A therapeutic interpersonal relationship can be defined as one which is perceived by patients to encompass caring, and supportive nonjudgmental behavior, embedded in a safe environment during an often stressful period. In the health care literature, numerous terms have been used to describe this type of relationship, including helping relationships, purposeful relationships, nurse—client relationships, and therapeutic alliances. The concept is also interrelated with that of patient-centered care.
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Patient-centered care also known as person-centered or patient- and family-centered care describes a standard of care that ensures the patient and their family are at the center of care delivery. Although therapeutic interpersonal relationships are widely acknowledged as being central to a constructive clinician—patient experience, 9 achieving them in the acute care setting is extremely challenging.
Therefore, the aim of this review is to identify strategies to enhance therapeutic interpersonal relationships between patients and health care professionals in the acute care setting. An integrative review is a research strategy involving the review, synthesis, and critique of extant literature. In addition, the reference lists of potential papers retrieved were examined to identify any further material that met the inclusion criteria.
Both versions of British and American spellings were used to construct the search strategy as to reflect a systematic and comprehensive approach. The concept of therapeutic interpersonal relationships is not confined to any specific time period or type of peer-reviewed publication, and so no limitations were placed on these parameters to ensure a broad and diverse scope of knowledge. Papers that focused on pediatrics and adolescence were also excluded as this review focused on adult patient—staff interaction. In addition, papers involving student cohorts were also excluded as were papers that reported solely on satisfaction surveys.
The search strategy initially identified papers after removal of duplicates Figure 1. The authors RK and KW independently identified 37 potential papers for inclusion based on titles and abstracts. The authors RK, KW, and JD independently appraised the 37 identified papers based on the inclusion and exclusion criteria. Disagreements that arose were resolved by debate and consensus. Thirty studies were subsequently excluded, leaving a total of seven. The reference lists of the included studies were reviewed, which eventuated in the identification of three additional studies for inclusion with ten studies included in this integrative review.
The findings were then integrated using a constant comparison method. Extracted data qualitative and quantitative were compared item by item, and similar data were categorized and grouped together into recurring themes. This approach to data analysis is used in integrative reviews because it is compatible with the use of varied data from diverse methodologies.
Ten papers meeting the inclusion criteria were selected. Study participants primarily included patients, physicians, and nurses.
Seven of the ten studies derived from a qualitative methodology with semi-structured interviews, and thematic analysis was the most frequently used data collection and analysis method. Two studies 8 , 25 employed mixed methods including questionnaires, observations, and interviews; and one study 19 had a qualitative design with a pre- and postintervention questionnaire.
All three themes were interlinked and contributed to therapeutic interpersonal relationships Figure 2. Conceptual map of the relationships between the key strategies of therapeutic interpersonal relationships. During this study, it became apparent that physician listening was a recurring theme. In addition, much of the focus on listening has been with the intent of improving diagnostic accuracy. In the theme listening as a healing and therapeutic agent, listening was seen by patients as creating the conditions to promote healing and recovery:.
Because if you listen to the patient and give the patient respect, what you are actually doing is helping that person take responsibility for their own health … they are also in control of the healing process and are involved somehow … Within the theme of listening as an instrument to create and maintain therapeutic interpersonal relationships, patients believed that listening helped physicians engage with their values and strengthen the therapeutic alliance:. Jagosh et al 23 conclude that listening can be an interpretive activity that contributes to a richer interpersonal dialogue, which can forge new understandings and meanings, especially in emotionally charged situations.
The development of the therapeutic interpersonal alliance relies on the use of high-quality communication skills. The course employed the Calgary-Cambridge Observation Guide in patient-centered communication as well as exercises in attentive listening, pausing, and summarizing. Participants were also involved in videotaped role play of simulated communication scenarios and follow-up sessions. Satisfaction of over 3, patients was assessed pre- and postintervention using the Interpersonal Skills Rating Scale.
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The study demonstrated statistically significant increases in patient satisfaction scores concerning the quality of information, continuity of information, and quality of care provided by health professionals after attending the 3-day course. The effect the response had on further communication was then examined. Toward responses tended to lead to the provision of emotional support, increased agreement about treatment, and facilitated the physician and patient alliance.
In addition, facilitating behaviors were positively related to adherence to treatment in patients with a language different to the health professional. Jones et al 21 found a formal process of supportive care that involved identifying unmet needs as identified by patients using a validated screening tool and a supportive care resource kit for clinicians, which improved communication between cancer patients and their clinicians.
The overall consensus of the participants was that the implementation of supportive care processes facilitated and, to an extent, enhanced therapeutic interpersonal communication.
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Patient centeredness and therapeutic engagement emerged as fundamental aspects of therapeutic encounters and relationships between health professionals and patients. Lees et al 20 found that therapeutic interpersonal engagement between nurses and patients for suicidal crisis intervention was the central tenet in quality of care. Lees et al 20 interviewed eleven nurses who had worked with suicidal clients and nine clients who had recently recovered from a suicidal crisis. Lees et al 20 identified through these interviews that therapeutic engagement could facilitate a reduction in feelings of isolation, loss of control, and distress.
Therapeutic engagement was seen by Less et al 20 as incorporating rapport, listening, empathy, relating as equals, compassion, genuineness, trust, time responsiveness, and unconditional positive regard. The importance of therapeutic engagement was made clear by a patient in Lees et al 20 study who stated:.
I wanted someone to sit down and talk with and go through it all … to just support me and ask me about it and how I was feeling … someone to make contact with me about it. Through a secondary analysis of interview data collected from older people, Mitchell and McCance 22 explored encounters and relationships within the context of person-centered care.
They state that nurse—patient encounters are largely dominated by task-orientated care, and therefore patients feel burdened by the perception that nurses are busy:. Well the nurses come in early in the morning and wash you … but apart from that, I just be in bed, you know. These perceptions reinforce a culture of patient passivity within a health care climate that requires the implementation of strategies to enhance the capacity of person-centered care for both the patient and the nurses.
In contrast, Mitchell and McCance 22 also identified five key aspects that defined person-centered care for elderly patients as encompassing informed mutuality — the opportunity for patients to be equal partners in decision making; transparency, making clear the intentions and motivations for actions and sympathetic presence; engagement with the patient that recognizes their value and uniqueness.
Respect for uniqueness or individuality was also one of the findings from a study by Sanghavi 25 who reviewed the elements of compassionate patient—caregiver relationships. Sanghavi 25 analyzed questionnaires and transcripts of rounds with patients, families, and staff conducted at 54 hospitals across 21 states in the USA. The analysis revealed communication, common ground, and respect for individuality as key aspects of compassionate relationships. Sanghavi 25 states that traditional structures of health care delivery are inadequate to sustain a culture of compassionate care and that a new innovative approach to the delivery of health care is required.
Interviews were conducted with 40 recently hospitalized patients, and participant observation and interviews were conducted with 32 nursing staff. The substantive theory of optimizing personal control to facilitate emotional comfort was developed.
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During their admission, patients interpreted interpersonal interactions as either emotionally comforting or discomforting. Patients identified feeling insecure, uncertain, and devalued as of concern and feeling secure, valued, and informed as important for emotional comfort. In addition, the study identified six specific types of therapeutic interaction that contributed to emotional comfort.
Patients felt emotional comfort when staff displayed ability and confidence in performing task; developed relationships through frequent contact and getting to know each other as people; were available and responded quickly to calls for assistance; provided information openly and honestly; used nonverbal interactions such as eye contact, touch, active listening, and positioning to enhance communication; and engaged in verbal interactions such as social chitchat and making encouraging comments.
In a study on therapeutic play, Greenberg 26 found that within the acute care setting, the use of humor facilitated emotional comfort and support and therapeutic engagement. Greenberg 26 defined the use of humor as therapeutic play that enhances health and well-being by developing therapeutic interpersonal alliances in illness. Humor was used as an effective icebreaker and allowed the development of trust within the therapeutic interpersonal relationship.
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Greenberg 26 states that mutual laughter is a powerful form of therapeutic interpersonal communication as it creates a culture of positive emotions between the patient and health professional as demonstrated by a participant nurse:. I use [humor] situationally. A lot of times you come into rooms and it is so confrontational because patients and families feel they are receiving some form of mistreatment. The catalyst for this review was the necessity to identify strategies that enhance therapeutic interpersonal relationships in the acute care setting.
These three themes are depicted in Figure 2 as key interrelated components of therapeutic interpersonal relationships within the acute care setting. Given the challenging acute care environment, it is not surprising that building therapeutic interpersonal relationships is fundamental focus of current trends in patient care. The findings suggest that the act of developing therapeutic interpersonal relationships has the capacity to nurture and fortify relations between the clinician and the patient.
Consequently, providing a supportive environment enhances clinician—patient engagement and communication.
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