The Therapeutic Alliance (TA) is an emerging concept within physiotherapy practice, reflecting the ongoing paradigm shift from a biomedical- (BMM) towards a biopsychosocial model (BPSM) of care. Current conceptual understanding of the TA is commonly based on Bordin’s (1979) definition, developed within a psychotherapy context. A concept analysis was conducted in order to provide conceptual clarity of the TA within physiotherapy literature.
An evolutionary method of concept analysis was followed. An extensive literature search was conducted, and eligible articles were submitted to inductive, semantic thematic analysis.
A total of 14 articles were included within this concept analysis. 5 master attribute themes, and 4 corresponding sub-themes were identified following thematic analysis. The master attribute themes were: ‘Seeing the person’, ‘Sharing the journey’, ‘Communication’, ‘Therapeutic space’ and ‘Fostering autonomy’. The 4 Sub-themes were: ‘Giving of self’, ‘Legitimising the experience’, ‘Physiotherapist characteristics matter’ and ‘Interpersonal collaboration’.
A heuristic interpretation of the TA within a physiotherapy context is offered. The TA is a dynamic construct within the clinical encounter and is influenced reciprocally between the person seeking care and the physiotherapist by biological, social and psychological contributing factors. ‘Communication’ may act as a catalyst in operationalising the TA in a physiotherapy context. Continued efforts are needed in physiotherapy education and training in both enhancing theoretical awareness of the role of the TA within physiotherapy practice, as well as guidance on its implementation in clinical practice.
Over the last decade physiotherapy practice has undergone a paradigm shift towards a biopsychosocial (BPS) model of care ( ). This contrasts a traditional biomedical, or therapist-centred approach ( ; ). This shift has been encouraged by governing bodies ( ), academics and clinicians ( ; ). Subsequently focus on concepts such as person-centred practice and the therapeutic alliance (TA) has emerged.
The TA is recognised as an integral aspect of care amongst allied health care professionals ( ; ) and has recently received increased focus in physiotherapy research. Studies suggest a strong TA has an association with improved physiotherapy outcomes ( ; ; ). Limited evidence exists however regarding its conceptual meaning and influence in physiotherapy practice ( ; ). The concept of alliance originates from Freud’s theory of transference and countertransference, whilst its characterisation was perhaps first discussed by , profiling the importance of the person’s experience of therapists empathetic approach ( ). Within physiotherapy practice tripartite definition of the Working Alliance (WA) is currently most widely utilised. Conceived within psychotherapy practice, the definition does not encompass central physiotherapy-specific facets of the care such as therapeutic touch, manual therapy or exercise. Thus, its applicability towards physiotherapy practice may be limited.
Many concepts of care exist within healthcare. These can be viewed as representations, or building blocks of existing theory ( ). Theoretical concepts are brought to life through operationalisation as they are reformatted towards the relevant clinical context, a process influenced by sociocultural and professional background ( ; ). Although there has been an increase in physiotherapy literature concerning the TA, no agreement exists regarding the TAs conceptual understanding and its subsequent operationalisation or influence on outcomes ( ; ). Recent systematic reviews have called for conceptual clarity of the TA concept in order to include the TA as an independent variable within research ( ; ; ). It is therefore the aim of the present concept analysis to seek conceptual clarity of the TA concept within physiotherapy literature.
Concepts can be considered mental constructions created to organise our environmental stimuli ( ), and so must contain categories of information which in turn enclose their defining attributes. Conceptual understanding is influenced by one’s ontological 1
1 Ontology: the study of being, or the nature of reality. Knowledge that exist externally to the individual.and epistemological 2
2 Epistemology: the study of knowledge external to the individual, concerns itself with the nature of knowing.position and may be construed as the characteristics and attributes enabling an individual to conceptualise an idea in different contexts.
A concept analysis strives to provide conceptual clarification, commonly through identification and meaning of words ( ; ). Failure to clearly articulate concepts’ definition and attributes may lead to impaired operationalisation, and confuse its intellectual understanding ( ). An evolutionary approach to concept analysis was used for this study ( ), forming a contemporary view of concepts. It adopts a constructivist 3
3 Constructivism: The means of acquiring knowledge from own experiences and one’s ideas.perspective as part of an inductive approach ( ; ).
This study followed a ‘concept analysis’ methodology. The evolutionary approach to concept analysis used follows 5 steps ( Fig. 1 ) ( ). Steps 1 and 2 relate to the methods, whilst step 3 bridges the methods and data analysis. For the purposes of this article the remaining steps of the evolutionary approach will be presented in the relevant journal article sections.
Identify concept of choice and surrogate (associated) terms
The TA concept within physiotherapy practice was selected. Preliminary searches of the ‘Therapeutic Alliance’ AND ‘Physiotherapy’ through Pubmed and AMED databases revealed surrogate terms linked with the concept ( Table 1 ). Surrogate terms are alternative words which express the ideas of a concept and formed part of the literature search strategy based on frequency of occurrence and contextual relevance to the TA. This ensured a wider and more applicable search.
Select appropriate setting and sample for data collection
Following the initial preliminary search, a comprehensive database search was conducted covering; Pubmed, MEDLINE via Ovid, AMED, CINAHL Plus, Cochrane, Psych Info and Embase via Ovid databases. The search was carried out utilising the listed surrogate terms ( Table 1 ) in combination with ‘Physiotherapy’ and ‘Therapeutic Alliance’. Additional application of Boolean operators ‘AND’ and ‘OR’ with truncations (*) and (“) were utilised ( Table 2 ).
A systematic search of the literature was subsequently carried out ( Fig. 2 ). No restrictions were applied to the year of publication as no prior concept analysis of the TA within physiotherapy practice was identified. This suggested a wide scope of the evidence base would be suitable. Titles and abstracts were screened (by PS) against inclusion criteria ( Table 3 ). In the event of uncertainty of conceptual clarity and study eligibility, studies were reviewed by GDK and CH for clarification.
|Peer reviewed literature|
|No year restriction to publication applied|
|Articles conceptually discuss the therapeutic alliance within a physiotherapy context|
|Literature published in Norwegian or English language|
Data collection through a literature search. Identify attributes, surrogate terms, antecedents and consequences
The literature search sought to identify conceptual antecedents, attributes and consequences relating to the TA. Conceptual antecedents describe events or phenomena which precede the concept. Attributes are characteristics which describe the concept at hand and provide its conceptual definition. Conceptual consequences describe the resulting events that may occur as a result of the concept ( ).
Fourteen studies ( Appendix 1 ) were selected for inclusion into the thematic analysis. The analysis phase contains steps 4 and 5 of the evolutionary concept analysis approach, and was conducted via inductive, semantic thematic analysis following Braun and Clarke’s 6-step guide ( Table 4 ) ( ).
|1. Familiarise yourself with the data|
|2. Generating initial codes|
|3. Searching for themes within the identified codes|
|4. Reviewing themes|
|5. Defining and naming themes|
|6. Providing the report|
Steps 4 and 5 of a concept analysis are sectioned within the data analysis as listed below:
Analyse data for each area and compare similarities (themes) and dissimilarities
Reveal the analysis implications and direction of further concept development.
Analyse data for each area and compare similarities (themes) and dissimilarities
It was not the purpose of the analysis to quality assess the included studies, consequently no quality appraisal was conducted. The focus of the analysis of the included studies remained on their conceptual discussion of the TA within a physiotherapy context.
A hermeneutic approach was applied and sought to discern and explore the inherent meaning within the data. Its application enabled consideration of individual components within the larger context, the TA ( ). Step 4 of the concept analysis compares similarities (themes) and dissimilarities within the data. This was conducted through the first author’s interpretivist, realist and rationalist lens, however all three authors worked in close co-operation during the data analysis process. Visual representations of the conceptual attributes were provided ( Figs. 3–7 ). The attribute themes act as master themes in outlining the concepts underlying characteristics. Step 5 highlights how the analysis findings may influence future discussions and conceptual development within the physiotherapy profession.