Kindness,Listening,and Connection: Patient and Clinician Key Requirements for Emotional Support in Chronic and Complex Care

Abstract

Emotional support for patients is critical for achieving person-centered care. However, the literature evidences an ongoing challenge in embedding emotional support within current health services. This study aimed to investigate the strategies to embed emotional support from the perspectives of patients and clinicians. This is an exploratory qualitative study that collected data through focus group discussions (FGDs) and interviews from 11 patients, 2 carers, and 7 clinicians in the multi-disciplinary care teams in an outpatient complex and chronic care setting in New South Wales, Australia. The FGDs and interviews were recorded, transcribed, and thematically analyzed. Three main themes emerged from the experience of both the patients and clinicians: (1) warmth and kindness, (2) deep listening, and (3) social connection in the process of treatment. Clinicians’ and patients’ shared experience of these themes was key to embed emotional support in care. Practical strategies including promoting shared understanding of emotional support, enhancing provider's capability to deliver emotional support, and building patient's networking opportunities in treatment processes were discussed to facilitate emotional support in patient care and health services.

Keywords

clinician–patient relationship communication organizational culture patient/relationship centered skills patient perspectives/narratives patient satisfaction trust

Introduction

Emotional support is recognized as an essential element in safe, high-quality patient and family centered care (1,2). Patient experience is positively enhanced when care encompasses both clinical and emotional aspects (3–6). Emotional support composes 3 components, including: a cognitive understanding of patient needs; an affective imagination of what the patient values; and an altruistic action to alleviate the patient's pain (7,8). A further inherent aspect of emotional support is narrative knowing (9). That is, shared understanding between the clinician and patient, regarding experience of the chronic disease and feelings such as helplessness and suffering (9). Additionally, there are other practices to facilitate emotional support such as active listening, empathetic communication, applying relevant therapeutic resources (7,10,11), and a trusting relationship (8).

Health organizations need to provide appropriate structures and processes for staff to deliver emotional support (12,13). To achieve this outcome requires integrating patient centric workplace culture and leadership (13,14), efficient use of resources (15), provision of staff education (16), and services knowledge and use of right model of care (11,17). While the requirement for effective emotional support is well established (7,18), the embedding of emotional support in treatment processes is an ongoing challenge for many services. Healthcare organizations should implement the suggestions to embed emotional support as this strategy would improve the patient experience, enhance the effectiveness of services, improve health professional working culture, and prevent the burnout of clinicians (5–7,12,13).

Emotional care is present in settings, such as psychiatry (19) and physiotherapy (20), but there are gaps in other services. Clinicians’ propensity to provide patients with emotional support is influenced by their experience of compassion in the organization (21) and availability of clinical supervision, which can be variable across service settings and professional groups. A further organizational constraining factor has been the focus on the task of treatment to patients rather than the quality of the therapeutic relationship with patients and ensuring emotional support is embedded in treatment delivery (22,23). Nevertheless, many clinicians value emotional care as it is a professional virtue (24) that contributes to their psychological vitality and wellbeing (21). Some experienced medical clinicians provide emotional support, whereas others assess that it is not their role to provide such care, or lack appropriate training to do so (25). Allied health team members, such as physiotherapists or social workers, are known to have acceptance and capacity to provide emotional support to patients with chronic disease (7,26,27). Overall, clinicians report diverse opinions and experience about how emotional support should be provided in clinical settings (25,28), including chronic and complex care (1,25,29,30).

The patient element of emotional support is best understood through the patient voice, as the perception of the care provided can be different between patients and clinicians (31). Patients, across chronic care settings, including COPD treatment programs (32), stroke (5), mental health (22), and cancer care (33), report emotional support as warm, personal, safe and being treated as a human being. Patients highly value clinicians who demonstrate emotional concern for them, including in rehabilitation and recovery phases (3,7,21).

How to effectively deliver emotional support deserves greater attention, particularly for patients with chronic and complex diseases. Patients with such conditions present with multi-morbidities, suffering from deteriorating quality of life and emotional wellbeing, and require individualized care plans (16,33–35). Understanding the challenges to providing emotional support in the patient journey is crucial for chronic and complex services to be able to: deliver person centered care (3,5–7); ensure the well-being of service providers (7,8); prevent staff burnout (12); and the ethical and value proposition of the health system (18). Hence, to address this important need and gap, the study aim is to investigate the strategies to embed emotional support in chronic and complex care settings.

Design and Methods

This research was conducted in outpatient services in a tertiary teaching hospital in Western Sydney, NSW, Australia, from May to August 2018. These services, conduct over one million outpatients and community visits each year, incorporating chronic and complex care, including geriatrics, rehabilitation, and chronic pain. Multidisciplinary teams, providing healthcare, include medical and rehabilitation specialists, physiotherapists, and social workers. The study used an exploratory-descriptive research design (36) with an inductive approach (37), using focus group discussions (FGD) and interviews (36,38). The team of researchers are experienced clinicians in the chronic and complex care services and academics in the discipline of health services management.

Participants, recruited across the 3 clinical areas comprised 2 cohorts: clinicians and patients with carers or relatives. Potential participants were made aware of the research by email, posters in the clinical area, or verbal invitation by staff. Patients were carefully selected by independent clinician colleagues. Qualitative research literature has drawn meaningful insights from the range of 5 to 25 research participants and the more experienced are the respondents, the lesser number of respondents would suffice (39,40). All the participants had substantial experience with patient care to answer the research question, hence, the recruited number of participants was deemed adequate for this study (41).

All those invited for the FGD, and interviews agreed to participate in person, in the setting of the outpatient services. All volunteered their time with no renumeration and provided written and verbal consent to participate in the study. Ethics approval was gained from a Human Research Ethics Committee in NSW. The clinicians participated in one group, and patients, families, or carers participated in either a group discussion or an interview. The inclusion criteria for patients were that they were currently attending the chronic and complex outpatient setting during the study period and were English speaking. The exclusion criteria were if the patients had an acute or chronic illness that would limit participation in the study and were a current patient of the first author. The inclusion criteria for carers and families were that they could speak English. The exclusion criteria for family and carers were that if they were a carer for a patient of the primary researcher. The inclusion criteria for clinicians were that if they were currently working at the chronic and complex outpatient service in the study.

The overarching research investigated the 6 patient centered-care domains (1), including: respect for patient preferences and values; emotional support; information; communication and education about treatment planning; involvement of family and friends throughout the care process; and, coordination of and access to care. This study focused on the domain of emotional support.

A study guide, used to direct interview and group discussions, comprised open ended questions; for example, “Could you tell me about the emotional care you received during treatment?.” Each activity which lasted between 30 and 60 minutes was recorded using an audio recorder and transcribed verbatim, with unique codes used to maintain anonymity, for example: R = patient in rehabilitation, P = patient from other setting, PT = physiotherapist, and D = doctor. Transcription was completed by the first author. Member checking was used with all transcripts offered to participants for review; but no amendments were suggested and made (42). Data analysis was conducted using thematic analysis (37). This step-by-step approach of thematic analysis includes 6 non-linear processes which included reading of the manuscripts using a reflective diary followed by coding, then the process of creating themes. The themes in this study related to the domain of emotional support in line with the research question that this paper is addressing. The themes represented the strongest ideas that consistently emerged across the data. The next process was reviewing the themes for authenticity, followed by defining themes. The last process was the drafting and revising the results. Members of the research team (first and second author) discussed the emerging codes and themes. The interim analysis was presented to and reviewed by the whole research team. Points and final phrasing were determined through collaborative discussion and agreement (43).

Results

There were 20 study participants, comprising approximately 60% patients, 10% carers, and 30% clinicians (Table 1). There were 3 overarching themes: warmth and kindness; deep listening; and social connection in the process of treatment. However, the associated subthemes for the patients and carers differed from those of the clinicians (Table 2).

Table 1.

Participant Details.

Participant group	Participant details	Number
Clinicians	Physiotherapists: 11 years’ experience average	4
	Geriatric Medical Specialist: 31 years’ experience	1
	Rehabilitation Medical Specialist: 30 years’ experience	1
	Social Worker: 10 years’ experience	1
Patients, family and carers	Patients: geriatric service (falls prevention program)	4
	Patients: rehabilitation service	5
	Patients : chronic pain service	2
	Family members or carers	2
Total		20

Table 2.

Overview of the 3 Themes and Associated Subthemes.

Themes	Subthemes patients and carers	Subthemes clinicians
Warmth and kindness	Personal attributes of staff Sense of being known Witnessing acts of kindness	Building trust Intention to create a positive therapeutic relationship
Deep listening	Importance of being listening to Listening facilitates engagement	Listening facilitates engagement Listen to the main complaint of the patient
Social connection in the process of treatment	Sharing lived experience of illness Making friendships	Strong social supports are important with chronic disease management

Warmth and Kindness

The first key theme was warmth and kindness. Patients explained this experience in three interrelated ways. Firstly, patients commented how the personal attributes of clinicians such as a friendly manner facilitated the therapeutic relationship. They described clinicians in friendly, engaging ways, including that the psychologist was “approachable” (P1) and the physiotherapy staff in the rehabilitation gym were “warm and personal” (P2). Secondly, it was the “sense of being known.” One patient stated that she developed, over a 2-year period, a close interpersonal connection with the treating physiotherapist who now “knew and cared for her” and that “they (the clinicians) sense when I am not ok” (R2). Another patient also stated that they too had become friends with their therapists during treatment (R1). Thirdly, patients witnessed staff extending acts of kindness to patients. Physiotherapy staff were observed in the hydrotherapy pool providing careful, attentive, intensive support to patients who had severe disabilities. This was illustrated by the comments: “Staff concentrated on the ones that needed the help” and “made sure we were all right” (P4).

Clinicians described warmth and kindness, as essential for recovery in care, and encompassed 2 elements. First, the necessity to build trust, and second, the intention to build a positive therapeutic relationship. Together they were considered key to emotional support and the foundation in the patient journey. A clinician stated the point “you need to build that trust and rapport first and then it [the therapy] is easy” (PT4). Kindness was a motivating factor for clinicians in supporting patients and building a therapeutic relationship, as reflected by: “I want to make a positive influence in their life” (PT1) and “I want the therapeutic relationship to be positive” (PT4). Another clinician talked about the need to persevere with patients whose mood was grumpy when they initially attended treatment. They explained how to use a warm and engaging manner to address barriers to therapeutic relationship, that is:

They’re the patients I really like to work with because it's a challenge for me and that where I get the positive kind of feedback or that feeling when you finally crack that really grumpy 94-year-old man that just doesn't want a bar of you. When you find something, you just see the change straight away, that's what I enjoy (PT2).

Deep Listening

The second key theme was deep listening. Patients explained this experience as follows: firstly, patients reported the importance of experiencing being listened to in the interaction with the clinicians. One patient summarized the positive experience as “(the) doctor really sat and listened” (PF1). Being heard assisted them to engage and participate in treatment. Patients reported that in most consultations, the clinicians were able to mindfully listen to them. Secondly, they explained that listening was important to develop trust within the therapeutic relationship motivating them to engage and adhere to the treatment plan, even when struggling physically or emotionally. One example of this was demonstrated when a patient said “they all listened. I was really impressed so I thought-yep-right well go with it” (PF1). Following this experience the patient enrolled in and completed a falls prevention program. Conversely, patients reported when, on occasion, the clinician was distracted and did not listen they felt distressed, irritated and there was a sense of emotional disconnection with the clinician.

Clinicians spoke about the necessity of listening to patients as the first step to engaging them in therapy and healing. They explained “listening is the basis of everything” (PT3) and “we listen to the patient … (because) …the patient wants to express how they feel” (PT1). There was consensus that an emotional connection must commence at the initial consultation. One doctor, reflecting the view of her colleagues, said her treatment methodology was to use “respectful engagement” involving the family, reporting: “… (I) talk to them (the patients), be respectful, and also then include the relatives into the conversations” (D1). Clinicians suggested practical ways to improve connection with patients and families, including asking about the patient's pets (PT2) or using humor to improve patient engagement, particularly when the patient seemed depressed (PT1). Additionally, the focus for clinicians was to discover what mattered to the patients by listening intently. Clinicians reported that successful treatment was achieved when they focused first on the patients concerns—be that social, pain or sleep issues—and then they undertook their assessments for cognition or functional ability. As one clinician explained: “(I) listened to the main complaint. They (the patients) may be coming to my clinic for cognitive impairment, but they say I’ve got a sore arm” (D1).

Social Connection in the Process of Treatment

Patients spoke about 2 elements facilitating the social connection in the treatment process. They first discussed how they valued the opportunity of sharing the lived experience of having a chronic illness with others. This social opportunity created by the treatment program—either at the physiotherapy gym, chronic pain service or the hydrotherapy pool—enabled conversations concerning the major challenges of having a chronic illness, thus, gaining and giving emotional support to each other. One patient from the chronic pain service explained this experience: “I’m surprised, because I haven't experienced that in the past, just talking to other people who have similar problems. I think that's really important” (P4). He suggested that there should be more group programs to manage chronic pain conditions to facilitate this peer support. The second element was that patients who attended the weekly physiotherapy program or the hydrotherapy pool reported that they formed new friendships. This was important to patients, because they were experiencing social isolation. A patient reflected on the physiotherapy rehabilitation gym at the hospital which she attended weekly stating “it's a supportive environment, I became friends with other patients here” and “it's a community environment” (R1). A confirmation of this theme of the social, emotional connection was noted at another rehabilitation venue as a patient reported “I met so many nice people at the hydrotherapy pool” and “once a month we go out and have coffee after we have been to the (hydrotherapy) pool” (P5).

The clinicians’ view confirmed that social supports were important for the patients, particularly with the geriatric population who live alone with chronic and complex illnesses. A clinician affirmed this idea explaining that “strong social supports and social networks were essential, so the patient is in a much better position to deal with ageing” (PT2). There was general agreement with this premise by the clinician FGD: they stated a positive dynamic became established; that is, patients who managed the chronic and complex disease in positive ways, had strong social connections, which led to better emotional wellbeing, enabling them to manage their health better.

Discussion

This study has established that in the setting of chronic and complex outpatient care, emotional support encompasses 3 elements: (1) warmth and kindness; (2) deep listening; and (3) social connection in the process of treatment. Additionally, the study makes a unique contribution in evidencing that a shared understanding of the experience of these 3 elements between the clinicians and patients is the key to embed emotional support in care. Hence, emotional support is simultaneously a simple, complex, and essential domain of person-centered care to support high quality patient health outcomes (7). “Warmth and kindness,” a key component of emotional care, is the clinician engaging the patient with warm interested personal interactions (11). Deep listening, which aligns with narrative knowing, is how the clinician develops an understanding of the individual's experience of their health issues and resultant physical, emotional, and psychological distresses (9). Together these actions facilitate a strong therapeutic relationship, a collaborative communication style between clinician and patient (44), and enhance adherence to treatment plans, and improved outcomes (9,45,46). A further, significant dimension to enhance the care process and outcomes was identified: social connection in the process of treatment. Patients sharing the lived experience of having a chronic illness, formed new friendships, gaining and providing emotional support. This activity is a highly effective strategy to drive improvements and aligns with the current practice of shared medical appointments (47). Patient networking is a psychosocial activity for managing chronic illness that can reduce isolation, promote shared understanding, and build resilience despite their health challenges (48). The flow on impact of social connection in treatment is increase in positive health outcomes for patients (49).

Implications

The findings of this study imply the need for 3 strategies to effectively embed emotional support in chronic and complex care. The first strategy is for the organization to promote shared understanding of emotional support between clinicians and patients. There is a lack of understanding of the necessity of emotional support by clinicians and education is required to ensure a common understanding exists (50). The education is a precondition for the practice of effective emotional support in an organization. This would include processes, for example, using patient feedback to develop shared understanding between patients and clinicians (50) and ensuring that an appointment has a consultation time of extended length to allow for in-depth communication between the clinician and the patient. The second strategy is for the health service to enhance the provider's capability for emotional support. This would include emotional support champions who are necessary to advocate, encourage, support, and guide colleagues to master this skill in practice (47). In addition, managers who encourage staff to bring the best of themselves to patient care are vital to join the team of champions to embed practice of emotional support as an organizational value (51,52). A final recommendation to support this strategy is clinician education for deep listening via organizational programs such as narrative supervision groups and Schwartz rounds, making uncaring behavior from staff burnout less likely (53,54). The third strategy is that networking opportunities during treatment, provided by not only clinicians but also via peer support, should be a norm for patients as it improves care outcomes and the patient experience. Health services, when possible, can combine the compassionate care provided by staff and facilitate connection between patients enabling a sharing of the lived experience of chronic illnesses (47).

Limitations

The study limitation is that it was based at one site, involving a modest number of participants. There was possibly unintended selection bias in the study due to the inclusion and exclusion criteria. If the study is replicated, then the inclusion of a randomized design would overcome this issue. Nevertheless, the research has provided a window into a challenging but important dimension of clinical practice. Further research is recommended in other locations, service types and different professions to continue emotional support knowledge and practice evidence development.

Conclusion

Emotional support, in chronic and complex settings, comprises warmth and kindness, deep listening and social connection during treatment. Emotional support is a challenging but essential component of the way healthcare services should, and can, be delivered. But, in practice, emotional support is recognized as a challenge for organizations and clinicians to implement and maintain. Systemic, multifocal, and comprehensive strategies that address the patient needs can embed emotional support and achieve enhanced clinical outcomes for patients and satisfying work for clinicians.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Ethical Approval

Approval was gained from the NBMLHD Human Research Ethics Committee, NSW.

ORCID iD

Jane Bradshaw

References

Care

P-C

. Improving quality and safety through partnerships with patients and consumers. Sydney, Australia: Australia Comm Saf Qual Healthcare. 2011:1.

Tzelepis

Sanson-Fisher

Zucca

, Fradgley

EA.

Measuring the quality of patient-centered care: why patient-reported measures are critical to reliable assessment. Patient Prefer Adherence. 2015;9:831-5. doi:10.2147/PPA.S81975

Han

Shiraz

Haldane

Koh

JJK

Quek

RYC

Ozdemir

, et al. Biopsychosocial experiences and coping strategies of elderly ESRD patients: a qualitative study to inform the development of more holistic and person-centred health services in Singapore. BMC Public Health. 2019;19, Original Paper. doi: 10.1186/s12889-019-7433-6.1–13.

Allen

Scarinci

Hickson

. The nature of patient- and family-centred care for young adults living with chronic disease and their family members: a systematic review. Int J Integr Care. 2018;18(2):14-14. doi:10.5334/ijic.3110

Northcott

Hilari

. “I’ve got somebody there, someone cares”: what support is most valued following a stroke? Disabil Rehabil. 2018;40(20):2439-48. doi:10.1080/09638288.2017.1337242

Rathert

Williams

McCaughey

Isqaidef

Patient perceptions of patient-centred care: empirical test of a theoretical model. Health Expect. 2015;18(2):199-209. Article. doi:10.1111/hex.12020

Bivins

Tierney

Seers

. Compassionate care: not easy, not free, not only nurses. BMJ Quality Saf 2017; 26(12):1023. doi:10.1136/bmjqs-2017-007005

Sharp

McAllister

Broadbent

. The vital blend of clinical competence and compassion: how patients experience person-centred care. Contemp Nurse. 2016;52(2-3):300-12. 2015/06/17. doi:10.1080/10376178.2015.1020981

Buckley

McCormack

Ryan

. Working in a storied way—narrative-based approaches to person-centred care and practice development in older adult residential care settings. J Clin Nurs. 2018;27(5-6):e858-72. doi:10.1111/jocn.14201

10.

Babaei

Taleghani

. Compassionate care challenges and barriers in clinical nurses: a qualitative study. Iran J Nurs Midwifery Res. 2019;24(213).

11.

Dean

Street

Jr . A 3-stage model of patient-centered communication for addressing cancer patients’ emotional distress. Patient Educ Couns. 2014;94(2):143-8. doi:10.1016/j.pec.2013.09.025

12.

Heath

Sommerfield

von Ungern-Sternberg

. Resilience strategies to manage psychological distress among healthcare workers during the COVID-19 pandemic: a narrative review. Anaesthesia 2020;75(10):1364-71. doi:10.1111/anae.15180

13.

Santana

Manalili

Jolley

Zelinsky

Quan

How to practice person-centred care: a conceptual framework. Health Expect. 2018;21(2):429-40. doi:10.1111/hex.12640

14.

Vogus

Gallan

Rathert

El-Manstrly

Strong

Whose experience is it anyway? Toward a constructive engagement of tensions in patient-centered health care. J Serv Manage. 2020;31(5):979-1013.

15.

Siddiqui

Fitzgerald

. Patient-centric workplace culture: a balancing act for nursing leaders. Am J Nurs Res. 2017;5(5):165-72.

16.

Prip

Pii

Møller

Dorte

Thorne

Jarden

. Observations of the communication practices between nurses and patients in an oncology outpatient clinic. Eur J Oncol Nurs. 2019;40:120-5. doi:10.1016/j.ejon.2019.03.004

17.

Smith

James

Brogan

Adamson

Gentleman

Reflections about experiences of compassionate care from award winning undergraduate nurses–what, so what… now what?

J Compassion Health Care. 2016;3(1):1-11. doi:10.1186/s40639-016-0023-x

18.

Abraham

Stewart

Solimeo

. The importance of soft skills development in a hard data world: learning from interviews with healthcare leaders. BMC Med Educ. 2021;21(1):1-7. doi:10.1186/s12909-021-02567-1

19.

Bolsinger

Jaeger

Hoff

Theodoridou

Challenges and opportunities in building and maintaining a good therapeutic relationship in acute psychiatric settings: a narrative review. Front Psychiatry. 2020;10(965):2.

20.

Morera-Balaguer

Botella-Rico

Catalán-Matamoros

Martinez- Segura

Leal-Clavel

Rodriquez-Nogueira

Patients’ experience regarding therapeutic person-centered relationships in physiotherapy services: a qualitative study. Physiother Theory Pract. 2019:):1-12.

21.

McClelland

Gabriel

DePuccio

. Compassion practices, nurse well-being, and ambulatory patient experience ratings. Med Care. 2018;56(1):4-10. doi:10.1097/MLR.0000000000000834

22.

Farr

Barker

. Can staff be supported to deliver compassionate care through implementing Schwartz rounds in community and mental health services? Qual Health Res. 2017;27(11):1652-63. doi:10.1177/1049732317702101

23.

Combes

Damery

Sein

Allen

Nicholas

Baharani

Distress in patients with end-stage renal disease: staff perceptions of barriers to the identification of mild-moderate distress and the provision of emotional support. PLoS ONE. 2019;14(11):1-20.

24.

Sinclair

Hack

Raffin-Bouchal

McClement

Stajduhar

Singh

, et al. What are healthcare providers’ understandings and experiences of compassion? The healthcare compassion model: a grounded theory study of healthcare providers in Canada. BMJ Open. 2018;8(e019701):1-13.

25.

Silverthorne

Daniels

Thompson

Robson

Ndosi

Swales

, et al. Clinicians’ perspectives on psychological distress and meeting patients’ support needs in rheumatology care settings. In: European Alliance of Associations for Rheumatology: European Congress of Rheumatology 2021.

26.

Absolom

Holch

Pini

Hill

Liu

Sharpe

, et al. The detection and management of emotional distress in cancer patients: the views of health-care professionals. Psycho-Oncology. 2011;20(1):601-8. doi:10.1002/pon.1916

27.

Holopainen

Vuoskoski

Piirainen

Karppinen

O'Sullivan

Patients’ conceptions of undergoing physiotherapy for persistent low back pain delivered in Finnish primary healthcare by physiotherapists who had participated in brief training in cognitive functional therapy. Disabil Rehabil. 2020:):1-12. doi:10.1080/09638288.2020.1861116

28.

Lafleur

Gagné

Paquin

Michaud-Couture

How to convince clinicians that ‘Soft’Skills save lives? Practical tips to use clinical studies to teach physicians’. Roles. MedEdPublish. 2018;8:1-18. doi:10.15694/mep.2019.000119.1

29.

Hammond

Stenner

Palmer

. What matters most: a qualitative study of person-centered physiotherapy practice in community rehabilitation. Physiother Theory Pract. 2020:1-12. doi:10.1080/09593985.2020.1825577

30.

Washburn

Grossman

. Being with a person in our care: person-centered social work practice that is authentically person-centered. J Gerontol Soc Work. 2017;60(5):408-23. doi:10.1080/01634372.2017.1348419

31.

Baguley

Dev

Fernando

Consedine

. How do health professionals maintain compassion over time? Insights from a study of compassion in health. Front Psychol. 2020; 11:3327. doi:10.3389/fpsyg.2020.564554

32.

Benzo

Wetzstein

Neuenfeldt

McEnvoy

Implementation of physical activity programs after COPD hospitalizations: lessons from a randomized study. Chron Respir Dis. 2015;12(1):5-10. doi:10.1177/1479972314562208

33.

Hui

Hannon

Zimmermann

Bruera

Improving patient and caregiver outcomes in oncology: team-based, timely, and targeted palliative care. CA Cancer J Clin. 2018;68(5):356-76. doi:10.3322/caac.21490

34.

Bass

Van Wijmeersch

Mayer

Maurer

Booster

Mandel

, et al. Effect of multiple sclerosis on daily activities, emotional well-being, and relationships: the global vsMS survey. Int J MS Care. 2020;22(4):158.

35.

Favarato

Germani

ACCG

Martins

M A

. Glimpsing the raging seas that stop swans: a qualitative look at living with multimorbidity and pain in patients from a tertiary care service. J Multimorbidity Comorbidity. 2021;11(2633556521999509):1-9.

36.

Chesebro

Borisoff

. What makes qualitative research qualitative? Qual Res Rep Commun. 2007;8(1):3-14. doi:10.1080/17459430701617846

37.

Braun

Clarke

. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77-101. doi:10.1191/1478088706qp063oa

38.

Hunter

McCallum

Howes

. Defining exploratory-descriptive qualitative (EDQ) research and considering its application to healthcare. J Nurs Health Care. 2019;4(1):1–8.

39.

Creswell

Clark

VLP

. Designing and conducting mixed methods research. California,USA: Sage Publications. 2017.

40.

Guest

Bunce

Johnson

. How many interviews are enough? An experiment with data saturation and variability. Field Methods. 2006;18(1):59-82. doi:10.1177/1525822X05279903

41.

Malterud

Siersma

Guassora

. Sample size in qualitative interview studies: guided by information power. Qual Health Res. 2016;26(13):1753-60. doi:10.1177/1049732315617444

42.

O’Brien

Harris

Beckman

Reed

Cook

Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245-51. doi:10.1097/ACM.0000000000000388

43.

Nowell

Norris

White

Moules

NJ.

Thematic analysis: striving to meet the trustworthiness criteria. Int J Qual Methods. 2017;16:1-13. doi:10.1177/1609406917733847

44.

Frost

Campbell

Maxwell

O'Carroll

E, Dombrowski

Williams

Effectiveness of motivational interviewing on adult behaviour change in health and social care settings: a systematic review of reviews. PLoS ONE. 2018;13(e0204890):1–39.

45.

Miciak

Mayan

Brown

Joyce

Gross

DS.

The necessary conditions of engagement for the therapeutic relationship in physiotherapy: an interpretive description study. Arch Physiother. 2018;1(8):1-12.

46.

Laryea

. A pedagogy of deep listening in e-learning. J Conscious Evol. 2018;11(11):2.

47.

Cohen

Parent

Taveira

Dev

W-C.

A description of patient and provider experience and clinical outcomes after heart failure shared medical appointment. J Patient Exp. 2017;4(4):169-76. doi:10.1177/2374373517714452

48.

Bruns

Befus

Wismer

Knight

Adler

Leonoudakis-Watta

, et al. Vulnerable Patients’ psychosocial experiences in a group-based, integrative pain management program. Manage Serv. 2019;25(7):719-26.

49.

Cockerham

Hamby

Oates

. The social determinants of chronic disease. Am J Prev Med. 2017;52(1):S5-S12. doi:10.1016/j.amepre.2016.09.010

50.

Baines

de Bere

Stevens

Read

Marshall

Lalani

, et al. The impact of patient feedback on the medical performance of qualified doctors: a systematic review. BMC Med Educ. 2018;18(1):5-12. doi:10.1186/s12909-018-1277-0

51.

Aij

Rapsaniotis

. Leadership requirements for lean versus servant leadership in health care: a systematic review of the literature. J Healthc Leadersh. 2017;9(1):1.

52.

Parris

Peachey

. A systematic literature review of servant leadership theory in organizational contexts. J Bus Ethics. 2013;113(3):377-93. doi:10.1007/s10551-012-1322-6

53.

Dickey

Truten

Gross

Deitrick

Promotion of staff resiliency and interdisciplinary team cohesion through two small-group narrative exchange models designed to facilitate patient-and family-centered care. J Commun Healthc. 2011;4(2):126-38. doi:10.1179/175380611X13022552566164

54.

Robert

Philippou

Leamy

Reynolds

Ross

Bennett

, et al. Exploring the adoption of Schwartz center rounds as an organisational innovation to improve staff well-being in England, 2009–2015. BMJ Open 2017;7(1):e014326. doi:10.1136/bmjopen-2016-014326