Exploring Interpersonal Relationships in a Nurse-Managed Clinic and Their Impact on Clinical Outcomes

Abstract

This study explores the impact of interpersonal relationships on processes and outcomes of care at a nurse-managed, primary care clinic in Southern California serving a vulnerable population. Ten semistructured interviews were conducted with all health care providers in the clinic to explore patient characteristics, types of relationships experienced, and how they may have affected processes and outcomes of care. Themes in interviews were identified through thematic analysis. We found that (a) patients with limited access to health care and resources establish different types of relationships to support their needs, and (b) interpersonal relationships, including those among providers, affect quality of care.

Introduction

With expanding patient populations and nursing roles, there is a growing number of nurse-managed clinics in developed nations (Ely, 2015; Sutter-Barrett, Sutter-Dalrymple, & Dickman, 2015). Nurse-managed clinics have been shown to be effective in disease prevention and management (Bodenheimer, Wagner, & Grumbach, 2002; Horrocks, Anderson, & Salisbury, 2002). However, evaluations of nurse-managed clinics have used conventional clinical-outcome indicators, such as hospitalization, treatment complications, chronic disease management, and patient satisfaction (Horrocks et al., 2002). Conventional indicators neglect the interpersonal aspect of health care delivery, which has tremendous impact on outcomes (Bower, Campbell, Bojke, & Sibbald, 2003). This study extends our understanding on the impact of a nurse-managed clinic that serves a vulnerable population from a relational perspective.

The study of health care quality takes many different shapes and forms. From a micro-organizational behavioral perspective (which focuses on the impact of individual qualities or group dynamics in organizations), interactions among individuals can affect health outcomes. Individuals connect with one another through interactions, and these interactions, together with individuals’ underlying cognition, form the foundation of interpersonal relationships. Because providing health care involves patients and providers working together, these interactions or relationships will affect the processes and outcomes of care and therefore, are worthy of study.

When health care is evaluated, interactions between patients and providers are usually captured by the concept of patient experience (Jakimowicz, Stirling, & Duddle, 2015; NHS National Quality Board, 2011). It is conceptualized “both as patients’ experiences of care and feedbacks about experiences” (Ahmed, Burt, & Roland, 2014, p. 235). Patient experience is an important health care quality indicator, as it is associated with improved health outcomes (Ahmed et al., 2014; Manary, Boulding, Staelin, & Glickman, 2013). Regardless of how often patients visit their health care providers, patient experience influences their health behavior and ultimately their overall health (Jha, Orav, Zheng, & Epstein, 2008).

Interactions among providers are more likely to be examined in studies of nursing work environments and collaborative interprofessional practice. For instance, studies reported that collegial relationships between nurses, and between nurses and physicians, were better in American acute care hospitals with Magnet designation (Kramer, Schmalenberg, & Maguire, 2010). In addition, collaborative interprofessional teams are less prone to human errors (Richardson & Storr, 2010), because interprofessional competency frameworks emphasize effective communication and reciprocity (Interprofessional Education Collaborative Expert Panel, 2011; Wood, Flavell, Vanstolk, Bainbridge, & Nasmith, 2009).

Despite growing evidence suggesting that relationships affect health care quality, very few studies have specifically examined interpersonal relationships and their impact on processes and outcomes of care in nurse-managed clinics. Among these studies, even fewer explored interpersonal relationships in vulnerable populations. Interpersonal relationships are important to explore in vulnerable populations because they often have limited resources and are hence more likely to seek help from friends, families, and others with whom they have established relationships (Jeon & Lubben, 2016). Because nurses play different roles in nurse-managed clinics than they do in physician-led clinics, it is important to understand whether and how patients relate to nurses in a nurse-managed clinic serving vulnerable populations.

Vulnerable populations include

the economically disadvantaged, racial and ethnic minorities, the uninsured . . . and those with other chronic health conditions, including severe mental illness. The vulnerability of these individuals is enhanced by race, ethnicity, age, sex, and factors such as income, insurance coverage (or lack thereof), and absence of a usual source of care. (Vulnerable populations: Who are they?, 2006, p. 348)

To illustrate how different relationships are valued by different populations, Jeon and Lubben (2016) reported different pathways of social support in elderly Korean immigrants and non-Hispanic White Americans, and that networks of social support affected depression symptoms in these individuals.

A search for literature about the impact of interpersonal relationships on processes and outcomes of care, specifically in outpatient settings, yielded several dozen studies. We excluded studies that focused on technical and verbal communication of facts and neglected other aspects of interpersonal connections, such as body language and good will. We reviewed literature on patient–provider relationships and provider-to-provider relationships. For patient–provider relationships, we found several studies on therapeutic alliances (Dearing, Barrick, Dermen, & Walitzer, 2005; De Bolle, Johnson, & De Fruyt, 2010; Ruglass et al., 2012). One study reported that positive patient–physician role relationship was associated with a higher level of patient activation (Alexander, Hearld, Mittler, & Harvey, 2012). They also found that patients of ethnic-minority background reported less out-of-office communication with their family doctors. A number of studies looked at provider–provider relations, most often the collaboration between pharmacists and physicians (Niquille, Lattmann, & Bugnon, 2010; Ohnishi et al., 2011). In one study that included patient outcomes, Anaya et al. (2008) found that collaborative drug-therapy agreements among physicians, patients, and pharmacists in diabetes-mellitus management led to better blood glucose control. These authors also found that pharmacist–physician collaboration reduced costs for hospitalization and emergency room visits.

We looked in particular for studies of relationships in nurse-managed clinics or of advanced practice nurse-to-physician relationships and found no studies on this topic. Of a handful of studies, one found that low-quality nurse–physician relationships were associated with fair or poor nursing care in acute care settings (Kenaszchuk, Wilkins, Reeves, Zwarenstein, & Russell, 2010). Collegial nurse–physician relations were considered part of positive nursing work environments. These environments were, in turn, associated with superior quality of care (Hutchinson & Jackson, 2013), higher levels of nursing job satisfaction, and lower rates of hospital nurse burnout (Shen, Chiu, Lee, Hu, & Chang, 2011). Bailey, Jones, and Way (2006) found that successful collaboration between nurse practitioners and family physicians was associated with (a) role clarity and trust, (b) addressing ideological differences regarding disease prevention and health promotion, (c) addressing differences in perceptions of collaborative practice, and (d) mutual understanding that collaborative relationships evolve over time. This study did not examine patient care outcomes.

Research Focus and Theoretical Framework

The results from the studies we reviewed contribute to an overall conclusion that positive patient–provider relations and a high level of provider–provider collaboration lead to better patient outcomes. However, the studies have three limitations. First, none were conducted in nurse-managed clinics. It is not known whether and how patients’ relationships with their health care providers differ in nurse-managed clinics, because nurses’ roles in patient care differ from conventional physician-managed clinics. Second, none of the studies concerned vulnerable populations but several suggested that patient–provider communication patterns differed in vulnerable and nonvulnerable populations. Third, most studies were rigid with their assumptions about the types of relationships that existed and measured them using unvalidated instruments. With scarce literature in nurse-managed clinics, it is possible that other aspects of interpersonal relations (e.g., power dynamics among providers and patients) may be missing.

In this study, we aimed to explore the different types of interpersonal relationships within a nurse-managed clinic that serves a vulnerable population and how these relationships affect processes or outcomes of care beyond conventional quality indicators. Specific research questions were the following:

Research Question 1: What types of relationship were experienced by staff and/or patients at this setting?

Research Question 2: How did these relationships affect clinic operation, teamwork and care provision?

Social capital theory is an appropriate theoretical framework to guide the study of relationships and its impact. Social capital is understood as shared possession nested within relational ties. It is officially defined as “sum of the actual and potential resources embedded within, available through and derived from the network of relationship possessed by an individual or social unit” (Nahapiet & Ghoshal, 1998, p. 242). When individuals develop a network of relationships, they create capital that is shared among the group. The attitudes and behaviors resulting from social capital can be described as an “in-group” phenomenon. Examples are respect, trust, acceptance, and shared vision. These qualities can be further classified into relational, cognitive, and structural social capital (Macke & Dilly, 2010). We contend that when individuals feel they “belong” to the same “group,” their shared “capital” will allow for coordinated actions, such as that in health care teams and within patient communities. For instance, positive forms of social capital (such as friends) have been associated with better physical health (Fiorillo & Sabatini, 2015) and mental health (Ehsan & De Silva, 2015).

Method

Research Approach and Setting

We chose a qualitative research approach of semistructured interviews with thematic analysis as the data analysis method because they allowed for an exploration of novel topics and phenomena (Braun & Clarke, 2006).

The study took place at a nurse-managed clinic in Southern California. It was a nonprofit clinic affiliated with a university, and its mandate was to (a) provide access to primary care in two underserved, predominantly Hispanic communities through a school-based clinic and (b) train undergraduate and graduate nursing students to help alleviate a shortage of clinical placements in the region. The clinic location and catchment area were confirmed by the Health Resources and Services Administration as a medically underserved area (MUA) (Department of Health and Human Services, 1995). The mainly ethnic-minority and underserved catchment communities of the clinic qualify them as vulnerable populations, according to the definition in the Introduction to this article. Clinic services were primarily provided in English, with Spanish-language support from an interpreter and clerical staff. The staffing model was based on an advanced practice registered nurse (APRN) care-delivery model (National Council of State Boards of Nursing, 2012) with support from a community organization that provided physician consultation services onsite 1 to 2 days per week. Case management (e.g., telephone follow-up) was performed by support staff (see Participants section), who were fluent in Spanish and had strong ties with the community.

Participants

All 10 of the clinic’s health care providers who had direct contact with patients were invited and agreed to participate in a 1-hr interview. This accounted for approximately 90% of the clinic’s providers. Participants comprised one physician, four nurse practitioners, two public health registered nurses, one medical assistant, and two support staff. Inclusion criteria were (a) being a staff member who had direct patient contact, (b) age 18 or above when recruited, and (c) able to understand and provide informed consent in English. There were no exclusion criteria. Patients were not involved as study participants after careful considerations of their vulnerability as undocumented migrants (e.g., deportation or detention) and a lack of resources available to protect their rights and identity (e.g., legal representation, anonymize interview data completely) at the time of study (McLaughlin & Alfaro-Velcamp, 2015).

To protect participants’ identity, detailed demographic information was purposefully omitted in this article. However, the authors acknowledged the role of culture in shaping perspectives and beliefs about interpersonal and social relationships (focus of study), and thus provided the following information about the overall staff body: Nurse practitioners at the clinic practiced as a team and worked closely with bicultural public health nurses, physicians, medical assistants, and support staff. All providers had prior experience working with the patient population (mostly undocumented Hispanic migrants). At least three providers were fluent in Spanish and resided in the community served by this clinic. The rest of the providers were English-speaking Caucasian men and women. The providers residing in the community were connected with the patient population through other community activities; they shared their experiences and perspectives with the entire staff body.

Semistructured Interviews

Following approval from the university’s research ethics board, investigators approached eligible participants to invite them to interviews. Informed consent was obtained before each interview. The interview guide was developed prior to all interviews based on research aims. Field notes were made during and after each interview. The notes described the interviewer’s thoughts, participant’s reaction or experiences related to the interviews. Confidentiality and anonymity were ensured by not collecting identifiable information from participants and by using study codes for interview data and recordings.

Data Analysis

The lead author read the transcripts to familiarize herself with their content and make observations before formal coding. Summaries of responses were put into tables. Then, the lead author worked with a research assistant to identify and code meaningful patterns observed across all interviews. Transcripts were read again carefully, alongside field notes to organize meaningful data into groups. Meaningful data could be words that were repeated by many participants or by the same participant multiple times, comments expressed with strong emotions, or content relevant to the study, based on the researchers’ knowledge.

These codes were then further organized into themes by drawing connections between or among codes. This process was guided by considerations of how different codes might combine to form an overarching theme. The resulting themes and subthemes were put into a thematic matrix for review. During the review, themes were examined for coherence (i.e., whether the extracted codes within a theme were coherent) and fit (i.e., whether the themes were appropriate for the dataset). Finally, the final themes were named and defined. Themes were extracted separately by the lead author and the research assistant, and disagreements were resolved through discussion with coauthors. The rigor of this study was ensured through careful and detailed documentation and demonstration of the coding process, identification of themes, and review of final thematic matrix (Morse, Barett, Mayan, Olson, & Spiers, 2002).

Findings

Description of Patient Population and Services at the Nurse-Managed Clinic

All participants described patients at this clinic as primarily Hispanic and having poor access to health care. Patients were mostly from the catchment area of one local school, which promoted the services of this clinic to its students and their families. Other descriptions included “poor” and “uninsured.” The patients are family members of students at the school where the clinic was located. One participant noted,

There is large majority that are undocumented immigrants requiring access to good healthcare, that they would not ordinarily get. (Provider 1)

Services provided

All participants felt that chronic disease management, including stabilizing chronic conditions, was a key function of the wellness center. Although other conditions seen at the wellness center included mental health problems and thyroid disease. The condition seen most often was diabetes. One participant recalled,

Our diabetic patients come to us with A_1Cs in the teens. We are successful, I believe, in getting those down into the 6s and 7s, but they are by and large a younger population with multiple, chronic disease processes. So it’s not just diabetes that they have. It’s Type 2 Diabetes, but they’re insulin dependent because their disease is so poorly managed, plus the lipids, plus the renal disease, plus the ocular disease, the neurologic disease, and they’re young. (Provider 9)

Patient care challenges

Participants reported three intertwined challenges in providing care to the population the clinic served: lack of health and health-systems knowledge, organization skills, and poverty. These challenges stem from the population’s vulnerability, as previously described.

Most participants identified patients’ lack of health and health care-systems knowledge and skills to organize and prioritize. This lack of knowledge and skills made it difficult for patients to manage their chronic illnesses.

The patients’ poverty exacerbated their lack of awareness of available services in trying to access health care. Patients’ lack of health knowledge, as well as their poverty, prevented them from adhering to health care providers’ teaching, prescriptions and discharge instructions. For instance, a participant described patients as lacking

knowledge about health prevention, health maintenance, what it means to have a healthy diet, what it means to take care of themselves, exercise, eating right, making sure that vaccinations are up-to-date. [Patients need to] Make sure that if they do have a problematic condition such as diabetes, that they maintain normal blood work, like an insulin regimen and make sure that they come in for frequent doctor visits, optometrist visits, foot doctor visits. That’s all something that the community is still kind of trying to grasp. (Provider 2)

Another participant felt that patients lacked organizational skills, remarking,

I think it’s time management . . . If you teach somebody how to organize their life. (Provider 4)

However, most participants felt that poverty intertwined with lack of knowledge and skills in patients’ difficulties accessing health care. As one participant commented,

I think the financial constraints are really big and some patients can’t even afford a $4 prescription at [the pharmacy]. That’s really a challenge. (Provider 8)

Another participant remarked,

Some of the access is transportation . . . because many of these patients take the bus or walk, a neighborhood clinic that’s centrally and easily accessible in terms of the location is really key. And we find sometimes they can’t go to [name of pharmacy removed] to pick up medicine because it’s too far away. It’s three bus rides or something. (Provider 8)

The clinic’s funding also limited patients’ access to health care. One participant noted,

We really do need a good network of specialists. So for example, a patient with the thyroid tumor was referred. She had an MRI, we knew she had a massive tumor, didn’t know it was cancer. Well, everybody figured it was, but we needed to get a fine needle aspiration or biopsy to confirm that. And so a referral was sent to [specialist] and months later it had not been handled. (Provider 8)

Types of Interpersonal Relationships Within the Clinic

We grouped interpersonal relationships into three main types: between patient and provider (patient–provider), among providers (provider–provider) and among patients (patient–patient). We found different themes within each type of relationship. For patient–provider relationships, we identified the themes of trust and ties with the community. For provider–provider relationships, we identified the themes of collegial relations among frontline staff and paternalistic leadership style with administrators. For patient–patient relationships, we identified the themes of self-selected peer support and connecting families, patients, and providers.

Patient–provider relationships: Trust

Participants observed trust from patients toward their providers, as well as ties with the patients’ community. Participants felt that patients came to trust them because of their willingness to advocate and act for patients’ best interests. One participant remarked,

The patient builds that sense of confidence with that provider . . . that sense of, “Okay, this person really cares for me. This person is taking care of me and is doing their very best to bringing the best level of health they can.” (Provider 2)

Another participant opined that this sense of being well cared for, which contributed to trust, stemmed from considerable amount providers spent with each patient.

Patient–provider relationships: Ties with the community

Participants described the clinic staff as well-connected with the community. One participant expressed that the clerical staff and medical assistant “felt the pulse of the community” (Provider 6) and followed up with patients outside of the clinic, especially with those who did not speak English. Another participant recalled,

I was actually kind of amazed at how much psychosocial background I could get in a very quick snapshot on these patients (during team huddles). My medical assistant would say, “This patient is being abused, but she’s not going to tell you that, but she told me, or she told so and so, and so she’s coming in for urinary tract infection. But really the issue is psychosocial.” (Provider 7)

In many instances, providers would refer patients to social services if deemed appropriate.

Providers and patients collaborated to encourage help-seeking behavior among community members. For example, one nurse practitioner encouraged an adolescent patient to seek help from the clinic if needed. This patient took this message home and convinced his mother to speak with the providers regarding her depressive symptoms. Another participant explained this collaboration:

We call it La Comadre, it’s sort of like my friend word. It’s a word-of-mouth. They only listen to what their friend says or what the neighbor said. So if she says it was good, that means it’s good, and so they’ll come. (Provider 4)

Provider–provider relationships: Collegial relationship

We found different themes in relationships between providers. Regardless of discipline, all participants were satisfied with their collegial interactions at the clinic. These relationships manifested in effective communication, shared knowledge, shared goal, and commitment to collaboration. Participants felt that all staff members, including the clerical support, understood one another well. One participant noted,

We know each other well. We know how each other practices. So I do think it’s efficient and I think in spite of the challenges we’ve had in terms of learning the EMR (electronic medical record) and that being a complicated system. (Provider 9)

Participants felt that all the health care staff shared the same goal: providing the best possible care to patients. As one participant remarked,

The relationship, the camaraderie between the medical assistants, the doctors, the nurses. You know, the nurse practitioners, it’s all great. They all work together cohesively. We’re all here for the patients and that’s what it boils down to. (Provider 2)

In addition, participants described a willingness among providers to collaborate. As one said,

We share patients. We share knowledge about patients. That’s pretty good. We do have some new physicians that come on just in the last couple of months so that’s a very new process. So I think they’re all incredibly amenable and flexible which is great. I think getting their kind of commitment to these patients is so impressive just because it’s new. (Provider 6)

Provider–provider relationships: Paternalistic leadership style

Participants also commented on a negative aspect of relationships: a paternalistic leadership style. About a third of participants felt there was a lack of options autonomy related to clinic administrative arrangements (e.g., reducing support staff, terminating or hiring new staff members without communication with frontline providers). As one participant commented,

The clinic is going to change [staffing, physician coverage schedule]. There’s no discussion about the changes. (Provider 10)

Patient–patient relationships: Self-selected peer-support

This category of relationship is rarely mentioned in primary care literature. In our study, participants frequently noted support among patients. This support was built on the notion of creating a family away from home, in a community where most residents left their families when they emigrated from their home countries. One participant explained,

Obviously obesity is also something we all battle with in this community. So they [patients in the community] are trying to take ownership . . . like, “Let’s walk, let’s do something in teams.” So the moms that are here in the mornings, they go walk down the street to [a department store] and they have exercise classes in the mornings. So it has made it a little bit more closer with them to actually say we have somebody—I know it’s not family but they actually have somebody to rely on. (Provider 4)

Patient–patient relationships: Connecting families, patients, and providers

One participant spoke of a continuum of relationships among patients, providers, and patients’ families. The clinic is closely linked with a local school. Students in that school may suggest that their parents to seek help after receiving care or teaching from clinic staff. One participant observed,

. . . a lot of the times, if you teach the kid, they’ll bring it back home. So if the kid sees that the Mom is crying at home, [the child would ask her] “Why don’t you go to the clinic?” . . . the kid doesn’t know why the Mom is depressed or why is the Mom crying . . . they just see it as it’s got to be a medical issue . . . there is a connection from the kids to the parents. We get a lot of—“Well my son told me to come.” But once they are in the room, it’s a completely different story. (Provider 4)

Despite a lack of aggregated data to support this as a theme, it converged with the idea of building a family away from home, as mentioned in the previous theme.

The Impact of Interpersonal Relationships on Healthcare Outcomes

Participants were asked to comment on whether and how relationships affected provision of care in the clinic. Overall, they felt that the effect was positive. We grouped their responses on the topic into four categories: (a) processes of care, (b) patient outcomes, (c) provider outcomes, and (d) system outcomes. Next, we described the positive and negative impacts of interpersonal relationships on these processes of care and outcomes. For processes of care, we identified the themes of reduced redundancy and improved care coordination. Positive health behavior was identified as a theme for patient outcomes. For provider and system outcomes, dissatisfaction related to paternalistic leadership was identified as a contributor to provider conflicts and errors. On the contrary, positive provider relations was said to improve follow-up rates and helped reduce patient vulnerabilities.

Processes of care: Reduced redundancy and improved care coordination

Participants observed that unprompted communication, a consequence of good interpersonal relationships, reduced redundancy. An example was provided:

There was a patient in particular who had cancer. Came in with a big mass on her neck. It turned out to be cancer. She was followed by X [name removed] here . . . but she’s only here one day a week. There was one day she [the patient] was going to see me. X had filled me in throughout the process of what the plan was, what the updates were and things like that when I was here with her. So I was very well aware. So when I approached her I already knew exactly what the situation was and saved time to start from the beginning. She was already known to me and even though I’d never seen her . . . [I know how] vulnerable the situation was to her [the patient]. I think that knowing how X practices helped. (Provider 6)

In this example, a sense of familiarity helped with efficiency in cross-covering patients.

Another participant suggested good interpersonal relationships helped with allocating work. When asked about how relationships among staff affect processes of care, one participant said,

[In this clinic] there is good understanding of who does what. Z spends time doing what they do best, which is care coordination, patient education, and we [nurse practitioners and physicians] spend time doing what we do best, which is deciding what the next path of treatment is going to be. (Provider 9)

Patient outcomes: Positive health behavior

Participants ob-served that patient–provider relationship enhanced adherence, motivation, satisfaction, and returns for follow-up. First, having established relationships with providers, participants felt that patients were more likely to adhere to providers’ advice. They believed that having relationships with providers led patients to feel obliged to carry out what providers suggested. As a participant said,

It [trust] adds to more compliance because they know, “Oh, my physician, my NP, my whatever, they really care about me. They are really keeping tabs on what I’m doing. And if I don’t do this, they are going to know.” It’s a little bit of pressure, it’s almost like Mom watching over you. (Provider 2)

Second, participants felt that patient–provider relationships can motivate patients. As another participant commented,

They’re happy to see us and they see that we’re happy when they make progress. “Look, you did so well!” or “Look, that medication is working for you!” And they get excited, too, and that’s motivating for them. (Provider 9)

Third, participants believed that having relationships with providers led to patients being more satisfied with their care. A support staff member said,

What I’ve seen is that they [providers] really stop and sit and look at the eyes and take the time to talk to the patient . . . Another thing is that I see that they want to reach the whole family. It’s not just the patient or it’s not just the physical problem. It’s also going inside, it’s going even farther . . . many patients seem really happy when they leave [the clinic]. (Provider 7)

Fourth, patient–provider relationships increased patients’ efforts and willingness to return for follow-up appointments. One participant noted,

Patients just not coming in because they didn’t feel—they feel like I don’t want to go there, they are not going to do anything for me, so why go back. But right now [in our clinic], the staff that we have right now is a great staff and we haven’t heard of those complaints. (Provider 3)

Provider outcomes: Dissatisfaction

One of only two negative impacts of interpersonal relationships that participants brought up was dissatisfaction with the paternalistic leadership style within provider–provider relationships. Participants felt that, when administrators made decisions without consulting providers, this style reduced the autonomy of nursing staff. A participant recalled,

This morning, an email this morning, as of [date], meaning this Friday, the RN who has been there [at the clinic] is no longer there. Okay? So something happened and there were no discussion about it. (Provider 10)

System outcomes: Good provider relations improved follow-up rates

Participants reported that provider–provider relationships increased patient returns for follow-up appointments. They explained that providers shared expectations and understanding of patients resulting in concerted efforts to ensure that patients returned to have their illnesses monitored. One participant remarked,

We know each other well. We know how each other practices. So I do think it’s efficient [in managing our patients] . . . in spite of [other] challenges. (Provider 9)

System outcomes: Provider conflicts contributing to errors

Errors resulting from provider conflicts were mentioned by participants. One participant noted,

You would hope that everyone gets along. Once you don’t get along, once there’s a problem, the first person that’s going to suffer is the patient. Things will get missed. Egos will take over. The compassion will be lost . . . [for example] Medications are not prescribed appropriately, critical lab values are missed. (Provider 1)

No specific examples of conflicts among providers were provided by participants. Our field notes suggested these conflicts were independent of the paternalistic leadership issue identified in the previous section.

Overall impact of interpersonal relations on care: Reducing patients’ vulnerabilities

The aforementioned themes regarding the impact of interpersonal relations suggested a reduction in this patient population’s vulnerabilities by improving their health. As a participant noted,

It’s the idea that we want to . . . make this community as healthy as possible and promote health in the community. Kind of the idea of not waiting till something has progressed to a point where it’s become a problem, an issue in life. That preventative health, making sure that they know about good nutrition, good exercise, coming in for regular check-ups. Having that clinic in the community is so important, yeah. (Provider 2)

Discussion

In this section, we compare and contrast the types and themes of relationships identified in our study with those in the literature. After that, we discuss how some of these relationships affect processes and outcomes of care in our study. Finally, we present the limitations of this work, followed by future directions for research.

The first aim of our study was to explore the different types of interpersonal relationships within a nurse-managed clinic that serves vulnerable populations. Three types of interpersonal relationships were evident: patient–provider, provider–provider, and patient–patient. Our discussion below highlighted novel or uncommon themes in the literature.

For patient–provider relationships, one novel idea was the notion of community advocacy that involved patient–provider collaboration. We provided the example of a patient referring his mother to the clinic, and a clerical support staff member who stayed in touch with members in the community, particularly those with language barriers. This collaboration occurred naturally and outside of the clinic boundary. Providers were described to know the “pulse” of the community, offer assistance whenever appropriate (e.g., providing referrals to social services).

To further our understanding of the term “advocacy” in our community setting, we drew on the work of Ezeonwu (2015). She contended that community health nursing advocacy should include (a) promoting and protecting health and safety, (b) providing support and assistance for access to health resources and social services, and (c) speaking up or for, and working on behalf of, clients through the care continuum. These attributes were present in our transcripts, which was unusual given the clinic did not have a specific outreach program. The collaborative and outreach aspects of advocacy described in our study had not been explored in the literature. One explanation for such occurrence could be due to the strong sense from our provider participants to fulfill patient advocacy and decrease the health disparity that was embedded in the nursing profession (this clinic is managed primarily by nurses and nurse practitioners) (Ezeonwu, 2015). Advocating for patients was associated with positive patient behavior. We discuss this issue in the next section where impact of relationships on processes and outcomes of care is described.

In terms of provider–provider relations, participants identified collegial relationships among providers as evident by effective communication, shared knowledge, shared goals, and a commitment to collaborate. These qualities were core features discussed in interprofessional education literature (Interprofessional Education Collaborative Expert Panel, 2011). It is believed that these qualities minimize errors in communication (Brock et al., 2013) and engender positive work environments (Pfaff, Baxter, Jack, & Ploeg, 2014) which in turn further reinforce effective communication. The association between collegial relationships and collaborative work behavior was supported by Jody Gittell’s theory of relational coordination (Gittell et al., 2000), which she described as managing dependencies at work through interpersonal relationships. Our findings addressed many of the dimensions of relational coordination (e.g., shared knowledge, shared goal and commitment to collaborate), confirming the impact of interpersonal relationships on collaborative behavior.

For patient–patient relationships, participants noted that patients supported one another without formal introductions or arrangements from providers, such as organizing walking sessions in the neighborhood. This phenomenon was not well explored in the literature and we identified it as “peer support by self-selection.” Peer support is defined as

the provision of emotional, appraisal and informational assistance by a created social network member who possesses experiential knowledge of a specific behavior or stressor and similar characteristics as the target population, to address a health-related issue of a potentially or actually stressed focal person. (Dennis, 2003, p. 321)

In this study, participants felt that patients worked with each other to promote healthy behavior (e.g., creating exercise opportunities for weight loss). Compared with the majority of studies on peer support that were formally established, where health professionals created social networks (Paul et al., 2007), our participants described their patients’ peer support to be informal and self-selected.

Informal, self-selected peer support was included in a concept analysis of peer support by Dennis (2003); however, there was no further elaboration on how it may differ from other forms of peer support. Dennis also discussed the antecedents, consequences, and theories that underlie improvement in health outcomes based on positive peer support. Her description concurs with findings from our study. For instance, Dennis contends that peer support is a type of social relationship, and that its attributes include emotional support, informational support and appraisal support. In our findings, the practice of diabetic patients going for regular walks in groups to promote weight loss is an example of emotional and appraisal support. Patients communicating with one another about resources available at the clinic is an example of informational support. Finally, peer support enhanced social integration with the development of peer relationship. Social integration reduces feelings of isolation, in turn increasing sense of control and broadens access to information, which in turn changes health practices (Dennis, 2003). Another explanation cited by Dennis is the protective effects that result from patient’s adjustment to illness, such as reducing the potential for harm by continuing with serum glucose monitoring for diabetes. More literature on how relationships affect patient care will be discussed next.

The second aim of our study was to explore how interpersonal relationships in the clinic affected processes or outcomes of care. We wish to offer explanations for these associations by drawing from existing literature. Our analysis below, with the exception of social capital theory, is organized by the type of relationship reported in the findings.

Patient–Provider Relationships: Perceived Advocacy

It appears that advocacy directly leads to better outcomes, such as increased resource allocation and access to health services. According to Bu and Jezewski (2007), successful advocacy leads to the development of positive attitude and increased sense of control and ability to care for themselves, which were some of the outcomes described by our participants. While there are no known theoretical links for advocacy and health outcomes, it is logical to believe that support to attain better health would lead to psychological (e.g., emotional validation), informational (e.g., knowledge on lifestyle adjustment), and practical gains (e.g., access to health care).

While the significance of patient–provider relationship is well documented in health care literature, patient–provider relationship in serving vulnerable populations has not been explored. Because very limited information is known about how patient–provider relationships differ in vulnerable populations (Alexander et al., 2012; Ong, de Haes, Hoos, & Lammes, 1995), more research is needed to further identify other features of patient–provider relations.

Provider–Provider Relationships: Collaboration

An abundance of literature supported the link between successful collaboration and better quality of care (Shortell et al., 2004) despite inconclusive evidence (Zwarenstein & Reeves, 2006). Positive collaboration led to technical and interpersonal gains (Interprofessional Education Collaborative Expert Panel, 2011). Technical gains included knowledge of everyone’s role, accuracy, and timeliness in expressing ideas. Interpersonal gains included a sense of mutual respect and good will. Both technical and interpersonal aspects improved quality of care by allowing for a more consistent and seamless approach to manage patients. Findings from our study added to the support in promoting collaboration for patient care.

Patient–Patient Relationships: Self-Selected Peer Support

For peer support and patient outcomes, Dennis (2003) explained that peer support enhanced patient outcomes through (a) directly producing an effect (e.g., walking together for weight loss); (b) indirectly benefiting health by protective actions (e.g., reminding one another to seek medical help early to control the effects of diabetes); and (c) influencing health through behaviors, cognition, and emotion (e.g., supporting one another emotionally). These three mechanisms were evident in our study.

All Types of Relationships: Social Capital Theory

Social capital exist in all types of relationship but is commonly observed in ethnic groups where strong support exists within communities (Kao, 2004), such as ones demonstrated in the present study. Social capital theory is particularly useful in the present study to further our understanding on the impact of relationships because of its close ties with culture and cultural values. Culture and cultural values were prominent in our findings (e.g., Hispanic patients supporting each other’s health behavior through a sense of family, which is important in their culture) (Nahapiet & Ghoshal, 1998). Culture may precede the establishment of relationships, but it may also form and develop with social or work groups. For our patient population, ethnic culture influences the patient-to-patient relationship, while the culture within this nurse-managed clinic probably developed as providers settled in and experience accumulated. Because ethnic minorities often have unique cultural values, their expectations of relating with providers of a different ethnicity may differ.

Nevertheless, not all the relationships identified by our participants are thought to influence care provision. We believe this is because relationships are not the sole factor that influences health care provision. As discussed under patient–provider relationship, above, patient experience is affected by multiple factors, including clinical skills and communication skills (Lee, 2013; Roter & Hall, 1991).

Limitations

Several limitations exist in this study. First, findings from a study of one nurse-managed clinic with patients and providers from one geographical location may not be replicable. Moreover, we acknowledge that our perspectives of patient–provider and patient–patient relationships may be limited because we did not interview patients. The inclusion of patients in this study would have enriched our views on interpersonal relationship.

Recommendations for Research

One area for future research would be to examine how informal, self-selected peer support differs from other types in the literature (Bahun & Savič, 2011). Informal peer support has been explored recently with the rapid expansion of social media. One potential question would be to examine how health care professionals can ensure accuracy of information and patient safety in self-selected peer support networks, particularly in vulnerable populations. This is because patients from vulnerable populations are less likely to have access to formal support (Gelberg, Andersen, & Leake, 2000). Another area to follow up on is to obtain further quantitative data to validate the link between relationship and health care quality, so that certain relational measures can become standard indicators in evaluation of health care quality. This would involve a multistep process, beginning with studies that validate measurements for health care outcomes beyond the conventional measures. These measurements are best to validate in different patient populations. Finally, because the catchment population of this clinic is small and specific, it is unclear whether the same relational themes are present in other communities. To generate better prediction of processes and outcomes of care, further research could explore characteristics that underlie the two forms of support.

Conclusion

Our study has explored types of relationships and their impact on outcomes at a nurse-managed clinic that served a vulnerable population. We noted some unique relationships that had not been described in existing literature, such as self-selected peer support and community advocacy beyond official mandate of the clinic. These characteristics supported patients in engaging in healthy behavior, such as forming new relationships to fulfill goals and needs. In vulnerable populations where resources can be scarce, such relationships are often useful. Findings also suggested that positive relationships within a nurse-managed clinic serving vulnerable people were associated with better patient outcomes.