seen as pivotal when hope and optimism wavered, as was the way in which nurses presented challenges, rules and restrictions in daily life (Colton and Pistrang <xref ref-type="bibr" rid="CR10">2004</xref>; Gulliksen et al. <xref ref-type="bibr" rid="CR20">2012</xref>; Offord et al. <xref ref-type="bibr" rid="CR35">2006</xref>; van Ommen et al. <xref ref-type="bibr" rid="CR36">2009</xref>; Sly et al. <xref ref-type="bibr" rid="CR51">2014</xref>; Wright and Hacking <xref ref-type="bibr" rid="CR63">2012</xref>; Zugai et al. <xref ref-type="bibr" rid="CR64">2012</xref>). However, restrictions as treatment interventions had to feel relevant and individually adjusted (Zugai et al. <xref ref-type="bibr" rid="CR64">2012</xref>), otherwise they were understood to be punitive and not strengthened (Colton and Pistrang <xref ref-type="bibr" rid="CR10">2004</xref>; van Ommen et al. <xref ref-type="bibr" rid="CR36">2009</xref>; Zugai et al. <xref ref-type="bibr" rid="CR64">2012</xref>). The nurse was viewed as a leader and a role model who made it possible to move forward in the process of recovery. On the other hand, the feeling of not being backed by the nurse evoked a feeling of resignation (Sly et al. <xref ref-type="bibr" rid="CR51">2014</xref>). Furthermore, Wright and Hacking (<xref ref-type="bibr" rid="CR63">2012</xref>) emphasised the importance of the nurse in the therapeutic relationship, as the nurse was described as a “saviour” that helped patients move away from the disease.</p></sec><sec id="Sec13"><title>Maintaining Structure, Responsibility and Normality</title><p>In the early stages of recovery, when patients’ compulsive behaviours were most intense, the nurses advocated for a structured approach (Bakker et al. <xref ref-type="bibr" rid="CR4">2011</xref>; van Ommen et al. <xref ref-type="bibr" rid="CR36">2009</xref>; Ross and Green <xref ref-type="bibr" rid="CR47">2011</xref>; Zugai et al. <xref ref-type="bibr" rid="CR64">2012</xref>). Patients considered it to be helpful when nurses took over responsibility for food intake when anorexic thoughts and behaviours became too strong, and maintained boundaries and structure in order to establish normality (Offord et al. <xref ref-type="bibr" rid="CR35">2006</xref>; van Ommen et al. <xref ref-type="bibr" rid="CR36">2009</xref>; Ross and Green <xref ref-type="bibr" rid="CR47">2011</xref>; Zugai et al. <xref ref-type="bibr" rid="CR64">2012</xref>). However, as nurses took control from the patients, it was considered essential that they clearly demonstrated empathy and understanding for the patients’ feelings (Bakker et al. <xref ref-type="bibr" rid="CR4">2011</xref>; van Ommen et al. <xref ref-type="bibr" rid="CR36">2009</xref>). When nurses were understanding but at the same time confident enough to challenge the patient, this was experienced positively and it strengthened the feeling that the nurses were there for them (Gulliksen et al. <xref ref-type="bibr" rid="CR20">2012</xref>).</p></sec><sec id="Sec14"><title>Presence and Availability</title><p>Several studies emphasised that a nurse’s presence and availability were essential for the relationship (Offord et al. <xref ref-type="bibr" rid="CR35">2006</xref>; van Ommen et al. <xref ref-type="bibr" rid="CR36">2009</xref>; Wright and Hacking <xref ref-type="bibr" rid="CR63">2012</xref>). Patients in the study conducted by Colton and Pistrang (<xref ref-type="bibr" rid="CR10">2004</xref>) believed that continual emotional support, such as short daily conversations, was better than scheduled, weekly therapy. In the study by van Ommen et al. (<xref ref-type="bibr" rid="CR36">2009</xref>), patients described the importance of knowing that nurses were “emotionally available” and that they could distinguish patients’ feelings and were willing to devote time to them. Furthermore, along the later phase in the recovery process, it was necessary that the nurses were able to find a balance between closeness and distance in order to help the patient move forward and make more independent choices concerning food intake and meals (Bakker et al. <xref ref-type="bibr" rid="CR4">2011</xref>; van Ommen et al. <xref ref-type="bibr" rid="CR36">2009</xref>). As the nurses became less present in the later phases, patients felt motivated and safe and this strengthened the patients’ self-esteem and feelings of independence (Offord et al. <xref ref-type="bibr" rid="CR35">2006</xref>). Nevertheless, as nurses’ presence decreased this was considered to be associated with an increased risk of remission as the patients were released (Bakker et al. <xref ref-type="bibr" rid="CR4">2011</xref>; van Ommen et al. <xref ref-type="bibr" rid="CR36">2009</xref>).</p></sec></sec><sec id="Sec15"><title>Knowledge</title><p>The last theme includes the nurses’ knowledge and understanding of the illness but also concerns the patients’ insights into the illness as crucial aspects of the relationships. The theme addresses aspects such as knowledge and understanding and the ability to manage and identify feelings. This included the nurse’s ability to provide the patients with strategies to manage their own feeling, to provide support to patients and to help them to identify, understand and manage their own feelings. The theme was broken down into two sub-themes: understanding, experience and knowledge; and emotional management and identification.</p><sec id="Sec16"><title>Understanding, Experience and Knowledge</title><p>Lack of knowledge about the illness often leads to inconsistency and ambiguity in the relationship (Micevski and McCann <xref ref-type="bibr" rid="CR32">2005</xref>)-in contrast to the consistency and structure that otherwise was considered important for the relationship (van Ommen et al. <xref ref-type="bibr" rid="CR36">2009</xref>). Collegial interactions and sharing relational issues with other nurses based upon their experience and knowledge was found to be perceived as helpful in order to develop relationships with patients. Lack of support from colleagues was thought to hamper relationships with the patients (Micevski and McCann <xref ref-type="bibr" rid="CR32">2005</xref>). The aspect of nurses experiences was also viewed from the patient’s perspective, as demonstrated in the study by Tierney (<xref ref-type="bibr" rid="CR54">2008</xref>). Lack of knowledge could result in a perception among nurses that the patients themselves were responsible for the illness and hence should be able to ‘fix themselves’ (Ramjan <xref ref-type="bibr" rid="CR45">2004</xref>). Such attitudes toward eating disorders entailed that the nurses performed routine behaviour and control work. In turn, the patients were perceived as rebellious, which reinforced the power struggle and hampered the relationship. In contrast, Bakker et al. (<xref ref-type="bibr" rid="CR4">2011</xref>) stressed the importance of being able to demonstrate an understanding of the illness but at the same time emphasised that nurses must have the knowledge and ability to openly discuss issues. As a consequence of nurses’ lack of knowledge about anorexia, the acute divest of patients’ control of meals resulted in power structures that extended into other areas of the patients’ lives. Due to the lack of understanding and empathy from nurses, the interventions in treatment were perceived more punitively, resulting in a worse relationship (Offord et al. <xref ref-type="bibr" rid="CR35">2006</xref>).</p></sec><sec id="Sec17"><title>Emotional Management and Identification</title><p>The nurses’ abilities to provide patients with strategies to manage their own emotions was yet another key aspect in a supportive relationship that allowed for the patients to move forward in the process (Pemperton and Fox <xref ref-type="bibr" rid="CR41">2011</xref>; Ross and Green <xref ref-type="bibr" rid="CR47">2011</xref>). The relationship with nurses was associated with a sense of being protected and being provided with support, as nurses had not only the ability to identify the patient’s feelings but also were able to validate and name them for the patient. (Jenkins and Ogden <xref ref-type="bibr" rid="CR25">2011</xref>; Pemperton and Fox <xref ref-type="bibr" rid="CR41">2011</xref>; Ross and Green <xref ref-type="bibr" rid="CR47">2011</xref>; Zugai et al. <xref ref-type="bibr" rid="CR64">2012</xref>).</p><p>The nurses’ reactions to the patients’ displays of feelings, particularly aggression, were deciding factors in whether patients could rely on them for help in the future. On the other hand, a difficulty with identifying and showing feelings, together with mistrust, contributed to more negative emotions -for example, the feeling of being abandoned-as well as a larger degree of suppressed feelings. This was eventually considered to act as a “trigger” and contribute to a further increase in anorexic behaviours (Pemperton and Fox <xref ref-type="bibr" rid="CR41">2011</xref>).</p><p>In Ross and Green’s (<xref ref-type="bibr" rid="CR47">2011</xref>) study, the nurses abilities to handle the patients’ emotions were seen as having the potential to affect the patients’ senses of security and belonging, which were previously described as central for a therapeutic relationship. The nurses’ abilities to understand and respond to the patients’ feelings with empathy and interpret the patients’ feelings were described as having supportive and nurturing effects. This contributed to the patients’ awareness of the disease and their understandings of past experiences, which affected the process toward better health (Ross and Green <xref ref-type="bibr" rid="CR47">2011</xref>; Zugai et al. <xref ref-type="bibr" rid="CR64">2012</xref>). The patients felt that the personal contact with the responsible nurses was the most helpful, as this gave ongoing validation and emotional support to the patient (Offord et al. <xref ref-type="bibr" rid="CR35">2006</xref>).</p></sec></sec></sec><sec id="Sec18" sec-type="discussion"><title>Discussion</title><p>In this review, we conducted a descriptive literature synthesis in which we reviewed 14 qualitative study articles in order to identify and describe factors that promote and impede the relationships between nurses and the children, adolescents and young adults who are diagnosed with AN. There is not yet enough evidence to reach a consensus about best practices and the gold standard of treatment (Marzola et al. <xref ref-type="bibr" rid="CR29">2012</xref>), and our review does not succeed to provide an answer to the golden standard either. Earlier studies have acknowledged that emotional alliances and trusting relationships is essential in psychiatric care (Borg and Kristiansen <xref ref-type="bibr" rid="CR8">2004</xref>; Denhov and Topor <xref ref-type="bibr" rid="CR14">2012</xref>), but in addition demonstrated the difficulties in creating an alliance with AN diagnosed patients (Pereira et al. <xref ref-type="bibr" rid="CR43">2006</xref>). This review has explicitly accounted on describing nurses’ establishment of health promoting relationships and contribute with important insights to the body of knowledge in this area of the literature. Our main findings demonstrate that the nurses first and foremost have to establish relationships that are characterised by feelings of solidarity, participation, equality, openness, sincerity and honesty and that they are able to convey a sense of trust and safety. These qualitative interpersonal values were understood as prerequisites for the coming therapy. The importance of establishing an alliance between patients and their caregivers is one key aspect in the recovery process (Bell <xref ref-type="bibr" rid="CR6">2003</xref>; De la Rie et al. <xref ref-type="bibr" rid="CR46">2006</xref>; Masson and Sheeshka <xref ref-type="bibr" rid="CR30">2009</xref>). Consistent with our key findings, previous research have reported that a relationship is necessary if the patient is to view the care as meaningful. We acknowledge that establishing a good relationship with patients who are diagnosed with AN is complex and nonlinear. From our findings we can conclude that nurses must value their efforts to commit to establishing and maintaining relationships with patients. In this sense, nurses’ expertise must go beyond linear thinking, according to pathophysiology and bio-physiological explanation models (cf. Coppa <xref ref-type="bibr" rid="CR11">1993</xref>).</p><p>The tenets of establishing a health-promoting relationship between nurses and patients has been stressed in nursing theories (Dahlberg and Segesten <xref ref-type="bibr" rid="CR13">2010</xref>; Peplau <xref ref-type="bibr" rid="CR42">1991</xref>). Even though relational aspects are important, we advocate for a more detailed theoretical understanding of patients with AN and their specific needs. Our findings have provided more far-reaching insights into strategies that can be adopted by nurses. This review also adds an understanding of how nurses’ attitudes may foster the relationship and have an impact on their abilities to motivate the patients with hope, a sense of their own responsibility and better knowledge in emotional management. We emphasise that those concepts in the findings are similar to concepts in recovery-models in mental health care. Anthony (<xref ref-type="bibr" rid="CR2">1993</xref>) portrayed recovery to be a deeply personal process of changing attitudes, values and feelings in order to develop new meaning and purpose in one’s life beyond the effects of mental illness. We stress the necessity of nurses that are able to balance their roles as leaders, role models, and those that maintain boundaries and structure, but they also must acknowledge the patient’s own capabilities and step aside to leave the patient with responsibility. When doing so, we see the potential to develop a caring attitude that is in line with Anthony’s conceptualization.</p><p>In order to further theorise on the nurse as a companion in the recovery process of the patient, we stress that aspects that promote and impede the relationship have been given less priority in research. Our results affirm that nurses, from their approaches, highly influence whether the relationship will promote or impede the patient’s health progress. A key aspect in the relationship was the nurses’ views of the patients and what the nurses wanted to accomplish with treatment. Nurses who view the patients as cases demonstrated a standardised response and interest, where the diagnosis was in the foreground and the goal was mainly to ensure weight gain. They made generalisations about the patient’s feelings and actions based on stereotypical prejudices toward the patient’s symptoms, which could reinforce the identity of being anorexic and impede the process toward better health (Gulliksen et al. <xref ref-type="bibr" rid="CR20">2012</xref>; Offord et al. <xref ref-type="bibr" rid="CR35">2006</xref>). We draw parallels between nurses’ behaviours and Plummer’s (<xref ref-type="bibr" rid="CR44">1979</xref>) description of secondary deviance, as nurses not only adopt a standardized approach and view patients as cases, but they also become responsible for a more far-reaching process in which the nurses also have the potential to negatively influence and impede recovery and gradually build a deviant self. This process of stigmatizing patients is the opposite of Anthony’s (<xref ref-type="bibr" rid="CR2">1993</xref>) idea of personal recovery process. Hence, we stress the importance of understanding the complex mechanisms that reach beyond the patient’s manifestations of symptoms in order to overcome negative spirals in the relationships. Furthermore, in several studies patients expressed that the one-dimensional view from professional theories were thought to give rise to expectations and prejudices based on general experience and assumptions as well as nurses’ own insecurities, which wasn’t experienced as supporting the progress toward better health (Jenkins and Ogden <xref ref-type="bibr" rid="CR25">2011</xref>; Offord et al. <xref ref-type="bibr" rid="CR35">2006</xref>; Pemperton and Fox <xref ref-type="bibr" rid="CR41">2011</xref>; Wright and Hacking <xref ref-type="bibr" rid="CR63">2012</xref>).</p><p>It was helpful when nurses were able to put the patients’ own motivations to be well at the centre of the care in order to build an alliance, a finding which is in accordance with previous studies (Kaplan and Garfinkel <xref ref-type="bibr" rid="CR26">1999</xref>; Westwood and Kendal <xref ref-type="bibr" rid="CR59">2011</xref>). The results emphasise that it is only when the nurse shows a genuine interest in the patient and has a deeper understanding of the patient’s life as well as when the patient perceives collaboration with the nurses that trust is born–the basis for a relationship. One study conducted by Topor et al. (<xref ref-type="bibr" rid="CR55">2006</xref>) demonstrated how professional roles may contribute to personal recovery. It was reported that when professionals depart from their formal roles, they risk to be criticised by colleagues, but, more importantly, such departures are view as meaningful and contribute to the patient’s personal recovery (Topor et al. <xref ref-type="bibr" rid="CR55">2006</xref>). In this sense, we accentuate the value of the nurses’ will and courage to care in favour of the interests of the patients. We posit that it is necessary for nurses to reflect on and translocate the ontological stance in nursing from caring for to caring with (cf. Barker and Buchanan-Barker <xref ref-type="bibr" rid="CR5">2005</xref>).</p><p>Lastly, we will discuss the methodological considerations. A broad range of search terms were used in three databases, all of which were highly relevant for nursing research and for the aim of this review. In addition to the search terms, free searches and manual searches were conducted. At the end of the search process, the authors repeatedly found the same articles, which we interpreted to indicate that no more relevant articles could be found. Alternative search terms might have yielded more studies. All included articles were evaluated based on quality, and several articles were excluded due to low quality. One author who was well-familiarised with the process of evaluating research articles evaluated the quality, although no assessment of inter-rater reliability was performed. The second author was mainly responsible for the analysis process. However, throughout the analysis process, both authors engaged in frequent discussions about the coding procedure, examining individual codes and their accuracy within specific categories as well as the labelling of categories and themes. Even though this exclusion of low quality articles gave more trustworthiness to our review, we might have missed aspects that were not reported in our findings. Since the purpose of our review was to describe the phenomena from both nurses and patients with AN, we recognise an imbalance between the two categories, which suggests a rationale for conducting future studies only from one perspective. All included articles were also conducted in the Western World, in countries with similar health care systems. This notion might have skewed the results. Surprisingly, we observed that the results in the 14 articles were strikingly similar even though the demographics of the included participants differed in age, length of illness and treatment forms (both in and out-patient facilities). The results from qualitative inquiries do not have external validity, and Creswell (<xref ref-type="bibr" rid="CR12">2007</xref>) argues for transferability as a measure of trustworthiness. As such, we do not claim that the findings are applicable in other healthcare settings than the studies.</p></sec><sec sec-type="supplementary-material"><title>Electronic supplementary material</title><sec id="Sec19"><p><supplementary-material content-type="local-data" id="MOESM1"><media xlink:href="10826_2016_534_MOESM1_ESM.docx"><caption><p>Supplementary Table1</p></caption></media></supplementary-material><supplementary-material content-type="local-data" id="MOESM2"><media xlink:href="10826_2016_534_MOESM2_ESM.docx"><caption><p>Supplementary Table2</p></caption></media></supplementary-material><supplementary-material content-type="local-data" id="MOESM3"><media xlink:href="10826_2016_534_MOESM3_ESM.docx"><caption><p>Supplementary Table3</p></caption></media></supplementary-material></p></sec></sec></body><back><notes notes-type="COI-statement"><title>Compliance with ethical standards</title><sec id="FPar1"><title>Conflict of interest</title><p> The authors declare that they have no conflict of interests.</p></sec></notes><ref-list id="Bib1"><title>References</title><ref id="CR1"><element-citation publication-type="book"><person-group person-group-type="author"><collab>American Psychiatric Association</collab></person-group><source>Desk Reference to the Diagnostic Criteria from DSM-5</source><year>2013</year><publisher-loc>Arlington, VA</publisher-loc><publisher-name>American Psychiatric Association</publisher-name></element-citation></ref><ref id="CR2"><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Anthony</surname><given-names>W</given-names></name></person-group><article-title>Recovery from mental illness: The guiding vision of the mental health system in the 1990s</article-title><source>The Psychosocial Rehabilitation Journal</source><year>1993</year><volume>16</volume><issue>4</issue><fpage>11</fpage><lpage>24</lpage></element-citation></ref><ref id="CR3"><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Arcelus</surname><given-names>J</given-names></name><name><surname>Mitchell</surname><given-names>A</given-names></name><name><surname>Wales</surname><given-names>J</given-names></name><name><surname>Nielsen</surname><given-names>S</given-names></name></person-group><article-title>Is there an elevated mortality rate in anorexia nervosa and other eating disorders?: A meta-analysis of 36 studies</article-title><source>Archives in General Psychiatry</source><year>2011</year><volume>68</volume><issue>7</issue><fpage>724</fpage><lpage>731</lpage></element-citation></ref><ref id="CR4"><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Bakker</surname><given-names>R</given-names></name><name><surname>van Meijel</surname><given-names>B</given-names></name><name><surname>Beukers</surname><given-names>L</given-names></name><name><surname>van Ommen</surname><given-names>J</given-names></name><name><surname>Meerwijk</surname><given-names>E</given-names></name><name><surname>van Elburg</surname><given-names>A</given-names></name></person-group><article-title>Recovery of normal body weight in adolescents with anorexia nervosa: The nurses’ perspective on effective interventions</article-title><source>Journal of Child and Adolescent Psychiatric Nursing</source><year>2011</year><volume>24</volume><fpage>16</fpage><lpage>22</lpage><pub-id pub-id-type="pmid">21272111</pub-id></element-citation></ref><ref id="CR5"><element-citation publication-type="book"><person-group person-group-type="author"><name><surname>Barker</surname><given-names>P</given-names></name><name><surname>Buchanan-Barker</surname><given-names>P</given-names></name></person-group><source>The tidal model: A guide for mental health professionals</source><year>2005</year><publisher-loc>London/New York</publisher-loc><publisher-name>Routledge</publisher-name></element-citation></ref><ref id="CR6"><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Bell</surname><given-names>L</given-names></name></person-group><article-title>What we can learn from consumer studies and qualitative research in treatment of eating disorders</article-title><source>Eating and Weight Disorders</source><year>2003</year><volume>8</volume><issue>3</issue><fpage>181</fpage><lpage>187</lpage><pub-id pub-id-type="pmid">14649780</pub-id></element-citation></ref><ref id="CR7"><mixed-citation publication-type="other">Björck, C. 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