Relationship-centered Care Research Articles

Students’ experiences with a hybrid learning environment in nursing homes: A qualitative study

AimThe aim of this study is to explore how students experience learning in a hybrid learning environment in a nursing home setting and their perceptions of relationship-centred care. BackgroundNursing homes are undergoing a culture shift from task-centred care to person- and relationship-centred care, requiring a different approach to how nursing home staff work and are educated. Hybrid learning environments aim to educate professionals who continuously work on their professional development by integrating and merging learning and working to facilitate the culture shift. DesignAn exploratory qualitative study design was used. The setting were nursing home wards organised according to a hybrid learning environment located in the Netherlands. Participants were students in two-year training for nurse assistants, three-year training for certified nurse assistants, or four-year training for vocationally trained registered nurses. Data were collected through semi-structured interviews and focus groups. Data were analysed using direct content analysis. ResultsAnalysis revealed three themes regarding how students experienced learning in the hybrid learning environment: 1) design of the learning process, 2) disconnection between working and learning and 3) learning resources. Regarding how learning in the hybrid learning environment influences students’ perceptions of relationship-centred care analyses revealed two themes: 1) recognising the essence of relationship-centred care and 2) overstaffing and student–resident interaction. ConclusionsThe hybrid learning environment in a nursing home setting remains underdeveloped. By considering some improvement points (e.g., clarity of the role of work supervisor and students’ awareness of learning while executing daily tasks), the hybrid learning environment can promote a shift from working task-centred to working relationship-centred. Additionally, students must grasp the essence of the concept of relationship-centred care and need support in developing reflection skills to provide it.

Mixed Method Evaluation of ACTS: Advancing Connection Through Storytelling-A Novel Approach to Improve Older Adult Engagement and Staff Interactions in Korean Nursing Homes.

A culture centered on relationships and communication is necessary to improve the quality of life of older adults living in nursing homes. To examine the effects of a storytelling program by examining the cognitive, emotional, and psychosocial changes in older adults in facilities and explore staff experience of changes in care. This mixed method study delivered a 6-week storytelling program based on relationship-centered care for residents of nursing homes (aged >65 years). Changes in emotional expression, depression, communication skills, social support, interpersonal relationships, nurse-patient interaction, and the person-centered environment as perceived by older adults were quantitatively analyzed using pre-intervention and post-intervention surveys. Qualitative data were collected through weekly stories created by residents, followed by focus group interviews with nursing home staff, analyzed using reflexive thematic analysis to enhance understanding of the program's outcomes. The 42 residents reported significant changes in their emotional expression, depression, communication skills, social support, interpersonal relationships, nurse-patient interaction, and person-centered environment scores after the 6-week intervention. Analysis of the residents' stories identified 5 themes. The staff focus group interviews identified 2 themes and 7 subthemes. Intervention group residents were more likely to initiate conversations, express themselves, carefully observe themselves and others, and actively participate in social activities. The storytelling program was useful in reducing older adults' negative emotions by allowing them to express their thoughts and feelings and improve their relationships, creating opportunities for social interaction. These effects could help foster relationship- and communication-centered facility cultures.

Postpartum care for parent-infant dyads: A community midwifery model.

Postpartum health is in crisis in the United States, with rising pregnancy-related mortality and worsening racial inequities. The World Health Organization recommends four postpartum visits during the 6 weeks after childbirth, yet standard postpartum care in the United States is generally one visit 6 weeks after birth. We present community midwifery postpartum care in the United States as a model concordant with World Health Organization guidelines, describing this model of care and its potential to improve postpartum health for birthing people and babies. We conducted semi-structured interviews with 34 community midwives providing care in birth centers and home settings in Oregon and California. A multidisciplinary team analyzed data using reflexive thematic analysis. A total of 24 participants were Certified Professional Midwives; 10 were certified nurse-midwives. A total of 14 midwives identified as people of color. Most spoke multiple languages. We describe six key elements of the community midwifery model of postpartum care: (1) multiple visits, including home visits; typically five to eight over six weeks postpartum; (2) care for the parent-infant dyad; (3) continuity of personalized care; (4) relationship-centered care; (5) planning and preparation for postpartum; and (6) focus on postpartum rest. The community midwifery model of postpartum care is a guideline-concordant approach to caring for the parent-infant dyad and may address rising pregnancy-related morbidity and mortality in the United States.

Characteristics Associated with Relationship-Centred and Task-Focused Mealtime Practices in Older Adult Care Settings.

Purpose: To assess care home and staff characteristics associated with task-focused (TF) and relationship-centred care (RCC) mealtime practices prior to the COVID-19 pandemic.Methods: Staff working in Canadian and American care homes were invited to complete a 23-item online survey assessing their perceptions of mealtime care, with one item assessing 26 potential care practices from the Mealtime Relational Care Checklist (relationship-centred=15; task-focused=11) reported to occur in the home prior to the pandemic. Multivariate linear regression evaluated staff and care home characteristics associated with mealtime practices.Results: Six hundred and eighty-six respondents completed all questions used in this analysis. Mean TF and RCC mealtime practices were 4.89±1.99 and 9.69±2.96, respectively. Staff age was associated with TF and RCC practices with those 40-55 years reporting fewer TF and those 18-39 years reporting fewer RCC practices. Those providing direct care were more likely to report TF practices. Dissatisfaction with mealtimes was associated with more TF and fewer RCC practices. Homes that were not making changes to promote RCC pre-pandemic had more TF and fewer RCC practices. Newer care homes were associated with more RCC, while small homes (≤49 beds) had more TF practices.Conclusions: Mealtime practices are associated with staff and home factors. These factors should be considered in efforts to improve RCC practices in Canadian homes.

Challenges and opportunities of relationship centred care in health care settings. My journey and the evolution of my approach

Understanding the complexities of relating in a health care context invites practitioners to anticipate and identify challenges and opportunities as they arise in their practice. This experiential paper will attempt to explore and illustrate some of the complexities of adopting a relationship centred approach in healthcare settings, from the perspective of one practitioner. 
 This paper will consider how the organisational culture can impact on the practitioners ability to interact with patients. In this context the influence of the organisational culture with its emphasis on task, diagnosis and treatment of disease, functioned to undermine this practitioners capacity to relate and take up a relationship centred approach.
 This paper, with reference to clinical material, will highlight the tension that exists between task and relationship in healthcare settings. Special reference will be made to how in some situations the wish to relate interrupted the task focused work, causing co nfusion and great challenge for the practitioner . The invitation to adopt relationship centred practice , while still attending to the task in hand restored the practitioners belief in the medical consultation’s potential to create a receptive , responsive and relationship centred space .
 Finally, this paper will conclude by considering how to navigate this complex context and to achieve a balance which includes relationship centred care , using these opportunities as they arise to ensure optimum health care outcomes for both practitioner and patients.

Health and social care needs of people living with dementia: a qualitative study of dementia support in the Victorian region of Gippsland, Australia.

There is a lack of information about the experiences of people living with dementia and their carers, especially in rural and regional areas. Understanding these experiences helps to identify gaps and unmet needs within the health system and improve quality of care and outcomes for people living with dementia. The aim of this study was to improve our knowledge of dementia support needs. This included access to health and social care services and supports for people living with dementia and those who provide informal or formal support to someone living with dementia. Interviews were conducted with 26 participants from the Gippsland region of Victoria, Australia with knowledge of dementia care. Purposive sampling engaged people with lived experience, carers/family members and health professionals delivering dementia care and social services. Discussions centred around participants' experiences of support services, the diagnosis process and what they thought was needed to improve the services and supports offered. Thematic analysis of the data was undertaken using the framework method. The interview data indicated that the needs of many people living with dementia and their carers were not currently being met. The themes were limited access to services and supports, including primary and specialist care, often impacted by lack of knowledge of care options, difficulty navigating the system and funding models as a barrier, leading to delays in getting a diagnosis and accessing specialist services; lack of holistic care to enable people living with dementia to 'live well'; and stigma impacted by a lack of knowledge of dementia among professionals and in the community. Relationship-centred care was described as a way to improve the lives of people living with dementia. Key areas for improvement include increasing community awareness of dementia and available local services, more support to obtain an early dementia diagnosis, increased help to navigate the system, especially immediately after diagnosis, and easier access to appropriate home support services when they are needed. Other recommendations include person-centred care across settings - supported by funding models, more education and communication skills training for health professionals and care staff - and greater support for and increased recognition of carers.

Building Authentic Connection in the Patient-Physician Relationship.

Delivering optimal patient care is impacted by a physician's ability to build trusting relationships with patients. Identifying techniques for rapport building is important for promoting patient-physician collaboration and improved patient outcomes. This study sought to characterize the approaches highly skilled primary care physicians (PCPs) use to effectively connect with diverse patients. Using an inductive thematic analysis approach, we analyzed semi-structured interview transcripts with 10 PCPs identified by leadership and/or colleagues for having exceptional patient communication skills. PCPs practiced in 3 diverse clinic settings: (1) academic medical center, (2) Veterans Affairs clinic, and (3) safety-net community clinic. The thematic analysis yielded 5 themes that enable physicians to establish connections with patients: Respect for the Patient, Engaged Curiosity, Focused Listening, Mutual Participation, and Self-Awareness. Underlying all of these themes was a quality of authenticity, or a state of symmetry between one's internal experience and external words and actions. Adopting these communication techniques while allowing for adaptability in order to remain authentic in one's interactions with patients may facilitate improved connection and trust with patients. Encouraging physician authenticity in the patient-physician relationship supports a shift toward relationship-centered care. Additional medical education training is needed to facilitate authentic connection between physicians and patients.

THE ESSENTIAL ROLE OF PAID CAREGIVERS IN HOME-BASED DEMENTIA CARE

Abstract Paid caregivers (e.g., home health aides, other home care workers) provide essential support to the rapidly growing number of people with dementia living in the community. This symposium presents innovative findings on the role of paid caregivers in home-based dementia care though exploration of the clinical, family, and care-delivery contexts in which paid caregivers work. First, Reckrey et al describe the scope of paid caregiving in dementia using nationally representative data examining factors associated with receipt of paid care among older adults with overlapping dementia and non-dementia serious illness. Next, we examine mechanisms of delivering paid care: Osakwe et al explore paid caregiver perceptions about the use of telehealth in home health and identify paid caregivers concerns about routine use of this technology in care of people with dementia, and Gordon-Wexler et al explore family caregiver perspectives on navigating Medicare and Medicaid insurance for people with advanced dementia and the challenges they experience coordinating paid care. Finally, we explore how paid caregivers work with other care team members. Quach et al discuss multidisciplinary perspectives about how paid caregivers support person-centered and relationship-centered care to family dementia caregivers, while Fabius et al examine information sharing practices within home care agencies and describe differences and similarities in information sharing needs for people with and without dementia. Taken together, these presentations highlight the important ways that paid caregivers work with providers and families within the care delivery system and identify ways to better support and integrate these essential workers into dementia care teams. This is a Paid Caregiving Interest Group Sponsored Symposium.

What's going well: a qualitative analysis of positive patient and family feedback in the context of the diagnostic process.

Accurate and timely diagnosis relies on close collaboration between patients/families and clinicians. Just as patients have unique insights into diagnostic breakdowns, positive patient feedback may also generate broader perspectives on what constitutes a "good" diagnostic process (DxP). We evaluated patient/family feedback on "what's going well" as part of an online pre-visit survey designed to engage patients/families in the DxP. Patients/families living with chronic conditions with visits in three urban pediatric subspecialty clinics (site 1) and one rural adult primary care clinic (site 2) were invited to complete the survey between December 2020 and March 2022. We adapted the Healthcare Complaints Analysis Tool (HCAT) to conduct a qualitative analysis on a subset of patient/family responses with≥20 words. In total, 7,075 surveys were completed before 18,129 visits (39 %) at site 1, and 460 surveys were completed prior to 706 (65 %) visits at site 2. Of all participants, 1,578 volunteered positive feedback, ranging from 1-79 words. Qualitative analysis of 272 comments with≥20 words described: Relationships (60 %), Clinical Care (36 %), and Environment (4 %). Compared to primary care, subspecialty comments showed the same overall rankings. Within Relationships, patients/families most commonly noted: thorough and competent attention (46 %), clear communication and listening (41 %) and emotional support and human connection (39 %). Within Clinical Care, patients highlighted: timeliness (31 %), effective clinical management (30 %), and coordination of care (25 %). Patients/families valued relationships with clinicians above all else in the DxP, emphasizing the importance of supporting clinicians to nurture effective relationships and relationship-centered care in the DxP.

Storied reflections: Development of a longitudinal interdisciplinary curriculum to improve patient-provider communication.

This article details the development of an interdisciplinary graduate medical education (GME) narrative curriculum. Descriptive statistics were conducted for the narrative session surveys. Two separate qualitative analyses were conducted. First, content and thematic analyses of the open-ended questions in the survey using NVIVO software occurred. Second, an inductive analysis of the participants' 54 stories was performed to identify unique themes not related to the prompt topics. Quantitative survey results demonstrated that 84% of learners' felt the session benefited their personal or professional sense of wellbeing and resilience, 90% of learners believed the sessions aided in their ability to listen more effectively, and 86% of learners could apply what they practiced or witnessed. Qualitative analysis of survey data showed learners focused on patient care and listening. Thematic analysis of participants' narratives revealed strong feelings and emotions, struggles with time management, increase in self- and other-awareness, and challenges managing job-life balance. The longitudinal interdisciplinary Write-Read-Reflect narrative exchange curriculum is cost-effective, sustainable, and demonstrably valuable to learners and their program directors across multiple disciplines. The program was designed for 4 graduate programs' learners to simultaneously experience a narrative exchange model to improve patient-provider communication, support professional resilience, and deepen relationship-centered care skills.

Interprofessional Practice Between Speech-Language Pathologists and Classroom Teachers: A Mixed-Methods Systematic Review.

There is an important need for interprofessional practice (IPP) between speech-language pathologists (SLPs) and classroom teachers (CTs) in mainstream schools to support student outcomes. This mixed methods systematic review aimed to synthesize existing literature to describe the experiences of IPP between SLPs and CTs in mainstream schools. A systematic review protocol was utilized to conduct a comprehensive search of six databases (PubMed Central, EMBASE, Cochrane Library, CINAHL EBSCO, ERIC, and ProQuest Dissertations & Theses Global) using key words related to the research question. A total of 1,876 unique studies were retrieved. Of these, 18 studies were identified as relevant to the research question, as they described the experiences of IPP between SLPs and CTs. Thematic analysis was used to analyze the quantitative and qualitative studies. Six main themes describing IPP experiences were identified: (1) what are you bringing to the collaboration table? (2) putting the value in collaboration, (3) sharing is collaborating, (4) the nature of collaboration varies, (5) the educational context matters, and (6) influences to collaboration beyond professional control. IPP between SLPs and CTs is complex, with various facilitators and barriers to IPP emerging within the education context. Competencies for SLPs and CTs related to having a shared understanding, adequate communication, and building relationships with each other help support IPP in schools. The utilization of a relationship-centered care approach between SLPs and CTs is also important to foster and support student outcomes. https://doi.org/10.23641/asha.24018732.

Implementation of cross-sector partnerships: a description of implementation factors related to addressing social determinants to reduce racial disparities in adverse birth outcomes.

Traditional perinatal care alone cannot address the social and structural determinants that drive disparities in adverse birth outcomes. Despite the wide acceptance of partnerships between healthcare systems and social service agencies to address this challenge, there needs to be more research on the implementation factors that facilitate (or hinder) cross-sector partnerships, particularly from the perspective of community-based organizations. This study aimed to integrate the views of healthcare staff and community-based partner organizations to describe the implementation of a cross-sector partnership designed to address social and structural determinants in pregnancy. We used a mixed methods design (in-depth interviews and social network analysis) to integrate the perspectives of healthcare clinicians and staff with those of community-based partner organizations to identify implementation factors related to cross-sector partnerships. We identified seven implementation factors related to three overarching themes: relationship-centered care, barriers and facilitators of cross-sector partnerships, and strengths of a network approach to cross-sector collaboration. Findings emphasized establishing relationships between healthcare staff, patients, and community-based partner organizations. This study provides practical insights for healthcare organizations, policymakers, and community organizations that aim to improve access to social services among historically marginalized perinatal populations.

Multi-Level Factors Associated with Relationship-Centred and Task-Focused Mealtime Practices in Long-Term Care: A Secondary Data Analysis of the Making the Most of Mealtimes Study.

Mealtimes in long-term care (LTC) can reinforce relationships between staff and residents through relationship-centred care (RCC) practices; however, meals are often task-focused (TF). This cross-sectional study explores multi-level contextual factors that contribute to RCC and TF mealtime practices. Secondary data from residents in 32 Canadian LTC homes were analyzed (n = 634; mean age 86.7 ± 7.8; 31.1% male). Data included resident health record review, standardized mealtime observation tools, and valid questionnaires. A higher average number of RCC (9.6 ± 1.4) than TF (5.6 ± 2.1) practices per meal were observed. Multi-level regression revealed that a significant proportion of variation in the RCC and TF scores was explained at the resident- (intraclass correlation coefficient [ICC]RCC = 0.736; ICCTF = 0.482), dining room- (ICCRCC = 0.210; ICCTF = 0.162), and home- (ICCRCC = 0.054; ICCTF = 0.356) levels. For-profit status and home size modified the associations between functional dependency and practices. Addressing multi-level factors can reinforce RCC practices and reduce TF practices.

Cultivating Relationship-Centered Care: Patient, Caregiver, and Provider Communication Preferences for and Experiences with Prognostic Conversations

ABSTRACT Prognostic conversations present many challenges for patients, caregivers, and providers alike. Most research examining the context of prognostic conversations have used a more siloed approach to gather the range of perspectives of those involved, typically through the lens of patient-centered care. However, the mutual influence evident in prognostic conversations suggests a relationship-centered care model may be useful in cancer communication research. Similarities and differences in preferences for and experiences with prognostic conversations among oncology patients, caregivers, and providers (N = 32) were explored. Identified themes were then mapped to the principles of the relationship-centered care framework to extend our understanding of prognostic conversations and contribute to a new direction in the application of relationship-centered care. Findings suggest fewer similarities than differences, point to important discrepancies among participant perspectives, and reinforce the utility of relationship-centered care in identifying communication practices that enhance the prognostic conversation experience.

Translation and psychometric testing of the sense of competence in Dementia Care Staff Scale in Chinese amongst dementia care staff in nursing homes of China

BackgroundAlthough China has the largest population of persons with dementia, there is no validated tool available to accurately assess formal caregivers’ competence in dementia care in long-term care settings. Appropriately assessing nursing staff’s level of competence in dementia care is the first step to develop precision training interventions to improve the quality of dementia care. The Sense of Competence in Dementia Care Staff scale (SCIDS) is a user-friendly tool with satisfactory reliability and validity. We adapted SCIDS into a Chinese version (SCIDS-C) and validated its uses in China’s socio-cultural context to assess nursing staff’s capability and competence in dementia care at nursing homes.AimsWe aimed to adapt and psychometrically test the tool among frontline nursing staff in long-term care settings in China.MethodsThe research employed a correlational design with repeated measures. In translation section, we adapted and tailored the original scale in the cultural and social context in China’s nursing homes. The scale’s adaptation consists of translating adaptation and semantic equivalence. In psychometric testing phase, we tested the validity and reliability of the scale with 174 nursing staff conveniently from six nursing homes. Construct validity was tested using exploratory factor analysis (EFA), including principal component analysis and maximum variance rotation method. Reliability was tested using Cronbach’s alpha value and intraclass correlation coefficient (ICC).ResultsThe SCIDS-C has 17 items, which belong to the two sub-scales, the Relationship-Centered Care(RCC) and Professional Care(PC). The Cronbach’s alpha value was 0.88, showing a good internal consistency. The full scale’s value of ICC was 0.94 which indicated good reliability. Exploratory factor analysis(EFA) extracted 2 common factors in each sub-scale, cumulative variance contribution rate was 56.71% and 53.92%, respectively. The named four factors are the same as the Sense of Competence in Dementia Care Staff (SCIDS) scale in English, including Building Relationships, Sustaining Personhood, Professionalism and Care Challenges.ConclusionThe SCIDS-C has shown good reliability and validity. It can be used as an appropriate tool to evaluate the competence of nursing care staff to provide dementia care for residents in nursing homes.

A narrative medicine intervention in pediatric residents led to sustained improvements in resident well-being

Background Burnout in pediatric residents is widespread. Certain factors are associated with decreased burnout, such as empathy, self-compassion, mindfulness, and resilience, while perceived stress is associated with increased burnout. Narrative medicine may reduce burnout by its impact on protective and exacerbating factors and can be an active tool to promote wellness. The objective of this pilot study was to evaluate immediate and delayed benefits of a longitudinal narrative medicine intervention for pediatric residents using qualitative and quantitative measures. Materials and Methods We designed a voluntary longitudinal narrative medicine intervention implemented via Zoom teleconferencing software over five months for pediatric residents at Nationwide Children’s Hospital. It consisted of six one-hour long sessions where residents engaged with literature, responded to a writing prompt, and shared their reflections. It was evaluated using open-ended survey questions and established quantitative assessment tools of well-being with validity evidence. Results were compared before the intervention, immediately after, and six months later using one-way ANOVA and multiple linear regression. Qualitative data was analyzed using thematic analysis. Results Twenty-two (14% of eligible) residents participated in at least one session. After the intervention, the following themes emerged for benefits to resident well-being: the ability to Build Community, have an Outlet for Self-Expression, reap Emotional and Mental Health Benefits, and work on Personal Growth. Benefits were sustained even six months later, which has not been shown previously. While there were significant qualitative findings, between all three time points, there was no change in any quantitative well-being measures. Conclusion Our longitudinal narrative medicine pilot study showed meaningful sustained qualitative benefits, though no quantitative changes, in measured well-being outcomes that have been previously associated with lower resident burnout. While not a panacea, narrative medicine can be a useful strategy for residency programs to improve pediatric resident well-being even after completion of planned interventions. Key Message We used a mixed-methods approach to assess the effects of a longitudinal narrative medicine intervention on well-being in pediatric residents. Open-ended responses indicated that residents found utility in and appreciated the intervention and experienced sustained improvements in their mental and emotional health, though the sample size was likely too small to show quantitative changes in well-being measures. Narrative medicine is not a panacea, but it can be a useful tool to provide to pediatric residents to promote sustained improvements in their well-being through the framework of relationship-centered care.

Evidence-Based Performance Indicators of Positive Inpatient Experiences.

Patient experiences affect the competitiveness and financial viability of a hospital. The purpose of this research was to ascertain the factors that contribute to positive inpatient experiences by using empirical evidence from national databases and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey data. Data were assembled from four publicly available U.S. government datasets. The HCAHPS national survey responses (n = 2,472) were based on four consecutive quarters of patient surveys. Measures of clinical complications obtained from the Centers for Medicare & Medicaid Services were used to assess hospital quality. Social determinants of health were incorporated into the analysis by including data from the Social Vulnerability Index as well as zip code-level information from the Office of Policy Development and Research. The study results show that hospital quietness, nurse communication, and care transition positively affected patient experience ratings and the patient's likelihood to recommend the hospital. In addition, findings show that hospital cleanliness positively influenced patient experience ratings. However, hospital cleanliness had little impact on the likelihood of a patient's recommending the hospital, and staff responsiveness had a negligible impact on both patient experience ratings and the likelihood to recommend the hospital. The results also revealed that hospitals with better clinical outcomes received better patient experience ratings and recommendation scores, whereas hospitals that serve more vulnerable populations received worse patient experience ratings and recommendation scores. Findings from this research demonstrate that managing the physical surroundings by providing a clean and quiet environment, providing relationship-centered care through interactions with medical personnel, and working to engage patients in their health as they transition out of care contributed to positive inpatient experiences.

Integrating Communication Skills, Awareness of Self and Others, and Reflective Feedback into One Inclusive Anatomical Representation of Relationship-Centered Health Care.

The American Veterinary Medical Association Council on Education mandates in standard 11 that all accredited colleges of veterinary medicine must develop and deliver formal processes by which students are observed and assessed in nine competencies. The eighth competency combines clinical communication and sensitivity toward soliciting and understanding individual narratives across a diverse clientele to facilitate health care delivery. Several frameworks have been designed to structure health care consultations for teaching and coaching purposes. The Calgary-Cambridge guide (CCG) provides an evidence-based approach to outlining the flow of consultations, incorporating foundational communication skills and elements of relationship-centered care into a series of sequential tasks. Although the CCG was intended for use as a flexible tool kit, it lacks visible connections between concrete experiences (e.g., the consultation) and reflective observation (e.g., the feedback). This teaching tip describes the development of a novel anatomical representation of the consultation that integrates process elements of the CCG with other core curricular concepts. By combining knowledge, technical skills, critical thinking, reflection, cultural humility, and self-awareness into a skeletal consultation model, linkages are established between communication and intergroup dialogue skills, diversity and inclusion (D&I). This model has been further adapted as feline, caprine, porcine, equine, avian, and reptilian versions for in-class use as strategic visual aids that highlight key areas of focus for Professional Skills class sessions. Future developments by the authors will explore how to link species-specific consultation models to assessment rubrics to reinforce the connection between content (what) and process (how).

Culture Change in Long-Term Care-Post COVID-19: Adapting to a New Reality Using Established Ideas and Systems.

The response to the COVID-19 pandemic in long-term care (LTC) has threatened to undo efforts to transform the culture of care from institutionalized to de-institutionalized models characterized by an orientation towards person- and relationship-centred care. Given the pandemic's persistence, the sustainability of culture-change efforts has come under scrutiny. Drawing on seven culture-change models implemented in Canada, we identify organizational prerequisites, facilitatory mechanisms, and frontline changes relevant to culture change that can strengthen the COVID-19 pandemic response in LTC homes. We contend that a reversal to institutionalized care models to achieve public health goals of limiting COVID-19 and other infectious disease outbreaks is detrimental to LTC residents, their families, and staff. Culture change and infection control need not be antithetical. Both strategies share common goals and approaches that can be integrated as LTC practitioners consider ongoing interventions to improve residents' quality of life, while ensuring the well-being of staff and residents' families.

Disruption to the doctor-patient relationship in primary care: a qualitative study.

Starfield described the importance of system-level components of primary care (first contact, continuous, comprehensive, coordinated), on countries' health systems. It is postulated that, at the individual level, interpersonal interactions and relationship-centred care are central to primary care. To explore the impact of COVID-19 on disruption to the doctor-patient relationship and subsequent development of new models of care. A series of 11 cross-sectional surveys of New Zealand (NZ) urban and rural primary care doctors, nurses, and managers, from May 2020 to February 2021, to understand and monitor responses to the pandemic. Using inductive content analysis, cumulated qualitative data from doctors were examined through the lenses of the doctor-patient relationship, its disruption, and resulting changes in models of care. There were 1519 responses to the surveys, representing 482 unique participants. The majority (86%) of responses were from doctors. The following four key themes emerged: moving to transactional consultations; task-shifting with team changes; creating a production line; and diminished communication and coordination across services. The advent of the pandemic led to severe and ongoing strain on practices requiring rapid change to the model of care. Team members took on new roles for triaging, testing, and separating patients with respiratory and non-respiratory symptoms. There was a rapid move to telehealth, with policies developed on where face-to-face consultations were necessary. Practice strain was exacerbated by disruption to coordination with secondary and other referral services. As new models of general practice develop, further disruptions to development of doctor-patient relationships must be avoided. This work extends Starfield's system-level paradigm to the individual level, with the core value of primary care the doctor-patient relationship. Successful sustainable models are likely to be where relationships are treated as of central importance.