Effective nurse-patient relationships in mental health care: A systematic review of interventions to improve the therapeutic alliance
International Journal of Nursing Studies 102 (2020) 103490
Contents lists available at ScienceDirect
International Journal of Nursing Studies
j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / i j n s
Effective nurse–patient relationships in mental health care: A
systematic review of interventions to improve the therapeutic alliance
Samantha Hartley a , b , ∗, Jessica Raphael a , Karina Lovell c , Katherine Be
y a
a Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Sciences
Centre, University of Manchester, Manchester M139PL, United Kingdom
Pennine Care NHS Foundation Trust, Ashton-under-Lyne OL6 7SR, United Kingdom
c Division of Nursing, Midwifery and Social Work, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M139PL, United Kingdom
a r t i c l e i n f o
Article history:
Received 7 June 2019
Received in revised form 30 September
2019
Accepted 18 November 2019
Keywords:
Alliance
Intervention
Mental
Nurse
Patient
Psychiatric
Relationship
Therapeutic
a b s t r a c t
Background: Therapeutic alliance is a core part of the nursing role and key to the attainment of positive
outcomes for people utilising mental health care services. However, these relationships are sometimes
difficult to develop and sustain, and nursing staff would arguably benefit from evidence-based support to
foster more positive relationships.
Objectives: We aimed to collate and critique papers reporting on interventions targeted at improving the
nurse–patient therapeutic alliance in mental health care settings.
Design: Systematic literature review.
Data sources: The online databases of Excerpta Medica database (Embase), PsycINFO, Medical Literature
Analysis and Retrieval System Online (MEDLINE) and Cumulative Index of Nursing and Allied Health Lit-
erature (CINAHL) were searched, eligible full text paper references lists reviewed for additional works and
a forward citation search conducted.
Review methods: Original journal articles in English language were included where they reported on in-
terventions targeting the nurse–patient therapeutic relationship and included a measure of alliance. Data
were extracted using a pre-determined extraction form and inter-rater reliability evaluations were con-
ducted. Information pertaining to design, participants, interventions and findings was collated. The papers
were subject to quality assessment.
Results: Relatively few eligible papers ( n = 8) were identified, highlighting the limitations of the evidence
ase in this area. A range of interventions were tested, drawing on diverse theoretical and procedural
underpinnings. Only half of the studies reported statistically significant results and were largely weak in
methodological quality.
Conclusions: The evidence base for methods to support nursing staff to develop and maintain good thera-
peutic relationships is poor, despite this being a key aspect of the nursing role and a major contributor to
positive outcomes for service users. We reflect on why this might be and make specific recommendations
for the development of a stronger evidence base, with the hope that this paper serves as a catalyst for a
enewed research agenda into interventions that support good therapeutic relationships that serve both
staff and patients.
© 2019 The Authors. Published by Elsevier Ltd.
This is an open access article under the CC BY-NC-ND license.
( http:
creativecommons.org/licenses
y-nc-nd/4.0/ )
W
H
H
d
(
W
h
0
hat is already known about the topic?
• The therapeutic relationship between nursing staff and patients
in mental health care is key to positive outcomes.
∗ Co
esponding author at: Division of Psychology and Mental Health, School of
ealth Sciences, Faculty of Biology, Medicine and Health, Manchester Academic
ealth Sciences Centre, University of Manchester, Manchester M139PL, United King-
om.
E-mail addresses:
[email protected] ,
[email protected] S. Hartley).
ttps:
doi.org/10.1016/j.ijnurstu.2019.103490
020-7489/© 2019 The Authors. Published by Elsevier Ltd. This is an open access article u
• Therapeutic alliance is a multi-faceted concept that is valued by
patients while being difficult for staff to develop.
hat this paper adds
• Interventions targeting the therapeutic alliance were identified;
including training, psychological formulation, reflective groups,
consultation and shared activity.
• The review showed that none of these is as yet confirmed ef-
fective and that the methodological quality of the evidence base
at present is predominantly poor.
nder the CC BY-NC-ND license. ( http:
creativecommons.org/licenses
y-nc-nd/4.0/ )
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2 S. Hartley, J. Raphael and K. Lovell et al. / International Journal of Nursing Studies 102 (2020) 103490
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1. Introduction
Nursing staff are the core of the caring profession and central
to their role is the development of effective relationships with the
individuals they support ( Hoeve et al., 2014 ; Zugai et al., 2015 ).
In the United Kingdom, engaging meaningfully with patients
(rather than ‘doing to’) runs through the principles of the nursing
profession ( Royal College of Nursing, 2010 ); while in the United
States, the interpersonal relationship is seen as foundational to a
person-centred, recovery-oriented approach within mental health
nursing ( Kane, 2015 ). Internationally, the alliance features heavily
in the remit of European and Australasian nursing associations,
who highlight the need for human connection and the ability
to demonstrate effective therapeutic relationships ( Australian
College of Mental Health Nurses, 2018 ; World Health Organisation,
2003 ).
The nursing relationship has been conceptualised as ‘a sig-
nificant therapeutic interpersonal process [that] functions co-
operatively with other human processes that make health possible
for individuals and communities’ ( Peplau, 1988 , p. 16). This
therapeutic alliance—the relationship connecting professional
and service user—is between one human and another, with a
uniqueness of each dyad ( Forchuk, 1995 ), which therefore requires
enewed efforts at each new pairing. Nurses see the development
of the alliance as requiring a convergence of interpersonal pro-
fessional skills with personal life experience ( Scanlon, 2006 ) and
clients view it as life-sustaining in its ability to foster collaboration
and a sense of being understood ( O’Brien, 2001 ). The concept has
ecently enjoyed a renewed focus, with an emphasis on consumer-
models that encourage personal recovery assisted by therapeutic
alliance ( Zugai et al., 2015 ).
Therapeutic alliance has the greatest impact on treatment
outcomes for those with mental health difficulties, over and
above the specific mode or model of intervention that is provided
( Duncan et al., 2010 ; Martin et al., 20 0 0 ; Messer and Wampold,
2002 ; Priebe and McCabe, 2006 ; Wampold, 2001 ). Emerging
initially within the psychoanalytic discipline and later generalised
to multiple therapeutic contexts, the concept of alliance has been
defined as an agreement on goals, tasks and a therapeutic bond
etween therapist and client ( Bordin, 1979 ). The phenomena can
e measured using various tools from both the perspective of the
professional and service user, with important differences between
the two ( Bachelor and Salamé, 20 0 0 ; Fitzpatrick et al., 2005 ).
In an age of increasingly remote therapeutic interactions, the
alliance and concomitants of it are still seen as intrinsic to change,
whether therapy is facilitated by phone ( Mulligan et al., 2014 ),
online dialogue ( Cook and Doyle, 2002 ) or even fully-automated
chat-bot ( Fitzpatrick et al., 2017 ).
Traditionally, research has focused on understanding and
improving the alliance between therapist and client; as part of
one-to-one, psychotherapeutic interventions ( Lambert and Barley,
2001 ; Martin et al., 2000 ). In contrast to these direct therapy roles,
there are also staff members who adopt a care coordination role
or act as a key worker; assessing, engaging and organising care
with individuals ( Burns, 2004 ; Simpson, 2005 ; Thurston, 2003 ).
All of these roles inevitably involve the building and maintenance
of an effective alliance and therefore research has shifted to
include definitions and exploration of the relationship as built
within these guises ( Fa
elly et al., 2014 ; Kirsh and Tate, 2006 ),
where it remains co
elated with outcomes ( Cruz and Pincus,
20 02 ; Howgego et al., 20 03 ) and is developed in a range of
settings.
As part of secondary care community services, nursing staff
coordinate care and deliver
ief therapies, which despite (o
possibly because of) their short-term nature require the adept
uilding of alliance. People supported by secondary care services
e those experiencing severe mental health difficulties, often in
he context of challenging relational and social circumstances.
ere, nurses strive to develop mutuality, reciprocity, synchrony,
nd sense of belonging with their clients ( Spiers and Wood, 2010 )
nd clients value being known and related to as a person rathe
han service-recipient ( Shattell et al., 2007 ), requiring a skilful use
f the self ( O’Brien, 20 0 0 ). Service users value therapeutic rela-
ionships with care coordinators in community settings, and view
hese as central to recovery; over and above the role of specific
are plans ( Simpson et al., 2016 ). These complex processes are
endered difficult for staff members by burnout, struggles building
ngagement with patients and ineffective team-working ( Koekkoek
t al., 2011 ; Singh, 20 0 0 ), with the nature of organisational struc-
ures and roles limiting the care that nurses can provide ( Simpson,
005 ).
The therapeutic role of nursing staff in mental health care is
specially pertinent in settings such as inpatient wards, where
atients interact with nurses for the largest proportion of time
nd the relationship with them is cited as key to therapeutic
ogression ( Hopkins et al., 2009 ; McAndrew et al., 2014 ), with
perceived interplay between therapeutic relationships and the
uality of care ( Coffey et al., 2019 ) . Engagement in these challeng-
ng contexts requires a balance of approaches, the development
f personalised understanding and use of the self to facilitate
ecovery-oriented growth of the patient ( McAllister et al., 2019 ).
owever, how these specific competencies can be developed is not
ully elucidated in the literature or supported by service structures.
he alliance can be impeded by individual and organisational fac-
ors that leave it unseen and stifled in practice ( Pazargadi et al.,
015 ), with nurses left to negotiate contradictory and challenging
elational minefields ( Cleary et al., 2012 ).
Despite the potential value and best effort s, attempt s to
evelop strong nursing alliance in mental health care can be
ampered by challenging settings where its development is im-
eded ( McAndrew et al., 2014 ). Moreover, interactions between
ursing staff and patients are often not supported or guided by
he psychological theory of relationships; there is a substantial
heory-practice gap ( Cameron et al., 2005 ) that might leave both
taff and service users vulnerable to relational difficulties and
he consequent impact on wellbeing and outcomes. It seems that
ervices, patients and staff place value on the therapeutic alliance,
ts core attributes have been explored and conceptualised, and yet
heoretically-driven, evidenced systems that support its develop-
ent and maintenance are lacking. With this deficiency in targeted
upport, staff members increasingly report feeling burnt-out as a
esult of managing complex and emotionally difficult relationships
Holmqvist, and Jeanneau, 2006 ; Nathan et al., 2007 ). This could
ead to compassion sometimes waning when it is needed most
Lombardo, and Eyre, 2011 ; Ray et al., 2013 ) and staff retention
oving extremely difficult, with subsequent strategic priorities
o improve this in both the United Kingdom and internationally
Andrews, and Wan, 2009 ; European Commission, 2014 ; NHS,
019 ; Parliament of Australia, 2002 ).
There has been some tentative progress in supporting ef-
ective relationships, with indications that clinical supervision
an protect against staff burnout ( Edwards et al., 2006 ) and
sychologically-informed case discussions can enhance positive
eelings towards service users and reduce staff self-blame ( Be
y
t al., 2009 ). Team-based training to develop staff skills using
sychological models can even improve patient engagement with
he service ( Caruso et al., 2013 ). However, there is no compre-
ensive, critical summary of interventions that have specifically
argeted the element of treatment that we know is essential; the
herapeutic alliance, for the group who potentially has the ca-
acity and context to deliver compassionate, caring relationships;
urses.
S. Hartley, J. Raphael and K. Lovell et al. / International Journal of Nursing Studies 102 (2020) 103490 3
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. Aims
In conducting this review, we systematically collated and cri-
iqued studies reporting on interventions targeting the therapeutic
elationship between nursing staff and service users in mental
ealth settings. We aimed to answer some key questions; what
ntervention methods have been tested, in what clinical contexts
nd with which groups, what outcome measures were utilised,
hat effects were demonstrated and what was the quality of the
ethods used.
. Method
.1. Protocol and registration
The review protocol was pre-registered and is available online
ithin the international prospective register of systematic reviews
PROSPERO) under the registration number CRD42018111022.
.2. Criteria for inclusion
Papers were considered eligible for inclusion if they: were
ublished as an original, peer-reviewed journal article; written in
nglish; included an intervention aimed to improve the therapeu-
ic relationship between nursing staff and use
s of psychiatric o
ental health services; included analysis of the impact of the in-
ervention utilising a standardised measure of alliance. The review
ncludes studies from any mental health service context (such as
ommunity, inpatient), client groups of any age, with any mental
ealth diagnosis or need and interventions targeted at the rela-
ionship with either qualified or non-qualified nursing staff. Where
he staff group incorporated other disciplines, these findings were
till eligible if that included nurses in the overall sample.
.3. Search methods
The cu
ent review was conducted in accordance with the Pre-
e
ed Reporting Items for Systematic Reviews and Meta-Analyses
PRISMA) guidelines ( Moher et al., 2009 ). Search terms were gen-
ated through review of empirical and opinion pieces regarding
lliance and systematic review papers of alliance (for example,
lvins, and Green, 2008 ; Flückiger et al., 2012 ; Horvath, and
uborsky, 1993 ; Priebe, and McCabe, 2006 ; Zaitsoff et al., 2015 ),
coping literature searches and consultation with experts in the
eld. A systematic search of Excerpta Medica database (Embase),
sycINFO, Medical Literature Analysis and Retrieval System Online
MEDLINE) and Cumulative Index of Nursing and Allied Health Lit-
ature (CINAHL) databases was conducted on 05/07/18 and then
pdated on 04/04/19 using the following search strings: (nurse ∗
R nursing OR staff) AND (alliance OR relationship ∗) AND (mental
R psychiatry ∗) AND (improve ∗ OR interven ∗ OR change OR sup-
ort). The reference lists of eligible papers were also consulted fo
ny additional studies and a forward citation search undertaken.
.4. Data collection and analysis
All potentially eligible records were imported into Endnote
eference management software package (Version 8) and duplicate
eferences identified and deleted. One reviewer screened titles and
stracts for relevance, using the inclusion criteria set out above
nd alongside regular discussion with the research team. Anothe
ndependent reviewer blindly assessed 50% (randomly selected)
f the full texts against the inclusion criteria demonstrating 88%
greement, with any remaining disagreements resolved through
iscussion with the project team, resulting in full agreement.
ata extraction was guided by a pre-specified data extraction
heet detailing key features of the study: sample, setting, design,
ntervention, outcome measure, analysis, effect size, limitations.
uthors were contacted where effect size data was not available in
he original paper. The review used a na
ative synthesis approach,
hereby an attempt was made to go beyond a description of the
tudies to explore relationships within and between them ( Popay
t al., 2006 ).
.5. Assessment of methodological quality
In order to evaluate the methodological rigour of the studies in-
luded and therefore to inform the critical synthesis of the findings
oduced and subsequent recommendations, the papers were as-
essed using a standardised quality tool. There is a distinct lack of
ssessment tools that fulfil both the need to be demonstrably re-
iable and valid and also appropriate for use with a range of study
esigns. Based on a previous review of quality assessment tools
Deeks et al., 2003 ), the Effective Public Health Practice Project tool
Effective Public Health Practice Project, 1998 ) was selected as one
hat could offer valid ( Thomas et al., 2004 ), reliable ( Armijo-Olivo
t al., 2012 ) and flexible appraisal of varying study designs. All of
he eligible papers were assessed for quality by the first autho
nd blind second-rated, with 86% agreement demonstrated. Initial
atings from the first author were reviewed collaboratively with
he second rater and a decision was made to retain these scores.
. Results
.1. Flow of records
The flow of records through the review process can be seen in
ig. 1 , in line with the Prefe
ed Reporting Items for Systematic
eviews and Meta-Analyses guidelines ( Moher et al., 2009 ). The
earch resulted in a total of eight papers which met inclusion
iteria. These are summarised in Table 1 .
.2. Methodological quality
Table 1 provides the overall quality rating for each paper,
ased on the constituent ratings of the Effective Public Health
actice Project tool and its guideline procedure. Full details of the
atings are available from the first author. As is evident, six of the
ight studies were rated as weak methodologically. Be
y et al.
2016) was the only study that met ‘strong’ design criteria, while
oreno-Poyato et al. (2018) was deemed moderate. The studies
ere predominantly down-rated due to lack of randomised de-
igns, blinding, confounder control and full reporting of retention
nformation.
.3. Participant and settings
The eligible papers included interventions delivered in a range
f settings (inpatient and community services, acute, rehabilita-
ion), in a number of different countries (United Kingdom, Aus-
alia, Sweden, Spain, Netherlands) for individuals with a range of
onditions under the um
ella of severe mental health problems,
ncluding psychosis and difficulties associated with a diagnosis
f personality disorder. As per the inclusion criteria, all studies
argeted the relationship between mental health nursing staff and
ervice users, although there were a range of additional criteria.
he range of settings and participants is reflective of the variety of
oles and services within which the therapeutic alliance is fostered.
.4. Interventions
The interventions varied in scope, focus and theoretical un-
erpinning. Be
y et al. (2012 , 2016 ) drew on psychological
4 S. Hartley, J. Raphael and K. Lovell et al. / International Journal of Nursing Studies 102 (2020) 103490
Fig. 1. Flow of records
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formulation (allied mainly to a cognitive behavioural model)
to foster understanding of drivers for patients’ behaviour and
clinical presentation within staff group workshops. Carpente
et al. (2007) offered group training in psycho-social interventions
that included focus on specific models and also core values of
therapeutic engagement. Kellett et al. (2019) utilised a consultancy
model provided to pairs of staff members and service users, with
cognitive analytic therapy as the underlying approach. Molin
et al. (2018) focused on the structure of ward timetables, creating
space for time spent together between nursing staff and patients,
providing opportunity for joint activities and meaningful engage-
ment. The authors involved staff on each ward in the precise
implementation structure to provide a good fit to routine ward
activities and preferences. Moreno-Poyato et al. (2018) utilised
a participatory action research approach whereby the nurses
involved in the study generated intervention elements in a bid to
each best practice, which ultimately involved daily interactions
with individual patients, reflective groups for staff and study of
scientific texts as selected by staff. Stringer et al. (2015) adopted
a
oad-based collaborative care programme that consisted of
elements including understanding (via timeline work), structural
changes (teams, treatment plans), specific interventions (problem
solving) and psycho-education. The primary focus of Byrne and
Deane’s (2011) intervention was to improve medication adherence,
with the alliance targeted as a mediating variable, involving mod-
fying clinician beliefs about non-adherent patients that can pose
a
iers to the relationship and support for adherence.
.5. Outcome measurement
The majority of the studies ( Be
y et al., 2012 , 2016 ; Byrne
nd Deane, 2011 ; Kellett et al., 2019 ; Moreno-Poyato et al.,
018 ) utilised the Working Alliance Inventory (WAI; Horvath and
eenberg, 1989 ) as the primary alliance outcome, reflecting its
ominence in the literature, although only Be
y et al. (2016) and
ellett et al. (2019) used both the patient- and clinician-rated
ersion, with the rest opting for the latter only. Others ( Molin
t al., 2018 ; Stringer et al., 2015 ) used the Caring Professional Scale
Swanson, 20 0 0 ), as rated by service users and the scale to asses
herapeutic relationships (STAR; McGuire-Snieckus et al., 2007 ),
espectively. Carpenter et al. (2007) relied on a non-validated but
ser-defined outcome scale ( Barnes et al., 20 0 0 ), which included
umerous items relevant to the alliance; including involvement,
istening and understanding.
Four of the eight included studies reported no statistically
ignificant difference as a result of the intervention in terms of
ssessed therapeutic alliance ( Be
y et al., 2012 , 2016 ; Molin et al.,
018 ; Stringer et al., 2015 ). Molin et al. (2018) did not provide
ata to facilitate a more nuanced interpretation....