Strategies for Fostering the Therapeutic Alliance with Older Adults

Ashley Sanchez, SPT & Rachel Sledge, SPT

Background:

Our shared passion for geriatrics emerged while collaborating as partners on a business project for the “Managing Contemporary Practice” course. As we both demonstrated a shared professional interest in working with older adults, we proposed developing a geriatric specialty outpatient physical therapy (PT) clinic. During this project we further realized the need for healthcare practitioners, particularly PTs, to work with the growing geriatric population. In our clinical experiences, we both found that we enjoyed working with the older adult population; however, we noticed that not all clinicians felt that they were successful in connecting with their older adult patients. As we have progressed through the Doctor of Physical Therapy Program (DPT), we have continued to discuss our interest in a co-capstone project focused on older adults. In Fall 2020, we each created a Critically Appraised Topic as part of the “Evidence-Based Practice II” course, in which both of our papers consisted of current, evidence-based literature on the topic of establishing the therapeutic alliance between healthcare providers and older adults. From there, we collaborated to develop this capstone project which includes an evidence table of the best-available literature on establishing therapeutic alliances with older adults and a digital presentation of these findings with actionable strategies for therapists and clinical students.Through every aspect of this project, we have worked together to communicate with our capstone advisor and committee to achieve all necessary steps of the project to arrive at the culminating capstone website.

Ashley’s Background:

My passion for geriatrics began while observing a PT at a large continuing care retirement facility (CCRF) during my senior year of high school. Upon initial observation, I was enamored with the unquestionable impact that the PT had on the older adult patients in a wide variety of settings within the CCRF ranging from the skilled nursing unit to the memory care unit. After high school, my aspirations for pursuing PT as a profession continued through my decision to major in Kinesiology with plans of applying to DPT programs. While obtaining my Kinesiology degree, my interest for geriatric-specific PT further flourished as I continued to volunteer at the CCRF as well as other PT settings. During my time in college, my maternal grandfather was in the advanced stages of a diagnosis of Lewy Body Dementia. The opportunity to serve as one of my maternal grandfather’s primary caregivers during the advanced stages of his diagnosis truly reaffirmed my passions for working with the geriatric population. The experience further affirmed the need for healthcare practitioners engaging in collaborative relationships with older adults to optimize the quality of life and maximize the functional independence of the older adult. Across the past three years of the DPT program, my interest in working with older adults has continued to grow through academic endeavors and clinical experiences. While brainstorming ideas for a co-capstone project with Rachel, our idea for an educational presentation focused on strategies for fostering the therapeutic alliance with older adults fully came to fruition.

Rachel’s Background:

As an “only child of older parents” I have spent most of my life interacting with older adults. As my parents and their friends have aged, I have gained an appreciation for not only their many contributions to society but also their nuanced perspectives on health, aging, and ability. In my didactic and clinical learning experiences, I enjoyed the challenge of navigating the complexities of multi-morbidity and chronic condition management inherent to working with older adults. My interest in understanding patient-therapist relationships comes from working with a wide variety of healthcare providers as both a family member and clinical student in inpatient and outpatient settings. In my experience, some providers really enjoyed working with older adults and were able to communicate effectively to build connections and help the patient meet their health goals. Other providers found this population frustrating or difficult to connect with, leading to suboptimal outcomes. Given the growing population of older adults in the United States and their increasing need for PT services, I feel it is critical that all PTs have the skills to build effective partnerships with this patient population. Finally,I have observed a concerning trend within healthcare, particularly in PT, that views providers as interchangeable deliverers of interventions and disregards the importance of the personal connection between patient and therapist. Thus, my hope for this capstone project is to provide new graduate PTs and students with the tools to build therapeutic alliances with their older adult patients and to add support to the literature on the importance of high quality patient-provider relationships for improving patient outcomes.

Statement of Need:

Ranging from addressing orthopedic challenges in the outpatient setting to optimizing functional mobility in acute care and skilled nursing settings, PTs regularly work with older adults. On average across all settings, 40-43% of PT caseloads are patients aged sixty years and older. 1,2,3,4 Older adults equate to nearly half of a full caseload, and these numbers are projected to increase due to growth of the geriatric population in the United States. 1–4

Although healthcare disciplines have advanced, providers continue to lack interest for utilizing their achievements to serve the older adult population. Despite the need for healthcare professionals in geriatrics, research notes many providers prefer younger individuals with acute, cureable conditions versus older adults with conditions requiring long-term management. 5–8

As these preferences can negatively impact patient-centered care, this capstone project will provide students and clinicians with strategies for fostering a therapeutic alliance with older adults. Therapeutic alliances foster positive patient outcomes, such as improved behavior change and long-term compliance. 9,10 Furthermore, therapeutic alliances are associated with “better quality of life, high perceived quality of care, and greater satisfaction support” 11–13. Thus, it is critical that physical therapists understand how to improve therapeutic alliances with their older adult patients to provide more efficacious care.

Purpose:

Upon becoming licensed physical therapists, shared professional goals entail working with older adults. Rachel plans to work in the outpatient setting mainly with vestibular, balance, and orthopedic disorders. Ashley plans to work in the acute care or skilled nursing settings, in which her interests involve generalized deconditioning, cognitive impairment and delirium, and balance disorders. After working with older adults on previous clinical rotations, Rachel and Ashley are both passionate about providing high-quality care to this underserved population. Despite increased education and training on working with diverse patient populations, generational differences among older adults and younger providers persist and can have detrimental impacts on the quality of care. Our goal with this capstone project is to provide evidence-based, actionable strategies through a digital presentation and evidence table to help clinicians and PT students improve their communication skills with older adults to foster a positive therapeutic alliance.

Products:

Evidence Table: We have created an extensive evidence table that consists of twenty-four peer-reviewed articles that focus on strategies for fostering the therapeutic alliance for the overall goal of prioritizing person-centered care. The evidence table initially presents with an abbreviation table and working definitions for therapeutic alliance, therapeutic relationship, and person-centered care. From there, the evidence table is subcategorized into articles that focus on therapeutic alliances in the general health care, outpatient PT, and inpatient PT populations. The evidence table concludes with articles relating therapeutic alliances and their impact on person-centered care. Across all articles included on the evidence table, there is emphasis on the article’s purpose, study design, subjects, outcome measures and measurement time, description of interventions, results, conclusion, and other pertinent takeaways. Additionally, we have clarified whether the article primarily focuses on the therapeutic alliance with a generalized patient population or was specifically studied in older adults. This clarification is listed in bold under the article’s information including primary publication author, title, and date.

VoiceThread Presentation:  We have summarized those findings into relatable and actionable strategies for healthcare practitioners to incorporate into everyday clinical practice through a self-paced VoiceThread presentation. The total time for the presentation is just under 30 minutes, making it an ideal length as a module on communication strategies within a geriatrics course or as a continuing education “lunch and learn” presentation. The presentation is organized around three main concepts of establishing an affective bond, creating partnerships in care, and educating for self-efficacy that contribute to the overall framework of fostering the therapeutic alliance.

PDF of Evidence Table: Final Draft of Evidence Table PDF_Sledge&Sanchez

Link to VoiceThread: https://unc.voicethread.com/share/17430262/

Evaluation:

We developed this presentation with the target audience of DPT students and new-grad clinicians who work with older adult patients. The goal was to present the best-available research on establishing therapeutic alliances specifically with older adults and actionable strategies to incorporate the findings into clinical practice. The presentation is digital recording so that it can be easily distributed for future “lunch and learn” continuing education presentations or be included as a module in a geriatrics or clinical education course. The nature of this presentation requires the learner to engage in self-reflection on their communication style and quality of their patient-provider relationships. For our pre-presentation survey, we created a digital version of the Working Alliance Inventory-Short Form by Paap and Dijkstra14 as this outcome measure prompts the learner to reflect on the quality of their relationships with patients. As this presentation is focused on older adults, we specifically ask the learner to reflect on their “most recent encounter with an older adult patient.” The survey can be found here: https://forms.gle/NZFdk8rky7xHJfLVA.

In order to obtain feedback on our presentation, we included a modified version of the UNC DPT Teacher/Scholar Presentation Evaluation form as an online survey link at the end of the presentation. We have converted this document into a Google Form so that participants can send feedback to us digitally as this presentation is an online resource. The form can be accessed here: https://forms.gle/v4FzBP2oTnErZjw58. We will use the feedback obtained through the survey to update or modify the presentation as needed.

Self-Assessment:

Ashley’s Self-Assessment:

Throughout the length of this capstone project, I have significantly expanded my knowledge base and appreciation for the indispensability of the therapeutic alliance between healthcare practitioners, particularly PTs, and older adults. Despite having a well-established passion and interest for working with the geriatric population, this project continuously encouraged me to step outside of my comfort zone to determine what approaches and/or components were necessary for optimizing the collaborative relationship between healthcare practitioners and older adults. While researching the evidence-based literature on the therapeutic alliance, I was challenged to initially discover applicable articles in an efficient manner followed by purposefully analyzing those articles for the purpose of the evidence table. This process instilled in me the importance of demonstrating unwavering integrity, persistence, and determination for utilizing the best evidence while being devoid of bias. Apart from being challenged while reviewing and analyzing the evidence-based literature, I was further challenged by engaging in the opportunity to create an enticing yet purposeful presentation that translated the evidence-based findings into actionable strategies. The process of creating a multimedia VoiceThread presentation was challenging, as I am not inherently technologically savvy; however, I exuded continued patience and perseverance through this challenging process. Despite the continuous challenges during the length of this capstone project, I remained wholeheartedly motivated with the considerations of how critical this educational topic is for all healthcare practitioners. Overall, this project has truly helped me evolve as a DPT student and soon-to-be PT, and I am thankful for that.

Rachel’s Self-Assessment:

This capstone project has been an incredibly challenging yet rewarding learning experience. During my DPT education, educators often emphasized the importance of “developing a rapport” and building trusting alliances with patients to improve clinical outcomes. While this seems like good advice, I was often frustrated by the lack of information on specific strategies clinicians should use to develop this relationship. Unlike other personal relationships where there is requisite mutual connection, health care providers are tasked with forming trusting and caring partnerships with patients they have just met and may have little in common. In my clinical experiences, I observed how the lack of high-quality patient-provider relationships lead to patient mistrust of the medical system, provider burnout and frustration, and suboptimal outcomes. I also witnessed many examples of positive therapeutic alliances between patients and providers that improved outcomes and established a long-term care partnership. These providers also seemed to have lower rates of burnout and appeared to have more satisfaction from their work. I wanted to know- what specifically did these providers do differently to create high-quality connections?

To start answering this question, I completed a Critically Appraised Topic on strategies for fostering the therapeutic alliance with older adults in the outpatient setting which evolved into this capstone project. Given the nature of the research question, I had to learn how to search, evaluate, and synthesize qualitative research. Previously, I had only worked with quantitative research, exposing me to a new body of allied health literature. While our focus was on therapeutic alliances within the context of PT, our capstone committee included experts from the fields of social work, occupational therapy, and physical therapy who encouraged us to search the literature beyond our field. I was surprised to learn that what is considered a relatively new concept within PT is well conceptualized in other disciplines. Thus, this experience reinforced the importance of collaborating with and learning across disciplines.

Overall, this capstone experience was an enriching learning opportunity to work with a wide variety of literature across disciplines, evaluate my own biases and communication strategies, and develop an engaging presentation suitable for clinicians and students. It was a joy to collaborate with my friend and colleague who shares my excitement for working with this patient population.

Acknowledgements:

To Dr. Deborah Thorpe, PT, PhD, thank you for your continued patience and assistance while serving as our shared capstone advisor. We truly appreciate your commitment to believing in this topic and for sharing our vision in why this topic is so important for students and new clinicians.

To Dr. Jane DeLoach, PT, DPT, GCS, CEEAA, CAPS, thank you for your support and guidance while serving as one of our capstone committee members. We genuinely appreciate your prompt, positive, and constructive feedback throughout the entirety of the capstone project. It was so helpful to have your perspective as an expert in working with older adults and as an educator.

To Denisé Dews, MSW, thank you for your continued patience and assistance while serving as one of our capstone committee members. We greatly appreciate your assistance throughout the capstone project, since you served as our expert for providing unique and meaningful feedback on connection and communicating with patients through your lens as a social worker.

To Dr. Jennifer Womack, PhD, MA, OTR/L, SCDCM, thank you for your thoughtful feedback and assistance while serving as one of our capstone committee members. One of our goals for this project was to understand how other health disciplines study and foster therapeutic alliances and your contributions from the occupational therapy literature helped broaden our perspective and enriched our presentation.

To Dr. Tiffany Shubert PT, PhD, thank you for your early feedback and encouragement to pursue this topic while the project was in its initial idea stage and for connecting us to our committee members.

References:

Bibliography

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