Therapeutic Relational Connection in Telehealth: Concept Analysis

BACKGROUND

Therapeutic relational connection (TRC) in telehealth is a new concept that refers to the intentional use of relationship connection between health care providers and their patients as both parties work toward a therapeutic aim. It has been demonstrated that TRC positively affects patient-centered outcomes including adherence, self-management, and satisfaction with care. What is not known are best practices for establishing TRC during telehealth visits. The rapid emergence of telehealth during the COVID-19 pandemic has identified a number of challenges. These challenges include lack of human contact, distance creating mistrust, the inability to rely on nonverbal communication, and a sense of depersonalization. Training for health care providers in these interpersonal communication skills needed to establish TRC during telehealth visits is needed.

OBJECTIVE

This paper aims to explore the evolutionary concept of TRC in telehealth. The purpose of this paper is to provide a concept analysis of TRC during telehealth interactions between providers and patients through a comprehensive review of the existing published literature.

METHODS

Rodgers' evolutionary concept analysis method was used to guide this study. PubMed, Embase, PsycINFO, and CINAHL were used to search for relevant publications. An integrative review strategy aided by Rayyan software was used to identify a final sample of 13 papers for analysis.

RESULTS

The proposed definition of TRC in telehealth is the experience of a mutually responsive patient-provider relationship that is built on mutual respect and understanding and informed by cultural humility, presence, empathy, and the ability to effectively evaluate patient concerns to work toward a therapeutic aim. The key attributes of TRC in telehealth are the provider's ability to evaluate patient concerns, interpersonal communication, cultural humility, mutual trust and respect, presence, empathy, and building relationships. Clinical presence, proper environment, knowledge about the use of technology (both patient and provider), use of verbal and nonverbal communication, and knowledge about community and culture are important antecedents of TRC. Consequences of TRC include improved communication resulting in mutual respect and caring, adherence to follow-up recommendations, increased coping, collaborative decision-making, and satisfaction with care.

CONCLUSIONS

Telehealth visits necessitate alternative approaches to establishing TRC as compared to in-person clinic visits. With the rapid expansion of telehealth platforms and a heightened acceptance of the technology, there is a need to integrate knowledge and provide a clear conceptualization of TRC in telehealth as TRC has been demonstrated to result in positive patient-centered outcomes. Identifying the attributes and antecedents of TRC in telehealth allows us the opportunity to develop guidelines and educational interventions aimed at training health care providers in the skills needed to establish TRC during telehealth visits.

Exploring Nurse and Patient Experiences of Developing Rapport During Oncology Ambulatory Care Videoconferencing Visits: Protocol for a Qualitative Study

Background

Telehealth videoconferencing has largely been embraced by health care providers and patients during the COVID-19 pandemic; however, little is known about specific techniques for building rapport and provider-patient relationships in this care environment. Although research suggests that videoconferencing is feasible and can be effective for some types of care, concerns about the impact of technology on provider-patient relationships exist across health disciplines. Suggestions for adapting some in-person rapport techniques, such as the use of small talk, eye contact, and body language to facilitate trust, personal connection, and communication during videoconferencing encounters, have been discussed in the popular press and clinical commentaries. Notably, evidence regarding the effects of these strategies on rapport and clinical care outcomes is lacking. Understanding how to establish rapport in videoconferencing visits is especially important in oncology nursing, where rapport with patients enables nurses to become a source of emotional support, helping patients adapt and navigate the cancer journey.

Objective

This study aims to investigate the nature of nurse-patient rapport in ambulatory cancer care videoconferencing visits. The objectives include exploring how patients with cancer and nurses describe experiences of rapport and strategies for cultivating rapport in videoconferencing visits and similarities and differences identified by patients with cancer and nurses between experiences of rapport in videoconferencing and in-person visits.

Methods

Semistructured narrative interviews of patients with cancer and nurses will be conducted to understand the experience of rapport building in videoconferencing visits. Nurses and patients will be interviewed separately to facilitate an understanding of the perspectives of both types of participants. Interviews will be conducted on a secure videoconferencing platform. This qualitative descriptive study will describe participant experiences in a manner that, although not without interpretation, is as close to the data as possible. The research team will meet regularly to discuss, define, and document codes, categories, and themes, and the team will maintain a detailed audit trail of analytical decisions. In addition, member checking will enhance the rigor of the study. Nurse and patient interviews will be analyzed separately using identical procedures and may be explored side by side in the final analysis to provide a comparative analysis. Data management and analysis will be performed using NVivo 12.

Results

Data collection will begin during summer 2021, with results from the data analysis anticipated by winter 2021. A research team trained in qualitative methodology will use conventional content analysis to analyze the data using first- and second-level codes derived directly from the transcribed text data.

Conclusions

This study aims to determine what behaviors, communication techniques, and relational practices need to be adapted in videoconferencing telehealth visits, setting the foundation for future development of interventions and evidence-based practice guidelines for relationship building during videoconferencing telehealth visits.

International Registered Report Identifier (IRRID)

PRR1-10.2196/27940

Innovations in U.S. Health Care Delivery to Reduce Disparities in Maternal Mortality Among African American and American Indian/Alaskan Native Women

Despite spending more on health care than any other country, the United States has the worst maternal mortality rate among all developed nations. African American and American Indian/Alaskan Native women have the worst outcomes by race, representing a stark health disparity within the country. Contributing factors disproportionately experienced by these minority populations include challenges of access to consistent and high-quality prenatal care, prevalence of underlying conditions, toxic stress due to systemic racism, and unconscious bias in health care. While many of these factors lie upstream in the lives of women, and seemingly beyond the scope of the clinical walls, the downstream health care delivery system can serve as a vital part of the solution via innovative practices, community-based collaborations, and by serving as advocates for the communities served. Such alignments between clinicians, community leaders, policymakers, and patients that extend beyond the health system can serve as the missing piece needed within the clinic to reverse the trajectory of maternal mortality for American women, especially those from traditionally underserved populations.

Discordance in Perceptions of Barriers to Breast Cancer Treatment Between Hispanic Women and Their Providers

Despite comparable screening and incidence rates that are 26% below that of non-Hispanic Whites, Hispanic women present with breast cancer at more advanced stages of disease, representing a continuing and troubling health disparity for this population. Reducing these disparities warrant more innovative research approaches to better understand perspectives of Hispanic patients regarding barriers to treatment and how these perspectives compare to those of their providers. A pilot qualitative study was conducted at a major urban cancer center in Arizona that measured both patient and provider perspectives regarding barriers to treatment. Through a multimethod qualitative analysis, researchers surveyed patients and providers to identify perceived barriers and discordance in shared understanding. Data collection and analysis consisted of surveying patients and providers, then performing inductive qualitative analysis. Results indicated the highest concordance, or shared understanding, between patients and providers was in recognizing barriers within delivery of care, such as cost of care and insurance coverage. The greatest discordance, or gaps in shared understanding, existed in upstream barriers of the health care system, such as emotional support and trust in systems. These results underscore the gap in shared understanding between patients and providers regarding upstream barriers to care as well as the nonclinical social determinants of health Hispanic patients face in accessing breast cancer treatment. More research is warranted using this approach as a tool to reduce health disparities.

Weight stigma is associated with provider-patient relationship factors and adherence for individuals with hypothyroidism

The goal of this study was to examine weight stigma experiences during medical visits as related to provider-patient relationship factors and adherence among individuals with hypothyroidism. A total of 362 participants recruited via social media participated in an online survey. Regression and mediation analyses indicated that weight stigma was negatively associated with adherence; this relationship was mediated by decreased trust in provider, less perceived provider empathy, and lower provider-patient depth-of-relationship. Structural equation modeling with BMI controlled revealed that weight stigma is associated with worsened provider-patient relationship and adherence. Findings suggest the importance of eliminating weight stigma experiences for patients.

Design and Validation of Patient-Centered Communication Tools (PaCT) to Measure Students' Communication Skills

Objective. To develop a comprehensive instrument specific to student pharmacist-patient communication skills, and to determine face, content, construct, concurrent, and predictive validity and reliability of the instrument. Methods. A multi-step approach was used to create and validate an instrument, including the use of external experts for face and content validity, students for construct validity, comparisons to other rubrics for concurrent validity, comparisons to other coursework for predictive validity, and extensive reliability and inter-rater reliability testing with trained faculty assessors. Results. Patient-centered Communication Tools (PaCT) achieved face and content validity and performed well with multiple correlation tests with significant findings for reliability testing and when compared to an alternate rubric. Conclusion. PaCT is a useful instrument for assessing student pharmacist communication skills with patients.

Can patients be 'attached' to healthcare providers? An observational study to measure attachment phenomena in patient-provider relationships

OBJECTIVES

To develop and assess the validity of measures of patients' attachment-related perceptions of experiences with healthcare providers (HCPs).

SETTING

Online survey.

PARTICIPANTS

181 people provided consent and 119 completed the survey (66%). Most participants were women (80%).

PRIMARY AND SECONDARY OUTCOME MEASURES

Questions were developed to assess possible attachment functions served by an HCP and patients' attachment-related attitudes towards an HCP. Scales were constructed based on exploratory factor analysis. Measures of adult attachment, therapeutic alliance, perceived HCP characteristics and health utilisation were used to validate scales.

RESULTS

Possible safe haven and secure base functions served by HCPs were strongly endorsed. A model with good fit (root mean square error of approximation=0.056) yielded 3 factors: 'HCP experienced as supportive and safe' (SUPPORT, α=0.94), 'HCP experienced as aversive' (AVERSE, α=0.86) and 'more and closer contact wanted with HCP' (WANT, α=0.85). SUPPORT was correlated with positive HCP characteristics and not with attachment insecurity. AVERSE was inversely correlated with positive HCP attributes and correlated with attachment insecurity. WANT was unrelated to positive HCP attributes, but correlated with attachment insecurity. Frequency of HCP contact was related to WANT (Kruskal-Wallis=21.9, p<0.001) and SUPPORT (Kruskal-Wallis=13.2, p=0.02), but not to AVERSE (Kruskal-Wallis=1.7, p=0.89).

CONCLUSIONS

Patients attribute attachment functions of secure base and safe haven to HCPs. SUPPORT is related to positive appraisal of HCP characteristics; AVERSE is associated with discomfort in the HCP relationship that is related with perceived HCP characteristics and patients' insecure attachment; WANT is associated with unmet needs for connection with an HCP related to insecure attachment, but not to perceived HCP characteristics. These scales may be useful in studying the application of attachment theory to the HCP-patient relationship.

Sociodemographic differences in fears and mistrust contributing to unwillingness to participate in cancer screenings

Effective provider-patient relationships are vital for positive patient health outcomes. This analysis assessed sociodemographic differences in fears and mistrust related to the provider-patient relationship, which may contribute to unwillingness to participate in cancer screenings (CSs). The data are from a stratified, random-digit dial telephone questionnaire of non-institutionalized households in New York, Maryland, and Puerto Rico. Statistically significant results indicate that Hispanics, compared with Whites, were nearly two times more likely to report that fear of being a "guinea pig" and lacking trust in medical people would make them unwilling to participate in CSs. Additionally, those with less education were over two times more likely to indicate a fear of being embarrassed during the screening would make them unwilling to participate in CSs. These results highlight areas where health professionals can improve interactions with their patients and be attentive to their fears and/or mistrusts to promote CSs utilization.

Does pediatric patient-centeredness affect family trust?

Despite its recognition as a key dimension of healthcare quality, it is often unclear what exactly patient-centeredness means. A generally accepted measurement model of patient-centeredness is still nonexistent, current operational definitions lack sufficient specificity to inform providers how it relates to outcomes, and the influence of patient-centeredness on pediatric patients and families has not been quantified. This study demonstrates that patient-centeredness is a measurable ability of pediatricians that increases family trust. As an ability, it is teachable. The study offers an evidence-based model for future research with specific implications for quality measurement and improvement in the outpatient pediatrician's office.

Primary care clinicians treat patients with medically unexplained symptoms: a randomized controlled trial

OBJECTIVE

There is no proven primary care treatment for patients with medically unexplained symptoms (MUS). We hypothesized that a long-term, multidimensional intervention by primary care providers would improve MUS patients' mental health.

DESIGN

Clinical trial.

SETTING

HMO in Lansing, MI.

PARTICIPANTS

Patients from 18 to 65 years old with 2 consecutive years of high utilization were identified as having MUS by a reliable chart rating procedure; 206 subjects were randomized and 200 completed the study.

INTERVENTION

From May 2000 to January 2003, 4 primary care clinicians deployed a 12-month intervention consisting of cognitive-behavioral, pharmacological, and other treatment modalities. A behaviorally defined patient-centered method was used by clinicians to facilitate this treatment and the provider-patient relationship.

MAIN OUTCOME MEASURE

The primary endpoint was an improvement from baseline to 12 months of 4 or more points on the Mental Component Summary of the SF-36.

RESULTS

Two hundred patients averaged 13.6 visits for the year preceding study. The average age was 47.7 years and 79.1% were females. Using intent to treat, 48 treatment and 34 control patients improved (odds ratio [OR]=1.92, 95% confidence interval [CI]: 1.08 to 3.40; P=.02). The relative benefit (relative "risk" for improving) was 1.47 (CI: 1.05 to 2.07), and the number needed to treat was 6.4 (95% CI: 0.89 to 11.89). The following baseline measures predicted improvement: severe mental dysfunction (P<.001), severe body pain (P=.039), nonsevere physical dysfunction (P=.003), and at least 16 years of education (P=.022); c-statistic=0.75.

CONCLUSION

The first multidimensional intervention by primary care clinicians led to clinically significant improvement in MUS patients.

Weight and its relationship to adolescent perceptions of their providers (WRAP): a qualitative and quantitative assessment of teen weight-related preferences and concerns

PURPOSE

To examine the relationship of body weight to satisfaction with care in adolescents, and to obtain qualitative data on preferences for general and weight-related medical care in normal weight and overweight adolescents.

METHODS

The Weight and its Relationship to Adolescent Perceptions of their Providers survey, a 4-page questionnaire containing previously validated satisfaction scales and open-ended qualitative questions regarding health care preferences, was administered to 62 severely overweight (body mass index [BMI] 38.9 +/- 8.4 kg/m2) and 29 normal weight (BMI 22.5 +/- 4.0 kg/m2) adolescents (age 13.9 +/- 1.7 years; 57% female; 50% Caucasian, 47% African-American, 3% Hispanic).

RESULTS

The affective subscale of the medical satisfaction scale was negatively correlated with BMI standard deviation score (r = -.22, p < .05). Multiple regression models predicting affective satisfaction with medical care included BMI standard deviation score; however, continuity with provider appeared to be the strongest independent predictor of affective satisfaction. Fifty-five percent of participants identified their mother as the person they felt most comfortable talking with about weight, although 68% believed their provider knew the most about healthy eating. "Overweight" was identified by 47% of participants as the preferred term for heavy teens. Seventy-nine percent of overweight adolescents stated their health care provider discussed their weight with them; however, only 41% of overweight adolescents desired to discuss their weight. Compared to normal-weight adolescents, overweight teens were more likely to report that their provider raised topics of weight (p < .001), diet (p < .01), and exercise (p < .01) at their last physical, and were more likely to report that they would have liked their provider to discuss diet and exercise (both p < .05). Ten percent of overweight teens expressed concerns regarding the public location of their provider's office scale.

CONCLUSIONS

Satisfaction with affective aspects of the provider-patient relationship is negatively correlated with BMI standard deviation score. Length of experience with one's provider is also a strong predictor of teen satisfaction with their medical care. Teens prefer the term "overweight" for those with high body weight. Sensitivity to confidentiality, privacy, and embarrassment regarding physical examination and weight are important for teen satisfaction.

Teaching personal awareness

Educators rarely consider the attitudes that determine whether a learner will use the clinical skills we teach. Nevertheless, many learners and practitioners exhibit negative attitudes that can impede the use of patient-centered skills, leading to an isolated focus upon disease and impairing the provider-patient relationship. The problem is compounded because these attitudes often are incompletely recognized by learners and therefore are difficult to change without help. We present a research-based method for teaching personal awareness of unrecognized and often harmful attitudes. We propose that primary care clinicians without mental health training can follow this method to teach students, residents, faculty, and practitioners. Such teachers/mentors need to possess an abiding interest in the personal dimension, patience with a slowly evolving process of awareness, and the ability to establish strong, ongoing relationships with learners. Personal awareness teaching may occur during instruction in basic interviewing skills but works best if systematically incorporated throughout training.