Paper 1. Literature Review for Journal of HV [4,000 words plus refs.] First of a series 5 papers for the Journal.

Title: Investigating the Parent/Health Visitor Relationship: Can it be measured?

Abstract

Health Visitors allege that positive parent/HV relationships are essential for positive outcomes for families.  Within psychotherapy and other helping relationships, researchers have developed measures of the therapeutic relationship to prove that the relationship with the therapist is indeed linked to positive outcomes.  However, within health visiting no such tools exist.  This paper explores the reasons why tools used in psychotherapy and other helping relationships may not be suitable for measuring parent/HV relationships, presenting a review of a number of the measures used and argues the need for a parent/HV relationship specific tool.

Key Words

Parent/health visitor relationship, psychotherapy, theories of helping relationships, measures

Introduction: This article is the first in a series of five papers that explore parent/HV relationships with a view to developing measures suitable for research and practice. It gives a summary of existing theories of helping relationships including that of the parent/HV relationship and explains why existing relationship measures from other professions may not be applicable as a valid instrument in health visiting research. The next two papers will consider the parent/HV relationship in more depth looking at each participant’s contribution. The fourth paper will consider the role of organisations in supporting practice that takes a relational stance. The final paper will present the instruments that were developed and consider applications of their use.

The helping relationship has been the subject of intense scrutiny in other helping professions, particularly psychotherapy where research has shown that it is crucial to positive outcomes for the client. Although health visitors assert that their relationships with parents are also of paramount importance to outcomes no tools to measure these relationships existed prior to this study. It is, therefore, difficult to defend working practices that enable positive relationships to develop or to demonstrate their impact on parents or children.

More recently the Institute of Health Visiting [iHV] in association with Health Education England published education standards for health visiting practice (Bishop, Gilroy, & Stirling 2015) in which a standard was set for health visitors to work therapeutically to effect change with children and families. This standard acknowledges the need for health visitors to develop skills in making relationships with parents and children and suggests that they receive feedback from service users in relation to the quality of the therapeutic relationship experienced or

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outcomes achieved. It also goes on to suggest measurement of these using validated tools.

The aim of the doctoral thesis from which these papers are derived was to investigate the possibility of developing and validating a tool that would measure the parent/HV relationship. The first step in this process was to establish the need for such a measure specific to parent/HV relationships. This will be the subject of this paper. Subsequent papers will explain aspects of developing and validating the new measure.

Background: Theoretical considerations of the helping relationship

Because helping relationships in other professions, especially psychotherapy, have already been examined in great detail they were the subject of a literature review in order to understand these in more depth, in the hope that they might shed light on the parent/health visitor relationship. It may also have been the case that tools developed in these other helping professions may have been useful in the quest for a of measure parent/health visitor relationships.

The notion that the helping relationship itself might be therapeutic developed from the time of Freud, the founding father of psychoanalysis. However, early behaviour therapists emphasised the importance of techniques rather than the relationship to change behaviour (Horvath 2000). Essentially it was the work of Carl Rogers (1959) that took the theory of therapeutic relationships one step further than either Freud or the early behaviour therapists. He asserted that the relationship itself was sufficient for therapeutic change advocating the necessary conditions of unconditional positive regard, empathy and congruence. This client-centred approach was the first that implied that it was the therapist alone who needed to be responsible for providing the conditions necessary for the client’s growth and development (Horvath 2000). The theory gave rise to research that has shown that the therapist-offered relationship is indeed the major means by which clients are helped. A positive relationship is correlated with positive outcomes. However, one of the most interesting outcomes of the research is the fact that it is the client’s subjective evaluation of the relationship rather than the therapist’s actual behaviour that has the most impact on the outcome of therapy. It is not the objectively measured congruence, empathy and unconditional positive regard that have the most powerful impact on therapy but the client’s perception of these qualities that is key to the positive outcomes of the helping process (Horvath 2000).

Moving on in the sixties and seventies, (Greenson 1963) and (Bordin 1979) worked on the concept of the ‘working alliance’. Unlike Rogers (1959) they emphasised agreements and collaboration between the therapist and client so that the responsibility for the relationship became two-way (Horvath 2000). It was also understood that the concept was generalisable across all helping relationships. This construct gave rise to the development of tools to measure the bond, tasks and goals of therapy. The subsequent research demonstrated that the strength of the

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relationship that is created between the professional and the client is associated with positive outcomes across a number of therapies, and is a robust predictor of therapy outcome (Horvath 2000; Martin, Garske, & Davis 2000). However, it was not so much the relationship itself that was therapeutic but the ‘working alliance’ that made it possible for the client to co-operate in therapy and follow the treatment plan (Bordin 1979).

A Conceptual Map of Therapist Client Relationships.

The collaborative or partnership model has been found in research to be associated with positive outcomes in other professions in the community, in psychiatry and in general medical practice (Little et al. 2001; Priebe & Gruyters 1999). The more paternalistic, expert and consumer models, however have been shown to correlate with negative outcomes such as non-compliance and early drop-out rate in psychiatry and medical practice (Britten et al. 2000; Geller, Astachan, & Flynn 1976).

Theories of the therapeutic relationship have been helpfully synthesised by Cahill et al. ( 2008) who reviewed eighty-three therapist-patient measures of relationship and were able, as a result, to build a conceptual map of therapist/patient interactions. They identified three developmental processes necessary for the provision of an effective therapeutic relationship: ‘establishing a relationship’, ‘developing a relationship’ and ‘maintaining a relationship’. They were able to identify the processes and objectives of each phase of the relationship. However, it is not certain that this model translates into the health visiting context. In psychotherapy the relationship is predicated on continuity of care by one therapist over a number of sessions whereas HVs working in the community may only see a parent on one occasion. That visit may, however, be all important for the further uptake of services should they become necessary, and is dependent upon the HV being able to establish a relationship with the parent very quickly. The HV may not be working with the parent to address a particular problem as the visit may be purely promotional and preventive. The relationship is not in these circumstances ‘therapeutic’ in the sense that it is not being used intentionally as a vehicle of treatment for a particular relational problem. The question arises therefore, as to what constitutes an effective relationship for these purposes. At present this remains relatively unknown and there has, consequently, been little attempt at measuring this elusive concept.

Measures developed in psychotherapy were relevant to the particular theoretical concept of relationship from which they were derived. Given all the factors noted above, a theoretical understanding of parent/HV relationships was therefore considered to be important to instrument development.

[Insert Figure 1 Conceptual Map of the Therapist/Client Relationship [based on Cahill et al. 2008] here.]

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Theories of Parent/HV Relationships

During the 1990s there were a number of qualitative studies that explored the HV/client relationship (Chalmers & Luker 1991; Collinson & Cowley 1998; De La Cuesta 1994). A review of these and other qualitative studies resulted in a definition of the parent/HV relationship as a:

‘respectful, negotiated way of working that enables choice, participation and equity, within an honest, trusting relationship that is based in empathy, support and reciprocity. It is best established within a model of health visiting that recognises partnership as a central notion. It requires a high level of interpersonal qualities and communication skills in staff who are, themselves, supported through a system of clinical supervision that operates within the same framework of partnership’, (Bidmead & Cowley 2005) p.207).

In a literature review of partnership working in health visiting Bidmead and Cowley ( 2008) suggested that the closest theory that the health visiting profession has to a theory of their working relationships may be found in the Family Partnership Model [FPM] (Davis & Day 2010).

[Insert Figure 2 here. The Family Partnership Model.]

Briefly, this model specifies a set of overarching outcomes to be achieved [e.g. to do no harm, to enable parents] and provides a framework for the process of helping as a set of tasks. These include, the building of an effective relationship, exploring issues from the family’s perspective, developing a clear understanding of the problems experienced, agreeing aims/goals, planning strategies, supporting their implementation and reviewing outcomes.

The nature of an effective relationship is made explicit as a partnership, which involves working closely together, sharing power, using their mutual expertise, showing each other respect, clear communication, and negotiation of differences, searching for agreement on all aspects of the work together. Within the model, helper qualities are also defined to enable the development of this working partnership [i.e. respect, empathy, genuineness, personal integrity, humility and quiet enthusiasm] and the skills to implement these [e.g. active listening, focused attending, empathic responding, the skills of exploring and the skills of challenging]. Finally the model provides an understanding of how people adapt to their situations based on the framework of personal construct theory (Kelly 1955).

Many HVs have been trained in this model, which brings a clarity to the elusive concept of parent/HV relationships that is helpful. Indeed, the approach is advocated in the Healthy Child Programme (Department of Health 2009).

Central to the Family Partnership approach is the helping process, which has been conceptualised simply in Figure 3.

[Insert Figure 3 here. The Helping Process.]

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For the sake of simplicity, and an understanding of the processes, the qualities and skills of the practitioner have been omitted in this representation of what occurs. The conceptual map of the therapeutic relationship [ ], on the other hand, includes these as part of the process, which includes the formation, development and maintenance of the relationship. The difference between the therapeutic approach and the helping process illustrated in Figure therefore, is the expressed intent of the therapist to use the relationship itself as the instrument of treatment. Through it the client comes to know themselves and how they relate to others. In health visiting the relationship has a much more utilitarian objective; that of exploring, and identifying health needs and facilitating the enhancement of health, which may or may not mean that a therapeutic relationship is required.

On occasions HVs may be required to establish a purely therapeutic relationship. This is particularly apparent when a mother is suffering from postnatal depression or may have other mental health problems. This therapeutic relationship may also be necessary in order to help mothers and fathers recover from traumatic birth experiences or when a child is diagnosed with special educational needs or a serious medical condition.

As a HV may never know when she may need to be more therapeutic in her approach to parents it is therefore important that at all times she maintains a respectful approach and a listening ear. She or he needs to be able to demonstrate that they could be relied upon to support parents therapeutically if the need arose. The FPM training develops these skills in HVs and is a useful means of ensuring an effective relationship is formed with the parents.

The FPM approach to health visiting provided a useful starting point from which to develop of a theory of parent/HV relationships for the purposes of this study. It provided a helpful foundation from which to further explore health visiting practice and identify any similarities or dissimilarities.

Although there are differences between the therapeutic relationship with clients in mental health settings and the HV relationship with parents, the measures that exist within the former provided an informative area of exploration.

The psychotherapy research shows that the establishment of a positive relationship early on in therapy was particularly important to positive outcomes. This early relationship in therapy is based on the expectation of continuity of care from one therapist over the course of a few weeks [3-5 sessions]. HVs may not have the luxury of so many contacts with a parent and so they are obliged to try and establish this relationship as early and effectively as possible, often in just one visit.

Bachelor and Salame (2000) show that if the early relationship [3-5 sessions] is unsuccessful then there is more likely to be client drop-out and de-motivation to invest the necessary energy in the change processes required. There is also evidence in mental health services that not being listened to and lack of participation

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in the decision-making process as reasons for disengagement (Priebe et al. 2005). In medical practice too, when the relationship was not experienced as collaborative but as a paternalistic or expert relationship then this was associated with non-compliance and drop-out (Britten et al. 2000). If HVs are going to be effective in their practice then there is evidence from other professions that they need to be able to establish collaborative relationships with parents as quickly as possible.

Parents have contact with the health visiting service for the first five years of their child’s life. During this time many issues may arise concerning the child’s health, development, behaviour or the parents’ health that may require the intervention of the HV. Only if the parent feels comfortable within the relationship with the HV is she or he likely to contact her and work towards resolution of difficulties or problems.

The research evidence on the experience and training of the therapist in relation to the alliance is ambivalent. Horvath and Bedi (2002) discuss this point, quoting Dunkle and Friedlander (1996), who found no relationship between the experience of the therapist and the quality of the alliance and Bein et al. (2000), who found that there was partial support for such a relationship. They explain this by quoting another study (Kivlighan, Patton, & Foote 1998) which found that more experienced therapists were better at developing an alliance with clients who found establishing relationships difficult. Clients who did not find relationships difficult did not show any differences in the strength of their alliances with experienced or inexperienced therapists. This may have implications for health visiting practice with more complex families. An experienced HV may be more adept at forming effective relationships with them than those newly qualified. It was therefore felt to be appropriate to gather data during the study as to the HVs’ years of experience as well as field notes pertaining to the problems experienced by the family.

Because there is a plethora of different relationship measures already in existence it was important to consider these to assess their utility in measuring the parent/hv relationship.

Methods

A review of measures was carried out between 2006 and 2008 and updated in 2012 seeking to answer the question: What measures of helping relationships already exist that may be relevant to measuring the parent/HV relationship?

Search Strategy

A systematic search of the Cochrane Library, PsycINFO, EMBASE, Medline and CINAHL and Journals@ovidfulltext was carried out. All were searched for relevant studies. Based on a facet analysis [Table 1], identical free text, MESH terms where appropriate, and truncations, were used on the searches of the databases. Terms were combined in the population group using the Boolean operator ‘or’. The same procedure was performed to combine the intervention set of terms and again for the

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outcome terms. At this stage, the results were combined using the Boolean operator ‘and’ [Table 1]. Duplicates were removed and the results screened for appropriate items.

[Insert Table 1 Facet Analysis about here.]

Inclusion criteria

The following inclusion criteria were used for the review:

The study described the formation of a measure of a helping relationship

The study was a review of relationship measures

That the study correlated the relationship between the helping professional and client in relation to outcome.

The papers were in English.

That the measures of relationship could be retrieved or was published with the papers describing their development.

Papers that were published up to January 2008 [updated 2012]. The starting date was kept open in order to maintain a wide search but the oldest retrieved was from 1969.

The studies that provided information about the development of the measure of relationship or about its performance in research were the most helpful. Overall there were 24 of these [Table 2]. 180 other papers described the helping relationship in relation to outcome. These were saved and reviewed as useful background reading to the study. The search was supplemented with papers from the reference lists of included papers or reviews found.

Quality Assessment

Although many of the measures that were included had reported validity and reliability scores some did not but were included because they had face validity and were used in a community context.

Findings and Critical Appraisal

Over all 24 measures were retrieved but some are examined together here, as they were by the same authors [e.g. Penn Scales and Vanderbilt Scales]. This meant that 18 scales were examined and critically appraised with regard to their validity and reliability and suitability for use within the community health and parenting support services [Table 2]. An overview of the measures reviewed is presented in Table 2.

When the review was updated in 2012 the most significant publication identified using a similar search strategy was the Cahill et al (2008) review of 84 measures of

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relationship in mental health settings. They found that very few of the measures reviewed were developed in the UK; only five. Many more [86%] were developed in the USA whilst the remaining measures were developed in Canada, Australia and Germany. The majority of the measures were pan-theoretical, psychodynamic/psychoanalytic in orientation, were observer-rated and pertained to adult population groups. The review team recommend that future research in the UK be developed to assess the transferability of these measures. They also suggest that any development of future measures should relate to other theoretical perspectives and more diverse population groups and focus on the therapist and patient constructs.

Another measure was also identified in the updated review that had not been identified in the first review but was noted to be of possible significance. This was the Agnew Relationship Measure [ARM] (Agnew 1996; Agnew-Davies et al. 1998). A short form of this tool [12 items] was used in a study of parent/HV relationships when delivering a post-natal depression intervention (Morrell et al. 2009). This proved to be the most relevant tool reviewed.

The HVs in the intervention arm of the post-natal depression trial all received training in one of two psychological interventions, either person-centred counselling or cognitive behaviour therapy. The training included the development of warm, empathic relationships with mothers. There was emerging evidence that this ability of HVs to form these relationships was preventive of post-natal depression in women who screen negatively for post-natal depression and that this had an enduring effect (Brugha et al. 2010).

Although the ARM measures the therapeutic relationship, which is used as an intervention in post-natal depression it appears that, this ‘therapeutic relationship’ had a universal application in the prevention of post-natal depression. The ARM may therefore, be of use in measuring the parent/HV relationship at a universal level with HVs who do not have the trial specific preparation in establishing therapeutic relationships. However, this remains to be tested.

[Insert Table 2 Summary of review of measures about here.]

Outcomes and Discussion

The tools identified in the review have all been used where treatment is the goal of the intervention and not in promotional and preventative interventions, where parent contact may be of much shorter duration. This means that the HV has to be very skilled in making positive relationships over a much shorter length of time than that given to therapy, especially where the parent may only be seen briefly to introduce the service. Furthermore, based on this introduction only, the parent may then be expected to access services if problems arise, so the relationship needs to endure. If a positive relationship has not been formed at the beginning when services are introduced this is not likely to happen. The idea that the relationship itself may be

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part of the solution to a client’s difficulty is not generally recognised within primary health service organisations but only more explicitly in the referral services of child and adolescent and adult mental health.

When community HVs visit parents at home it is not unusual for others to be present. This may happen for a variety of reasons, not least because the client feels vulnerable and may feel supported by the presence of a friend or relative (Jack, DiCenso, & Lohfeld 2005). The tools developed within other professions do not consider this. The relationship has to be developed with whomever is present whether the parent alone, the child, and/or other friends, relatives or neighbours. This fact in itself might change how the relationship is established and needed to be taken into account with the development of the new measure.

The tools identified in this review measured the therapist/client relationship from one of three perspectives, that of the therapist, client or observer. As it was likely that each of these perspectives measured different facets of the relationship they were examined more closely to see if this, in fact was the case.

Method

In the computer programme, EXCEL, a database was constructed of all the measures reviewed. The items in the initial review were coded according to themes. The questionnaires were then colour coded to identify the three relationship perspectives, therapist, client and observer. A separate database was then constructed for each of these and a separate analysis undertaken.

Findings

The analysis revealed that observer tools had the potential to measure more components of the relationship than either of the other two perspectives. However, the observer measures were extremely detailed and time consuming to use and required skilled researchers to code the interactions thus making them unsuitable for use with parent/HV relationships.

Of the 24 measures retrieved there were eight shared factors between the therapist-rated, observer- rated and client-rated measures [Error: Reference source not found4]: working together- involvement, participation [19 measures]; agreed goals [12 measures]; mutual trust and respect [20 measures] ; empathy & helper understanding [21 measures]; hope, enthusiasm, motivation and commitment [20 measures]; client understanding of problems changed [12 measures]; interested [6 measures] and outcomes, progress, review [12 measures]. There was obvious interplay between the characteristics of the relationship i.e. working together and mutual trust and respect; the skills of the helper i.e. empathy, hope, enthusiasm etc. and the process of helping, i.e. client understanding of problems changed. It appears when measuring the relationship this cannot be divorced from the interaction, which underpins it. How the process of health visiting is accomplished

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will be as important to capture in a tool as this is the vehicle through which the relationship is established, developed and maintained.

[Insert Figure 4 Comparison of the Shared Facets of Relationship across Relationship Measures here.]

Conclusion

The in-depth analysis of the scales added clarity to the ways in which the construct under consideration, i.e. the helping relationship, had been measured. The clarity with which the construct is conceived is the key to the validity of the tool. Within the research the developers have used different theories of relationship depending upon their professional background to help them develop their understanding of the components that need to be measured when considering the helping relationship.

When developing indicators of the characteristics of the relationship or bond that HVs and their teams are aiming to establish, theories such as FPM present a good starting point.

The measures reviewed contain facets of the relationship that are the skills or qualities of the therapist e.g. supportive and warm, interested, listening, challenging, hope, enthusiasm and motivation and commitment, empathy and helper understanding, body language, technical knowledge, self-disclosure. Yet other facets of the measures present are distinct parts of the helping process e.g. exploration, clarification, agreed goals, problem management, outcome/progress and review [Figure ]. It appears that relationship formation and development cannot be separated from the process itself because it is the foundation of the work that is done.

It is the combination of the variety of concepts included that makes them measures of helping relationships. How the health visiting process is negotiated and the relational skills that HVs and parents use needed to be studied in more depth and were the subject of in depth qualitative research. This will be the topic of future papers in this series.

(4,070 words excluding tables, figures and refs.)

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Figure 1. Conceptual Map of the Therapist/Client Relationship [based on Cahill et al. 2008]

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Figure 2. The Family Partnership Model [FPM] (Davis & Day 2010)

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Figure 3. The Helping Process (Davis & Day 2010)

Population Intervention OutcomeTherapist or and Measure/s or and Relationship orPsychotherapist or Scale/s or Working alliance orPsychiatrist or Questionnaire or Helping alliance

orNurse or Inventory or Helping relationship or

Community nurse or Rating scale or Therapeutic alliance orHealth visitor or Instrument or Therapeutic bond orPublic health nurse or Tools Alliance or

Mental health nurse or Bond Community Mental health nurse or

Psychiatric nurse orSocial Worker orHelper orPhysician or

Doctor

Table 1. Facet analysis of search terms

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Measure Client Group Scale Description Validity & ReliabilityInpatient Treatment Alliance Scale [I-TAS] (Blais 2004)

Psychiatric inpatients

10 item scale developed from factor analysis of WAI, Penn Helping Alliance questionnaire & CALPAS.Items measure : Primary bond [3 items] Goals [4 items] Collaboration [3 items]

Strong psychometric qualities related to relevant outcome variables.Strong internal consistencyAdequate test-retest reliability.

Client Reactions Systems (Hill et al. 1988)

Psycho-therapy clients

Uses a video-tape of the interaction & asks client to rate reactions at different points of the tape. Lists positive &negative reactions

Validity and reliability not reported

The Relationship Inventory [BLRI] (Barrett-Lennard 1986)

Person- centred psychotherapy clients

64 items rated by client questionnaire. Empathic understanding:Congruence; Positive regard:Unconditional regard

High internal consistency: Subscales highly inter-correlated.Highly correlated with WAI

The Therapeutic Bond Scales [TBS] (Saunders, Howard, & Orlinsky 1989)

Psycho-therapy clients

Measures the three dimensions of the therapeutic bond (Orlinsky & Howard 1986): Working alliance -15 items Empathic resonance –17 items Mutual affirmation - 18 itemsAlso a Global Bond Scale which is a composite of the above.Patients rate their experience during therapy on a 21-point scale.Developed specifically to measure patient experience.

Research support for reliability of scales (Saunders, Howard, & Orlinsky 1989).Internal reliability of each subscale:r = .72 to r = .87Internal reliability of Global Bond Scale r = .62Two scales failed to correlate.All three scales and the Global Bond Scale related to patient ratings of session quality [r = .34 to .60]Only Global bond scale related to observer ratings of termination outcome [r = .19]

The Working Alliance Inventory [WAI] (Horvath & Greenberg 1989)

Psycho-therapy clients

Measures three aspects of (Bordin 1979) alliance on a 7-point scale using 36 items:

Three versions: Patient Therapist Independent observer

Strong research support for reliability. High inter-rater reliability and internal consistency Reliability ranges from r = .85 to r = .93 (Horvath & Greenberg 1989) & Greenberg 1989)Highly correlated with CALPAS and VTASSubscales highly inter-correlated

Penn Scales (Alexander & Luborsky 1986)

Psycho-therapy clients

Rates the alliance from the patients’, therapists’ and observers’ perspectives. Based on the working alliance measuring:1. The patient’s experience of the therapist

as providing the help needed. 2. The patient’s experience of treatment as a process of working together with the therapist toward the goals of treatment. (Martin, Garske, & Davis 2000)

Moderate inter-rater reliability.68Test re-test reliability .55Overall reliability .74Internal Consistency - Cronbach’s alpha .91

The Parent Advisor Service Satisfaction Questionnaire (Davis & Spurr 1998)

Parents in the communityIn England

22 questions rated on four-point scale. Question 23 qualitative appraisal of service.8 items on how the Parent Adviser made the mother feel.7 items of parental perception of Parent Adviser3 items about the quality of the relationship with the Parent Adviser

No information about validity & reliability but has face and content validity.

California Psychotherapy Alliance Scale [CALPAS – P] [patient version] (Gaston 1991)

Psycho-therapy clients

24 items on a 7-point scale to measure four aspects of the alliance (Gaston 1991).1. Working Capacity Scale,2. Patient Commitment Scale3. Therapist Understanding and Involvement Scale4. Working Strategy Consensus Scale.

Adequate test-retest reliability and high inter-rater reliability.Two factors: alliance and therapist influence CALPAS-P highly correlated with the WAI-P and VTAS

Nurse Client Relationship Inventory (Barnard 1998)

Parents at home treated by nurses in USA

27 items rated on a 5 point scale No statistical information re validity & reliability. Face & content valid.

Helping Relationship Inventory for Social Work [client version] [HRI –C] (Poulin & Young 1997)

Social work clients 2 main components described as: Structural i.e. focus on goals and tasks -10 items rated on 5 point scale and Interpersonal i.e. focused on psychological bond between social worker and client – 10 items rated on 5 point scale.

Factor analysis described. Reliability of structural index alpha coefficient .91Reliability of interpersonal index alpha coefficient.96Overall 20 item alpha coefficient .96. Correlated with WAI .84 [p < 001]

Perception of Empathy Inpatients in Patient rated measurement of nurse’s empathy. Reliability – Cronbach’s alpha .94

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Inventory [PEI] (Wheeler 1990)

hospital concerning their nurses

33 items rated on a 4 point scale. Developed from BLRI

Item to item correlation alpha.94Content validity determined by 2 experts.Face validity determined by 4 patients. Construct validity determined by correlation with Spielberger State Anxiety Inventory. Significant relationship determined [r= .52, p = .008] Also Pearson Correlation for demographic variables.

Caring Professional Scale [CPS] (Swanson 2002)

Patients cared for by nurses

18 items rated on a 5 point scale Criterion validity established correlating with BLRI [r =.61, p < 0.001]Internal consistency Cronbach’s alpha .74 - .97

Vanderbilt Psychotherapy Process Scale [VPPS] (Gomes-Schwartz 1978)Vanderbilt negative interaction scale [VNIS]Vanderbilt Therapeutic Alliance Scale [VTAS] (Hartley & Strupp 1983)

Psychotherapy relationships

Clinical observers rate segment of therapy. 80 items were rated on a 5-point scale (O'Malley, Suh, & Strupp 1983)VNIS explores negative effects.VTAS developed specifically to measure alliance. Observer scale for segment of therapy each of the 44 items rated on 6 point scale. 14 patient items, 18 therapist items, 12 items of patient-therapist interaction

Internal consistency Cronbach’s alpha .91Inter-rater reliability .83Overall reliability .86

Relational Communication Scale for Observational Measurement of doctor patient interactions (Gallagher, Hartung, & Stanford 2001)

Doctors and their patientsin America

34 items covering 6 domains rated on a 7 point Likert scaleImmediacy/affectionSimilarity/depthReceptivity/trustComposureFormalityDominance

Internal consistency strong but not for DominanceInter-rater reliability for formality and dominance scalesConstruct validity not statistically significant for formality or dominance.

Scales for the assessment of interpersonal functioning (Carkhuff 1969)

Scales for Assessment of Interpersonal Functioning

Six scales:Empathic UnderstandingCommunication of respectFacilitative GenuinenessFacilitative Self-disclosurePersonally relevant concreteness of specificity of expressionConfrontation

Validated in extensive outcome research (Truax & Carkhuff 1967)r = .84 inter-rater correlation coefficient

The Medical Interaction Process System [MIPS] (Ford et al. 2000)

Doctors and their patients

Observation method for coding interaction processes includes non-verbal as well as verbal responses to assess micro and macro features of interaction. Patient codes and Doctor codes are analysed for mode, content, and affective global categories.

Inter-rater reliability first data set:Mode pts. 0.96, doctors 0.94Content, pts. 0.98, doctors 0.97Affective global categories pts. 0.96, doctors 0.94.Second data set:Mode pts. & doctors 0.88Content pts. 0.91 doctors 0.95Convergent validity correlated with RIAS [Roter interaction scale] coefficients exceed 0.50.

Caring Nurse-Patient Interaction Scale (Cossette et al. 2006)

Nurses Based (Watson 2002) theory of nurse-patient relationships. Measures:Humanistic CareRelational CareClinical Care, Comforting care

Reliability coefficients of humanistic care scale low 0.63-0.74, however for relational care 0.90 to 0.92.Validity: Factor analysis 0.94 = very high.

Helping Relationship Inventory for Social Work [worker version] (Poulin & Young 1997)

Social workers Two domains: structural index 10 items rated on 5 point scale and interpersonal index 10 items rated on 5 point scale.

Structural index –alpha coefficient .86Interpersonal index –alpha coefficient .91Combined 20 –item alpha coefficient .93Validity correlated with WAI .87 [p < .001]

Table 2. Summary of Review of Relationship Measures

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Figure 4. Comparison of the Shared Facets of Relationship across Relationship Measures

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