Therapeutic Alliance: Development, Evaluation, and Application of the Kim Alliance Scale

Abstract

The quality of therapeutic alliance between the patient and healthcare provider is a pivotal contributing factor toward optimal healthcare in the current context of rising healthcare costs, shorter hospital stays, and patient's rights. The availability of a well-designed and sound therapeutic alliance instrument can provide understanding and insight into improving the quality of healthcare. The purpose of this study was to develop a reliable and valid therapeutic alliance instrument, to evaluate its psychometric properties, and to explore its usefulness in predicting patient satisfaction. The retroductive triangulation method provided a framework for the development of the instrument, the Kim Alliance Scale (KAS). In a preliminary psychometric testing, a sample of 68 nurses evaluated their alliance with their own healthcare providers from their experiences as patients using a 48-item KAS. The testing resulted in a 30-item KAS having a reliability alpha of 0.94. Initial support was found for convergent and divergent validity. For the subsequent study in an outpatient clinic, data were collected from 297 adult patients. An exploratory principal component factor analysis with orthogonal varimax rotation was performed. The instrument was revised further into a 28-item KAS containing five factors: bonding, connecting, partnering, goal-setting, and alienating. The multidimensionality of the KAS was supported with correlation coefficients among the five factors ranging from 0.32 to 0.67. The internal consistency reliability was estimated with Cronbach's alpha of 0.94 and split-half alphas of 0.88 and 0.89. The convergent and divergent validity were supported. A combination of all the demographic variables accounted for 8% of the variance in therapeutic alliance. None of the individual demographic variables reached statistical significance in predicting therapeutic alliance. Therapeutic alliance accounted for 36.9% of variance in the 4-item General Satisfaction subscale score and 46.5% of the variance in the 18-item Patient Satisfaction with Healthcare Provider Scale score. The KAS is a promising tool for assessing the quality of the therapeutic alliance and identifying the foci for nursing interventions.