Does therapeutic alliance exist in team-based hospital settings? A qualitative study in complex continuing care

Therapeutic Alliance is a measurable construct reflecting patient-provider relationships. It is known to predict important healthcare outcomes in both the mental health and general medical contexts. However, it has not been validated in team-based healthcare settings, such as hospitals. Complex Continuing Care (CCC) is a chronic-care hospital setting that manages patients with significant multi-morbidity and extensive nursing care needs, beyond the capacity of long-term care. The combination of long lengths of stay and very large health-care teams make CCC an environment where patient-provider relationships are a prominent part of the healthcare experience. We sought therefore to explore therapeutic relationships in CCC, using a qualitative approach to determine whether patients experience team-based care as a collection of individual therapeutic relationships, for which alliance could be measured, or conversely whether they experience team-based care as a diffuse, team-based relationship to which individual therapeutic alliances as currently understood do not apply. To do so, we interviewed 16 CCC patients using a semi-structured format. Interviews were transcribed and analyzed via qualitative analysis. This analysis revealed that the predominant emphasis was upon 1:1 relationships with healthcare providers as most determinant of care experience, with little emphasis on diffuse or team-based relationships. This study shows that in a setting of high clinical complexity, despite care being delivered by a large team of multiple disciplines, the centrality of 1:1 relationships between patients and their clinicians was paramount, providing the first-ever qualitative evidence for the validity of therapeutic alliance in the team-based setting.