Background: Response to treatment in anorexia nervosa entails various challenges, including an increased risk of relapse and re-admission in those treated as inpatients. A better understanding of patients’ experiences is paramount to improve treatment acceptability and outcome. This qualitative study aimed to explore the lived experiences of adult female inpatients undergoing a specialist inpatient treatment programme for anorexia nervosa. Methods: Semi-structured interviews were carried out with 21 female participants (aged 18-41 years) with a diagnosis of anorexia nervosa, undergoing treatment in a specialist inpatient eating disorder unit. Data were analysed using interpretative phenomenological analysis (IPA). Results: Qualitative analysis highlighted 5 master themes which underpinned treatment experiences: (1) Shifts in control, (2) Experience of transition, (3) The importance of supportive staff relationships, (4) Sharing with peers and (5) Process of recovery and self-discovery. Conclusions: Overall, findings suggest patients experience a process of change and adjustment during inpatient treatment in relation to their levels of perceived control, attachment to the treatment environment and a sense of self-identity. Treatment experiences appear to be influenced by the development of supportive relationships and the provision of individualised care.

Philosophiae Doctor - PhD / Introduction: The overall aim of this study was to develop a programme to facilitate quality client-centred care in Primary Health Care clinics of the rural West Coast District. Research design and -method: Both quantitative and qualitative methods were applied for this study . Phase 1, a situational analysis collected and analysed quantitative data from the perspective of clients and clinical nurse practitioners via structured questionnaires. The population included all clients 18 years and older (N=137 991) of the fixed clinics (N=25) in the five subdistricts of the West Coast District. According to the Cochran formula a sample of (n=383) should be adequate to represent the population. Non-proportional sampling was applied to estimate the number of participants per clinic. An all-inclusive sample of (n=64) clinical nurse practitioners participated in the study. Phase 2, the qualitative part of the situational analysis, applied five focus group discussions to explore and describe the managers and allied health professionals’ perceptions about quality client-centred care. A semi-structured interview schedule was compiled to guide the focus group discussions. An all-inclusive sample was utilised to include all the managers and allied health professionals of the five subdistricts (N=43). Phase 3 included the development of the programme based on the study findings and literature. Quantitative results: The analysis revealed the following quality client-centred care challenges, namely: Patient Rights (Domain 1) were not always respected and adhered to as these were characterised by: language (statistical p<0.001 and practical significant with a large effect size d=0.74); Satisfaction and Safety (statistical p<0.001 and practical significant with a medium effect size d=0.55); Referral Procedures (statistical significant p<0.001); Waiting Times (statistical p<0.001 and practical significant with a medium effect size d=0.47) and Confidentiality difficulties (statistical p<0.001 and practical significant with a medium effect size d=0.68). The Domain 2, Clinical Governance, Care and Safety showed shortcomings as highlighted by the Client and his/her Family (statistical p<0.001 and practical significant with a large effect size d=0.77). Clinical Support Services, Domain 3, revealed inadequacies regarding the continuous availability of medication (statistical significant p<0.008) and the reporting of side-effects (statistical significant p<0.001). Furthermore, Public Health Domain 4, showed that clients identified community health promotion and disease prevention events (statistical p<0.01 and practical significant with a large effect size d=0.79), and home visits by the community healthcare workers (statistical p<0.001 and practical significant with a large effect size d=1.09) as both a “problem” and a “gap”. Leadership and Corporate Governance, Domain 5 was characterised by the lack of: visible organograms (clients mean 2.40), community communication (clients mean 2.12 & clinical nurse practitioners mean 2.36), visibility of goals, values and future plans of the Western Cape Department of Health (statistical p<0.001 and practical significant with a medium effect size d=0.59) and role and function of the clinic committees (statistical significant p<0.008). Moreover, Domain 6, Operational Management was challenged by inadequate staffing levels (statistical significant p<0.003). Lastly, Domain 7: Infrastructure was characterised by the lack of drinking water in the waiting areas (clients mean 2.08 & clinical nurse practitioners mean 2.02), inadequate clinic space (clients mean 2.10 & clinical nurse practitioners 2.23); maintenance not up-to-date (statistical significant p<0.002); physical appearance of the clinic (statistically significant p<0.001) did not have a positive effect on staff morale and evacuation plans (statistical p<0.001 and practical significant with a medium effect size d=0.54) were not visible. In addition, correlations between the domains showed that the domains are not in silos, but are interdependent on another. Qualitative results The qualitative, thematic data analysis revealed various inadequacies regarding quality client-centred care. Theme One about the Patient Rights revealed that patients were not always treated with the necessary respect and dignity. Theme Two concerning Patient Care, revealed that focus group participants were well-informed on what the concept client-centred care entailed. However, patients and or clients did not always experience their care as client-centred. Theme Three about the Clinical Support Services, indicated shortages of medication and medical equipment; long waiting time for specialists and rehabilitation referral appointments. Theme Four, referring to the Public Health confirmed that health promotion and prevention activities are limited, due to various organizational factors and community healthcare workers’ activities which are limited to home-based care activities. Theme Five, Corporate Governance and Leadership matters were characterised by too many processes or “red tape” resulting in inefficient procurement processes, inadequate staffing and inactive health committees. Theme Six, Operational Management highlighted the severe pressure under which the operational managers have to work, resulting from their twofold role of being the clinic manager and at the same time operate as a clinical nurse practitioner. Theme Seven refers to Infrastructure and Facilities and is characterised by inadequate maintenance and lack of space according to the number of clients and package of care. To summarise: The situational analysis revealed 81 problems. These problems form the evidence base for the development of the programme to facilitate quality client-centred care in primary helth care clinics of the rural West Coast District.

The aim was to investigate the effects of an intervention, based on education given to staff and implementation of an individualized nutritional programme given to the residents, to compare assessments on admission with a previous study, and to perform diagnostic test and inter-rater reliability of the Mini Nutritional Assessment (MNA). A further aim was to identify and describe factors with regard to appetite among the residents. Upon admission, and after a four month intervention period, residents were classified as being either protein energy malnourished (PEM), or not, based on anthropometry and biochemical measurements. On both occasions, the Activity Index and the Mini Mental State Examination were used. In order to identify individuals in need of nutritional care, the MNA was performed. Information about medical data was obtained. A total of 127 residents were consecutively admitted to eight resident homes in a municipality in Sweden. Three resident homes constituted the experimental unit (n = 68) and five the control unit (n = 59). Fifteen residents were interviewed using a qualitative method, to investigate what affects their appetite. On admission 32 % of the residents were classified as PEM, which was similar to in the previous study. A higher frequency of residents in the present study had severe medical diseases and cognitive impairment, compared with the previous study, indicating changed admission criteria in the present study. Between the experimental and the control groups, no differences were seen in any specific anthropometric or biochemical variable. Within the groups, statistically significant differences were seen, as the number of PEM residents in the experimental group decreased, and motor activity and overall cognitive function improved. In the control group, motor activity deteriorated. This indicates that the intervention improved nutritional status and functional capacity in the residents. Diagnostic sensitivity was 73 % regarding MNA versus PEM, and 89 % regarding MNA short form (MNA-SF) versus MNA, which indicates a rather high degree of sensitivity in both tests. Inter-rater reliability of MNA, carried out by simultaneous assessments by registered nurses and researcher showed a moderate agreement of 62 % (kappa 0.41). The interview study showed that the willingness to eat was what affected the residents´ appetite. The willingness to eat contains internal factors, dependent on mood and personal values, as well as external factors, dependent on wholesomeness, food, eating environment and meal fellowship. When planning and realizing residents´ nutritional care, factors affecting the residents´ appetite have to be taken into consideration. In conclusion, the results show that it is important to implement and develop strategies for individual nutritional care, in order to prevent and treat malnutrition in elderly people, which is in line with recommendations given by the European Society of Parenteral and Enteral Nutrition (ESPEN) and with the Swedish goal of nursing actions.