JHQ 138 - Development of Relationship-Centered Care

Jacqueline L. Wylie, MSN MA RN; Ellen Wagenfeld-Heintz, PhD
Keywords: Care, Consumer satisfaction, Management and leadership, Relationship centered, Research
January/February 2004

In 1992, the Pew Health Professions Commission and the Fetzer Institute, known collaboratively as the Pew-Fetzer Task Force on Advancing Psychosocial Health Education, launched a national initiative. The task force’s purpose was to set “…an agenda for encouraging development or expansion of educational programs that reflect an integrated biomedical-psychosocial perspective” (Tresolini & Pew-Fetzer Task Force, 1994, p. 8). The goal was “…the broadening of our understanding of how schools can help students learn and apply an integrated approach to healthcare” (p. 57–65). A result of the committee’s work was the Health professions education and relationship-centered care: Report of the Pew-Fetzer task force on advancing psychosocial education (Tresolini & Pew-Fetzer Task Force).

The Pew-Fetzer report stated, “The phrase ‘relationship-centered care’ captures the importance of the interaction among people as the foundation of any therapeutic or healing activity” (Tresolini & Pew-Fetzer Task Force, 1994, p. 10). Interactions within a person (i.e., reflection or self-talk) are considered equally important in the relationship-centered care (RCC) model. Being genuinely present for self and others goes beyond patient-centered practice, as previously described in the literature, to include patient-practitioner, practitioner-practitioner, practitioner-community, and a dimension of self-awareness often referred to as reflective-practitioner. The report categorized dimensions of relationship-centered care into knowledge, skills, and values to be utilized in teaching the RCC model (see Tables 1, 2, and 3). The dimensions included patient-practitioner, practitioner-community, and practitioner-practitioner. RCC was described as the basis for a new practitioner skill set, transforming the process of caring for all partners in healthcare. Mutuality and reciprocity are key elements in the interactive process that make the RCC model different. The purpose of the literature review was to determine which dimensions of relationship-centered care have been developed most and by which healthcare profession since the publication of the Pew-Fetzer report.

Articles for this review were generated by using the key words “relationship-centered care” for the years 1995–2001 in the following bibliographic databases: SocAbs, Article 1st, ECO, Medline, CINAHL, Wilson Select Plus, PerAbs, and PsychInfo. Twenty articles were found. In addition, a search for articles written by a physician proponent of RCC, Thomas Inui, was conducted. The reading list available on the Fetzer Institute’s Web site (www.fetzer.org/rcc) was also used as a source, as well as articles and a nursing textbook. A total of 47 articles and chapters were found. Actual numbers of physicians as first author was 22, with one contributing two works to the review. Actual numbers of nurses as first author was five, with one contributing three works.

Publications were read and sorted for the following criteria: (a) professional affiliation of the first authors (e.g., nurses, physicians, and others), (b) dimension of RCC, (c) citations from the Pew-Fetzer Task Force report, and (d) reference to activities of regional RCC networks affiliated with the Fetzer Institute. When the Pew-Fetzer Task Force report was not cited, the relationship model used was noted. These articles included only patient-practitioner relationship without consideration for the effect of mutuality and reciprocity.

Forty-seven published works were reviewed. The findings are summarized in Table 4. The three dimensions of RCC, patient-practitioner, community-practitioner, and practitioner-practitioner relationship, guided the analysis for the extent of the RCC model inclusion and development in current healthcare education and practice (Tresolini & Pew-Fetzer Task Force, 1994). The fourth dimension, self-awareness was added, as an area of conscious development needed prior to skill building in relationships with patients, other practitioners, and communities. Because of its importance in the transformation of relational process, self-awareness education is treated as a dimension for the analysis in Table 4, as it was in the Pew-Fetzer research project (C.P. Tresolini, personal communication, June 25, 2002).

The task force report or reports from regional, Fetzer Institute-affiliated, relationship-centered care networks were cited by 22 of the 47 publications (47%). Publications were further categorized according to article purpose: 26 (55%) of the works were scholarly essays; 9 (19%), research studies; 6 (13%), editorials; portions of 3 (6%), books; and 1 (2%) booklet on story sharing. Focus on curriculum was evident in 16 (34%) of the publications and is identified in the category column in Table 4.

First authors included 24 physicians, 7 registered nurses, and 14 others who are not identified as nurses or physicians but were professionals affiliated with medical schools, journalists included. Of the 24 physician publications, 7 (29%) cited the Pew-Fetzer Report. Seven nurse publications (100%) and 7 (58%) in the “other” category cited the report. The publication of the Second National Gathering of the Fetzer Institute (Fetzer Relationship-Centered Care Conference, 2000) describes the power of relationship-centered care by patients and healthcare professionals who were invited to share their stories at the stories gathering. The stories published in the booklet provide a glimpse into the power of relationship.

This category included publications that focus attention on one-on-one interaction, interviews with patients, and movement toward patient-led, patient-focused agendas. Thirty-four (79%) of the publications reviewed included a patient-centered focus, although 20 of the 34 did not cite the Pew-Fetzer Task Force (Table 4). Patient-centered agendas were the focus in most of these articles, or a movement toward patient control within the physician-interviewing process and away from physician-directed interviews. A self-awareness dimension was included in 3 of the 20 publications. Seventeen authors in this group did not include practitioner self-awareness and self-care as a necessary first step, or as a conscious activity in the practice or teaching of patient-practitioner relationship.

Eighteen (38%) of the articles reviewed included (a) attention to inner work; (b) listening to self-talk; (c) connecting one’s feelings, thoughts, and actions; and (d) the skills of small-group discussion and journaling to document self-discovery (Table 1). Three (6%) articles, including a self-awareness area, did not cite the Pew-Fetzer Task Force Report, although one of the authors, Remen (1998), was a member of the Pew-Fetzer Task Force (Tresolini & Pew-Fetzer Task Force, 1994).

In the review of the practitioner-practitioner dimension, the following question was posed: How do providers care for each other, within or across disciplines, and within the agencies in which they practice? Sixteen (34%) of the articles included discussion about practitioner-practitioner relationships, including notions about physician-physician interaction in works authored by physicians, whereas the nurses focused more on interdisciplinary efforts (see Table 4). This lower number may be attributed to the fact that intra- and interprofessional relationships have not been part of most prevailing curricula as evidenced in the Pew-Fetzer research project (Tresolini & Pew-Fetzer Task Force, 1994).

Interdisciplinary possibilities for practitioners to offer support and recognition for others’ expertise across professional domains were recognized in four of the seven works published by nurses (Walker, 1997, 1998; Interdisciplinary Health Education Panel of the National League for Nursing, 1998).

The dimension of practitioner-community relationship is the least cited of the 4 areas, with discussion in 11 of 47 (23%) articles (Table 4). The level of RCC development could be one possible explanation for this low number. Because this is the most complex dimension, it may be that this particular dimension cannot fully develop until the other dimensions are well in place. This finding may represent the developmental trajectory of the RCC model. The Pew-Fetzer research project recognized family and community medical practices for addressing this dimension more often (Tresolini & Pew-Fetzer Task Force, 1994).

The publications suggest a pattern of development for relationship-centered care that has continued to evolve since the publication of the Pew-Fetzer Task Force Report (Tresolini & Pew-Fetzer Task Force, 1994). There is evidence within this literature review that more nurses and physicians are leaning toward the notion of mutuality and reciprocity and relationship with self, others, and community that honors all persons. The report states, “Nursing…has long held as a central value the formation of caring relationships with patients. Relationships, however, have never become a defining force in health care” (p. 7).

The Pew-Fetzer Task Force findings encouraged patients and practitioners to join into a “transforming relational process” (Suchman, Bothelho, & Hinton-Walker, 1998). The past 6 years reflect that some professionals are reaching out to each other and their patients as partners to explore and learn more about the connection of quality care with the RCC skill set and how this relationship might become a more positive force in the development of a more effective healthcare system.

In addition to its initial purpose, this literature review supports the inclusion of the RCC model skill set into healthcare practitioner curricula and self-health management actions. Suchman et al. (1998) recognize that healthcare professionals must be part of a new order. Patients now have increased knowledge and power because of direct access to medical information on the Internet. Medical knowledge is no longer the domain of a sole profession (Toffler, 1990).

Suchman et al. (1998) note, “Sadly, the actual practice of partnership in healthcare is primitive at best” (p. 13). This review demonstrates the push by some healthcare professionals over the past 6 years to recognize the part that mutuality and reciprocity play with our inner selves, with others, and in our communities. The RCC model has the potential to affect quality systems.

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Author's Biography
Jacqueline L. Wylie is a nurse educator with graduate degrees in nursing science, adult health, and communications arts and sciences with a focus in interpersonal relationships. She has been on the coordinating committee of the Southwest Michigan Relationship-Centered Care Network since 1999.

Ellen Wagenfeld-Heintz is a postdoctoral fellow at the Institute of Gerontology, University of Michigan. Her work is supported by an institutional research training grant from the National Institute of Aging (T32 AG0014-19 “Multidisciplinary Research Training in Aging”). Her academic training is in sociology, psychology, holistic health, and family studies. She has been a member of the Southwest Michigan Relationship-Centered Care Network since June of 1999.

For more information on this article, contact Jaqueline L. Wylie by phone at 269/387-8158 or by e-mail at jacque line.wylie@wmich.edu.

Acknowledgements
The authors are grateful for Dr. Carol Tresolini’s comments, corrections, and clarifications in describing the historical process of the Pew-Fetzer Task Force and Research Project, the Fetzer Institute’s permission to reprint tables, and editorial comments from Dr. Joyce Thompson, Dr. Richard Frankel, Dr. Morton Wagenfeld, Dr. Katherine Matas, Dr. Judy Hoelscher, Dr. Linda Thede, Mickey Olivanti, Diane Heintz, Barbara Groh, and Hazel Starcher.

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Objectives
Journal for Healthcare Quality is pleased to offer the opportunity to earn continuing education (CE) credit to those who read this article and complete the form on page 60 of the January/February 2004 issue of JHQ or online. This continuing education offering, JHQ138, will provide one contact hour to those who complete it appropriately.

By participating in this independent study offering, the reader will be able to do the following:
1. Describe the four dimensions of relationship-centered care (RCC) according to the authors.
2. Explain the authors’ findings.
3. Justify the RCC as a developmental process.

Core CPHQ Examination Content Area
I. Management and Leadership