Relationship-centered Care Research Articles

The Financial Costs of Registered Nurse-Led Relationship-Centred Care: A Single-Case Australian Feasibility Study

People with intellectual disability are accommodated and cared for in a variety of settings in Australia. Direct care is delivered by a mixture of qualified health professionals (nurses) and unlicenced disability support workers in varying combinations depending on the complexity and chronicity of comorbidities experienced by people with intellectual disability. Although some of these disability services continue to employ registered nurses, the size and specialised education of this workforce is decreasing due to a myriad of policy changes, which has the effect of compromising continuity of care and adverse effects on health outcomes. The objective of this study was to compare the differences on the financial cost of a single case using different models of care with, and without, specialised registered nursing input. The single case had profound intellectual disability and multiple chronic and complex health problems and was cared for by a model that included 24 h registered nurse care and support. Four financial scenarios are presented, and the differences both in terms of actual cost, and potential health outcomes are discussed. This study has set the scene for a large study where health economic data can be compared against multiple cases, across a range of care contexts, in order to advance evidence about which models provide the better health outcomes for people with intellectual disability and associated multiple chronic and complex health problems.

Impact of a relationship-centered care communication curriculum on pediatric residents’ practice, perspectives, and opportunities to Develop expertise

ObjectivesTo investigate the impacts of a Relationship-Centered Care (RCC) communication curriculum with coaching on pediatric residents 1) self-reported use of RCC strategies and perspectives, and 2) opportunities to develop adaptive expertise. MethodsResidents (n = 77) completed a 4 h RCC training and shared resultant RCC goals with Coaches (n = 15). Data included resident surveys and reflections immediately post-training, and resident and coach surveys 6-months later. Reported use of RCC strategies were compared over time with paired t-tests. Qualitative data were analyzed using open coding guided by sensitizing principles from the RCC framework and adaptive expertise. ResultsPediatric residents reported significant increases (p < 0.001) in use of 4/9 RCC strategies after 6 months: eliciting all concerns, chunking information, checking for understanding, and teach-back. Resident reflections highlighted shifts in perspective around RCC. Training combined with coaching provided opportunities for residents to develop adaptive expertise through adapting and innovating across settings and contexts. ConclusionResidents had significant increases in reported use of key RCC strategies after a training combined with coaching and demonstrated opportunities to develop adaptive expertise. Practice implicationsResidency programs should include RCC training with an emphasis on the new and challenging strategies and provide opportunities to practice and receive coaching.

Working in a Dutch nursing home during the COVID-19 pandemic: Experiences and lessons learned.

AimsTo gain insight into how direct care staff in Dutch nursing homes experienced work during the COVID‐19 pandemic.DesignA qualitative study consisting of semi‐structured, face‐to‐face focus groups was conducted using “the active dialogue approach”.MethodsParticipants (n = 29) were care staff from four care teams at Dutch nursing homes. Teams were selected based on the number of COVID‐19 infections amongst residents. Data were analysed with conventional content analysis.ResultsThemes emerging from the data were the loss of (daily) working structure, interference between work and private life for direct care staff, the importance of social support by the team and a leader, and the effects on relationship‐centred care of the measures. Results offer concrete implications for similar situations in the future: psychological support on‐site; autonomy in daily work of care staff; an active role of a manger on the work floor and the importance of relationship‐centred care.

Patient Experience in Virtual Visits Hinges on Technology and the Patient-Clinician Relationship: A Large Survey Study With Open-ended Questions.

BackgroundPatient satisfaction with in-person medical visits includes patient-clinician engagement. However, communication, empathy, and other relationship-centered care measures in virtual visits have not been adequately investigated.ObjectiveThis study aims to comprehensively consider patient experience, including relationship-centered care measures, to assess patient satisfaction during virtual visits.MethodsWe conducted a large survey study with open-ended questions to comprehensively assess patients’ experiences with virtual visits in a diverse patient population. Adults with a virtual visit between June 21, 2017, and July 12, 2017, were invited to complete a survey of 21 Likert-scale items and textboxes for comments following their visit. Factor analysis of the survey items revealed three factors: experience with technology, patient-clinician engagement, and overall satisfaction. Multivariable logistic regression was used to test the associations among the three factors and patient demographics, clinician type, and prior relationship with the clinician. Using qualitative framework analysis, we identified recurrent themes in survey comments, quantitatively coded comments, and computed descriptive statistics of the coded comments.ResultsA total of 65.7% (426/648) of the patients completed the survey; 64.1% (273/426) of the respondents were women, and the average age was 46 (range 18-86) years. The sample was geographically diverse: 70.2% (299/426) from Ohio, 6.8% (29/426) from Florida, 4.2% (18/426) from Pennsylvania, and 18.7% (80/426) from other states. With regard to insurance coverage, 57.5% (245/426) were undetermined, 23.7% (101/426) had the hospital’s employee health insurance, and 18.7% (80/426) had other private insurance. Types of virtual visits and clinicians varied. Overall, 58.4% (249/426) of patients had an on-demand visit, whereas 41.5% (177/426) had a scheduled visit. A total of 41.8% (178/426) of patients had a virtual visit with a family physician, 20.9% (89/426) with an advanced practice provider, and the rest had a visit with a specialist. Most patients (393/423, 92.9%) agreed that their virtual visit clinician was interested in them as a person, and their virtual visit made it easy to get the care they needed (383/421, 90.9%). A total of 81.9% (344/420) of respondents agreed or strongly agreed that their virtual visit was as good as an in-person visit by a clinician. Having a prior relationship with their virtual visit clinician was associated with less comfort and ease with virtual technology among patients (odds ratio 0.58, 95% CI 0.35-0.98). In terms of technology, patients found the interface easy to use (392/423, 92.7%) and felt comfortable using it (401/423, 94.8%). Technical difficulties were associated with lower odds of overall satisfaction (odds ratio 0.46, 95% CI 0.28-0.76).ConclusionsPatient-clinician engagement in virtual visits was comparable with in-person visits. This study supports the value and acceptance of virtual visits. Evaluations of virtual visits should include assessments of technology and patient-clinician engagement, as both are likely to influence patient satisfaction.

Relationship-Centered Care in the Physician-Patient Interaction: Improving Your Understanding of Metacognitive Interventions.

The concept of relationship-centered care was first introduced approximately 20 years ago, but this important concept has not yet been widely disseminated in clinical practice. Relationship-centered care in the health profession focuses on all relevant relationships in health care, not only between health care professionals and patients but also among colleagues, staff members, students, community, and self. This review summarizes the key literature to date on relationship-centered care as it pertains to the physician-patient relationship. Becoming more aware of the physician (self) and patient is a form of metacognition, thinking about what is happening in the moment as physicians and patients come together. Considering the complexity of the physician-patient relationship, we can implement simple metacognitive techniques toward the daily habitual practice of relationship-centered care.

How to stay motivated: A focus group study of Norwegian caregivers' experiences with community healthcare services to their parents with dementia.

Motivation to provide care is a significant predictor of informal caregiving among family caregivers of persons with dementia. Adequate support is an important source of help and relief to caregivers, but fragmentation of dementia care services is common and better ways of supporting these caregivers are needed. Knowledge of adult-child caregivers' motivation and how this motivation is influenced by community healthcare services is lacking. The aim of this study is therefore to describe and explore adult children's experiences with community healthcare services for their home-dwelling parent with dementia and how these influence their caregiver motivation. The study applied a qualitative design based on three focus group interviews with 15 of these caregivers (40-69years) in Norway in 2017. The study results indicate three categories supporting adult children's sustained motivation as caregivers: (a) caregivers prioritize their parent's need for healthcare services over their own need for support; (b) caregivers need acknowledgement through respect and involvement; and (c) caregivers need timely information and competence as the dementia progresses. To stimulate collaboration among adult-child caregivers, their parents with dementia, and community healthcare services, we claim that a relationship-centred care framework could be emphasised as a way of supporting sustained motivation among caregivers to parents with dementia as part of community healthcare services.

'Emotion is of the essence. … Number one priority': A nested qualitative study exploring psychosocial adjustment to stroke and aphasia.

Stroke and aphasia can have a profound impact on people's lives, and depression is a common, frequently persistent consequence. Social networks also suffer, with poor social support associated with worse recovery. It is essential to support psychosocial well-being post-stroke, and examine which factors facilitate successful adjustment to living with aphasia. In the context of a feasibility randomized controlled trial of peer-befriending (SUPERB), this qualitative study explores adjustment for people with aphasia in the post-acute phase of recovery, a phase often neglected in previous research. Semi-structured interviews were conducted with 20 people with aphasia and 10 significant others, who were purposively sampled from the wider group of 56 people with aphasia and 48 significant others. Interviews took place in participants' homes; they were analysed using framework analysis. Participants with aphasia were 10 women and 10 men; their median (interquartile range-IQR) age was 70 (57.5-77.0) years. Twelve participants had mild aphasia, eight moderate-severe aphasia. Significant others were six women and four men with a median (IQR) age of 70.5 (43-79) years. They identified a range of factors that influenced adjustment to aphasia post-stroke. Some were personal resources, including mood and emotions; identity/sense of self; attitude and outlook; faith and spirituality; and moving forward. Significant others also talked about the impact of becoming carers. Other factors were external sources of support, including familial and other relationships; doctors, nurses and hospital communication; life on the ward; therapies and therapists; psychological support, stroke groups; and community and socializing. To promote adjustment in the acute phase, hospital staff should prioritize the humanizing aspects of care provision. In the post-acute phase, clinicians play an integral role in supporting adjustment and can help by focusing on relationship-centred care, monitoring mental health, promoting quality improvement across the continuum of care and supporting advocacy. What this paper adds What is already known on the subject Anxiety and depression are common consequences of stroke, with depression rates high at 33% at 1 year post-onset. There is evidence that the psychological needs of people with aphasia are even greater than those of the general stroke population. Social support and social networks are also negatively impacted. Few studies have examined adjustment when people are still in hospital or in the early stages of post-stroke life in the community (< 6 months). Further, many stroke studies exclude people with aphasia. What this paper adds to existing knowledge Adjustment to living with stroke and aphasia begins in the early stages of recovery. While this partly depends on personal resources, many factors depend on external sources of help and support. These include doctors, nurses and hospital communication, their experience of life on the ward, and their therapists' person-centred care. What are the potential or actual clinical implications of this work? Clinicians play an integral role in facilitating people with aphasia to utilize their personal resources and support systems to adjust to life after stroke. They can help by focusing on relationship-centred care, monitoring mental health, promoting quality improvement across the continuum of care and supporting advocacy.

Clinician-patient-family member interactions in COVID-19 serious conditions: A glimpse from the other side of the limbo

• Family members might experience numbness and difficulties in representing the experience they are living, like being in a limbo. • Paraverbal and non-verbal (visual) communication might be more salient than verbal expressions in delivering difficult COVID-19 conversations. • Key relational elements are a combination advocacy, compassion, respect for dignity, and hope. • Clinicians might vicariously care for an affective relationship with isolated patients and this generated gratitude in family members. • The COVID-19 pandemic opens the door to relationship-centered care.

Partners in Sickness and in Health? Relationship-Centered Veterinary Care and Self-Educated Pet Owners in Germany: A Structural Equation Model.

In recent years, the web has become a widely used source for health information. Pet owners seem to respond to the supply of medical information on the Internet by increasing their self-education. However, after more than a decade of the digital revolution, little is known about the Internet's impact on the veterinarian-pet owner relationship. Recent research has raised concerns regarding the increase in self-education among pet owners. However, reasons suggest that the Internet might be a valuable source of pet-owner education for veterinarians. In particular, relationship-centered approaches of care might benefit from the information provided. Our study aimed to determine the perception of German veterinarians with regard to pet owners' self-education on different aspects of veterinary care. An online survey was conducted for German veterinarians from November 2016 to June 2017. Data were analyzed using exploratory factor analysis and structural equation modeling. Within the structural equation model, we evaluated how the veterinarians' attitude toward relationship-centered care might affect the evaluation of pet owners' self-education. A total of 585 valid questionnaires were completed. The majority of veterinarians (83.6%) welcomed the principles of shared decision-making. Practically, all veterinarians reported a noticeable increase in pet owners' self-education within the last few years. Perceptions on self-education's impacts on veterinary practice varied among the participants. A beneficial impact of self-education was reported regarding the general quality of veterinary care and quality of follow-up care. Most concerns were related to a negative impact on the veterinarian-pet owner relationship and the pet owners' demands on the veterinarians' work after self-education. Moreover, many participants were afraid that unfiltered information may unsettle pet owners and, therefore, advised them against self-education. The structural equation model confirmed the hypothesis that a veterinarian's positive attitude toward shared decision-making, empathic behavior, and his/her evaluation of self-education were associated. Therefore, we concluded that while there are beneficial potentials, there seem to be barriers that prevent the effective use of the Internet as a supportive medium in veterinary care. Further research and training are needed to enable the use of the Internet as an ancillary medium.

Making the Most of Mealtimes (M3): Association Between Relationship-Centered Care Practices, and Number of Staff and Residents at Mealtimes in Canadian Long-Term Care Homes

ObjectivesTo determine if (1) number of staff or residents, when considering home-level factors and presence of family/volunteers, are associated with relationship-centered care practices at mealtimes in general and dementia care units in long-term care (LTC); and (2) the association between number of staff and relationship-centered care is moderated by number of residents and family/volunteers, profit status or chain affiliation. DesignSecondary analysis of the Making the Most of Mealtimes (M3) cross-sectional multisite study. Setting and ParticipantsThirty-two Canadian LTC homes (Alberta, Manitoba, Ontario, and New Brunswick) and 639 residents were recruited. Eighty-two units were included, with 58 being general and 24 being dementia care units. MethodsTrained research coordinators completed the Mealtime Scan (MTS) for LTC at 4 to 6 mealtimes in each unit to determine number of staff, residents, and family or volunteers present. Relationship-centered care was assessed using the Mealtime Relational Care Checklist. The director of care or food services manager completed a home survey describing home sector and chain affiliation. Multivariable analyses were stratified by type of unit. ResultsIn general care units, the number of residents was negatively (P = .009), and number of staff positively (P < .001) associated with relationship-centered care (F9,48 = 5.48, P < .001). For dementia care units, the associations were nonsignificant (F5,18 = 2.74, P = .05). The association between staffing and relationship-centered care was not moderated by any variables in either general or dementia care units. Conclusion and ImplicationsNumber of staff in general care units may increase relationship-centered care at mealtimes in LTC. Number of residents or staff did not significantly affect relationship-centered care in dementia care units, suggesting that other factors such as additional training may better explain relationship-centered care in these units. Mandating minimum staffing and additional training at the federal level should be considered to ensure that staff have the capacity to deliver relationship-centered care at mealtimes, which is considered a best practice.

Relationship-Centered Mealtime Training Program Demonstrates Efficacy to Improve the Dining Environment in Long-Term Care

ObjectivesMealtimes in residential care tend to be task-focused rather than relationship-centered, impacting resident quality of life. CHOICE+ uses participatory approaches to make mealtimes more relationship-centered. The aim of this study was to demonstrate the efficacy of the 12-month external-facilitated implementation of CHOICE+ to improve the mealtime environment. DesignModified stepped-wedge time series design. Setting and ParticipantsDining rooms in 3 homes were entered into the intervention every 4 months; total study length was 20 months. Pre- and postintervention evaluations were attained from residents (n = 27, n = 19) and staff (n = 39, n = 29) respectively. MethodsFive meals in each home were observed by a blinded trained assessor every 4 months using the Mealtime Scan+ to assess physical, social, and relationship-centered practices and overall quality of the dining environment. Repeated measures analysis determined change in mealtime environment scores. The Team member Mealtime Experience Questionnaire and 5 questions from the InterRAI Quality of Life Questionnaire for residents and family were administered at pre- and postintervention. ResultsThere were significant increases in physical and social environments, relationship-centered care practices, and overall quality of the mealtime environment during the intervention period at all sites (all P < .001) and significant site by intervention interactions for physical (P = .01) and relationship-centered care (P = .03). Statistically significant site differences were noted for relationship-centered care practices (P < .001) and overall quality of the dining environment (P < .002). There was no significant difference in staff and resident/family pre-/postintervention questionnaire results. Conclusions and ImplicationsThe external facilitated model of CHOICE+ resulted in significant improvements in the mealtime environment. Although site context impacted implementation, this study demonstrates that mealtimes can be improved even in homes that have challenges. Future work should determine impact of these improvements on other outcomes such as resident quality of life, using more specific measures.

Guiding lights for effective workplace cultures that are also good places to work

Background: Working environments and relationships influence healthcare workers’ satisfaction and intent to stay, as well as service-user outcomes. With staff shortages a global issue, co-creation of effective workplace cultures that are also good places to work is more important than ever. Since our original research in 2011, a growing body of theoretical insights into workplace cultures has shown how complex it can be to develop them. We were curious about what staff felt works or what is needed. Aim: To develop a guiding theory with and for healthcare practitioners on effective workplace cultures in settings that are also good places to work. Methods: A three-phase study was used, based on principles of appreciative inquiry and realist evaluation. A blog generated initial interest, followed by a Twitter chat posing provocative questions. A series of Context-Mechanism-Outcome (CMO) configurations emerged and were presented to a new audience during an international conference. Endorsements and additions enabled further refinement of the initial programme theories, which were again presented for reflections during a second Twitter chat. Subsequent analysis resulted in a realist programme theory ready for further testing in practice. Findings/results: There are four guiding lights for co-creating effective workplace cultures in settings that are also good places to work: collective leadership; living shared values; safe, critical, creative learning environments; and change for good that makes a difference. When each is given adequate attention and all are combined, the ultimate outcomes include: high-performing teams that flourish and provide person- and relationship-centred care that is safe, effective and independent of the agency of specific individuals; and teams that develop effective partnerships within and across boundaries. Conclusions: Based on the voices of international frontline healthcare staff, we propose the retention of staff committed to providing care valued by staff and service users can be achieved by: collective leadership; living shared values; safe, critical, creative learning environments; and change for good as determined by those providing and experiencing care. Implications for practice: Healthcare managers, leaders and commissioners need to recognise and support microsystem culture development that staff and service users experience as good and safe Workplace culture development should be continuous, collaborative, inclusive and participatory, and driven by staff and service-user experiences, not top-down action planning and box ticking Responsive and person-centred leadership enables effective workplace cultures and collective leadership

Guiding lights for effective workplace cultures that are also good places to work

Background: Working environments and relationships influence healthcare workers’ satisfaction and intent to stay, as well as service-user outcomes. With staff shortages a global issue, co-creation of effective workplace cultures that are also good places to work is more important than ever. Since our original research in 2011, a growing body of theoretical insights into workplace cultures has shown how complex it can be to develop them. We were curious about what staff felt works or what is needed. Aim: To develop a guiding theory with and for healthcare practitioners on effective workplace cultures in settings that are also good places to work. Methods: A three-phase study was used, based on principles of appreciative inquiry and realist evaluation. A blog generated initial interest, followed by a Twitter chat posing provocative questions. A series of Context-Mechanism-Outcome (CMO) configurations emerged and were presented to a new audience during an international conference. Endorsements and additions enabled further refinement of the initial programme theories, which were again presented for reflections during a second Twitter chat. Subsequent analysis resulted in a realist programme theory ready for further testing in practice. Findings/results: There are four guiding lights for co-creating effective workplace cultures in settings that are also good places to work: collective leadership; living shared values; safe, critical, creative learning environments; and change for good that makes a difference. When each is given adequate attention and all are combined, the ultimate outcomes include: high-performing teams that flourish and provide person- and relationship-centred care that is safe, effective and independent of the agency of specific individuals; and teams that develop effective partnerships within and across boundaries. Conclusions: Based on the voices of international frontline healthcare staff, we propose the retention of staff committed to providing care valued by staff and service users can be achieved by: collective leadership; living shared values; safe, critical, creative learning environments; and change for good as determined by those providing and experiencing care. Implications for practice: Healthcare managers, leaders and commissioners need to recognise and support microsystem culture development that staff and service users experience as good and safe Workplace culture development should be continuous, collaborative, inclusive and participatory, and driven by staff and service-user experiences, not top-down action planning and box ticking Responsive and person-centred leadership enables effective workplace cultures and collective leadership

"For Me, This Has Been Transforming": A Qualitative Analysis of Interprofessional Relationship-Centered Communication Skills Training.

In 2018, Yale Medicine (YM)—an academic multispecialty practice—and Yale New Haven Health System (YNHH), partnered with the Academy of Communication in Healthcare to develop a one-day interprofessional workshop to introduce relationship-centered communication skills to all of their nurses and physicians. Relationship-centered communication skills include showing positive regard, listening actively and expressing empathy and have been demonstrated to improve patient outcomes. A professionally diverse group of 12 nurses and physicians, committed to improving patient experiences, were purposefully selected for training to teach the workshop. Individual interviews with trainers 3 months post training revealed themes reflecting the intrapersonal, interpersonal, and organizational impact of participation in the Train-the-Trainer program. At the intrapersonal level, training contributed to personal growth, skillfulness, and confidence. At the interpersonal level, it expanded and strengthened professional networks. As an organizational catalyst, training transformed the work experience among nurse and physician trainers, thereby supporting YM/YNHH’s vision to provide interprofessional relationship-centered care. Results suggest that trainer training had additional benefits beyond learning to deliver the workshop, including improving the quality of trainers’ personal and professional relationships, and enhancing organizational efficiency and interprofessionalism.

Co-Produced Care in Veterinary Services: A Qualitative Study of UK Stakeholders' Perspectives.

Changes in client behaviour and expectations, and a dynamic business landscape, amplify the already complex nature of veterinary and animal health service provision. Drawing on prior experiences, veterinary clients increasingly pursue enhanced involvement in services and have expectations of relationship-centred care. Co-production as a conceptualisation of reciprocity in service provision is a fundamental offering in the services sector, including human medicine, yet the role of co-production in veterinary services has been minimally explored. Utilising a service satisfaction framework, semi-structured interviews (n = 13) were completed with three veterinary stakeholder groups, veterinarians, allied animal health practitioners, and veterinary clients. Interview transcript data were subject to the qualitative data analysis techniques, thematic analysis and grounded theory, to explore relationship-centred care and subsequently conceptualise co-production service for the sector. Six latent dimensions of service were emergent, defined as: empathy, bespoke care, professional integrity, value for money, confident relationships, and accessibility. The dimensions strongly advocate wider sector adoption of a co-produced service, and a contextualised co-production framework is presented. Pragmatic challenges associated with integration of active veterinary clients in a practitioner–client partnership are evident. However, adopting a people-centric approach to veterinary services and partnerships with clients can confer the advantages of improved client satisfaction, enhanced treatment adherence and outcomes, and business sustainability.

214TF Advancing Communication Excellence at Stanford in Emergency Medicine Residency: A Curriculum for Interns

Effective communication is essential for patient safety and enhancing the patient experience in the Emergency Department. Effective communication also promotes efficiency in practice and a culture of wellness needed to attain professional fulfillment. Patient-centered care may conflict with physicians creating boundaries and their attempt to advocate for self-care and self-valuation in their roles as healers. With a strategic focus of developing a relationship-centered culture, the EM residency leadership, EM interns and the Physician Partnership Team in Patient Experience designed an innovative pilot using formative and summative evaluation to identify how best to deliver knowledge, and practice 3 relationship-centered communication (RCC) skills. A series of 4 workshops and individualized coaching observations were part of the design. We proposed a curriculum for EM interns focusing on relationship-centered care using the Advancing Communication Excellence at Stanford (ACES) initially designed for Stanford faculty. By teaching evidenced-based strategies on managing challenging interactions in the health care arena, we hope to provide our EM interns a curriculum to develop skills that will enhance the physician-patient relationship, while also addressing physician wellbeing. The primary objective was to learn how best to engage EM interns to learn and adopt the 3 foundational RCC ACES skills. The second objective was to design a reproducible EM RCC curriculum within the residency program based on time constraints and entry-level cognitive demands. Curricular Design: We developed a curriculum for EM interns, supplemented by individualized coaching and asynchronous learning using the flipped-classroom model. We used intern-driven scenarios and role-playing techniques to demonstrate and emphasize key communication skills. We used online surveys and text-messages check-ins to assess the effectiveness and further iterate this learner-centered curriculum. The first 3 sessions included a reflection, a check-in, demonstration of a skillset and small group practice with an ACES coach. Bedside clinical EM coaching was scheduled with each intern between sessions 3 and 4. Session 4 integrated all 3 skills with a standardized patient. This session was video-recorded and coded in addition to the immediate feedback and debrief after each encounter. This will be used in the final individual coaching session. The ACES in EM Residency Curriculum is an effective way to teach communication skills that promote relationship-centered care. We have successfully integrated the RCC into the EM intern curriculum over 3 in-person, 60-90-minute workshop sessions and individualized clinical coaching. The impact will be assessed through a learner self-assessment and coaching assessment. We plan to scale this to the entire EM residency.

Caring for older people with dementia in the emergency department.

Admission to an emergency department (ED) may expose the older person with dementia to a range of negative consequences, including a deterioration in their behavioural symptoms. The authors conducted a review of primary research relating to the experiences of older people with dementia, their carers and ED nurses, to understand how these experiences might inform nursing practice. Integrative review with a search of the electronic databases of Medline, CINAHL and PSYCHINFO using specified inclusion and exclusion criteria. Three themes were identified: carers and older people with dementia-waiting and worrying; nurses juggling priorities; and strategies for improvement-taking a partnership approach. Older people with dementia may be exposed to disparities in treatment in the ED. A practice partnership between carers and ED nurses may help to prevent this. ED nurses need support to blend technical- and relationship-centred care. Participatory research exploring the experiences of older people with dementia, their carers and ED nurses is needed.

The Rules of Engagement: Utilizing Improve to Build Relationship-Centered Care

The Rules of Engagement: Utilizing Improve to Build Relationship-Centered Care

The Rules of Engagement: UtilizIng improve to Build Relationship-Centered Care

During this unprecedented time of older adults (specifically those living with dementia) requiring services, caregiving and social opportunities amongst their places of residence (including long term care facilities, senior apartment buildings, supportive living spaces and within the community), it is imperative that we adjust our current model of care from “patient-centered” to “relationship-centered”.

Spotlight on the Clinician in the Life Participation Approach to Aphasia: Balancing Relationship-Centered Care and Professionalism

Background Speech-language pathologists make clinical decisions informed by evidence-based theory and “beliefs, values and emotional experiences” ( Hinckley, 2005 , p. 265). These subjective processes, while not extensively studied, underlie the workings of the therapeutic relationship and contribute to treatment outcomes. While speech-language pathologists do not routinely pay attention to subjective experiences of the therapeutic encounter, social workers do. Thus, the field of social work makes an invaluable contribution to the knowledge and skills of speech-language pathologists. Purpose This clinical focus article focuses on the clinician's contribution to the therapeutic relationship by surfacing elements of the underlying subjective processes. Method Vignettes were gathered from clinicians in two community aphasia programs informed by the principles of the Life Participation Approach to Aphasia. Results and Discussion By reflecting on and sharing aspects of clinical encounters, clinicians reveal subjective processing occurring beneath the surface. The vignettes shed light on the following clinical behaviors: listening to the client's “whole self,” having considerations around self-disclosure, dealing with biases, recognizing and surfacing clients' identities, and fostering hope. Speech-language pathologists are given little instruction on the importance of the therapeutic relationship, how to conceptualize this relationship, and how to balance this relationship with professionalism. Interprofessional collaboration with social workers provides a rich opportunity to learn ways to form and utilize the benefits of a strong therapeutic relationship while maintaining high standards of ethical behavior. Conclusion This clinical focus article provides speech-language pathologists with the “nuts and bolts” for considering elements of the therapeutic relationship. This is an area that is gaining traction in the field of speech-language pathology and warrants further investigation.