Therapeutic alliances in stroke rehabilitation: a meta-ethnography

OBJECTIVE: To synthesize qualitative studies exploring patients' and professionals' perspectives and experiences of developing and maintaining therapeutic alliances in stroke rehabilitation. DATA SOURCES: A systematic literature search was conducted using the following electronic databases: PsycINFO, CINAHL, Embase, MEDLINE, Allied and Complementary Medicine Database, Applied Social Sciences Index and Abstracts, and ComDisDome from inception to May 2014. This was supplemented by hand searching, reference tracking, generic web searching, and e-mail contact with experts. STUDY SELECTION: Qualitative peer reviewed articles reporting experiences or perceptions of the patient or professional in relation to therapeutic alliance construction and maintenance in stroke rehabilitation were selected for inclusion. After a process of exclusion, 17 publications were included in the synthesis. DATA EXTRACTION: All text identified in the results and discussion sections of the selected studies were extracted verbatim for analysis in a qualitative software program. Studies were critically appraised independently by 2 reviewers. DATA SYNTHESIS: Articles were synthesized using a technique of meta-ethnography. Four overarching themes emerged from the process of reciprocal translation: (1) the professional-patient relationship: degree of connectedness; (2) asymmetrical contributions; (3) the process of collaboration: finding the middle ground; and (4) system drivers. CONCLUSIONS: The findings from the meta-ethnography suggest that the balance of power between the patient and professional is asymmetrically distributed in the construction of the alliance. However, given that none of the studies included in the review addressed therapeutic alliance as a primary research area, further research is required to develop a conceptual framework relevant to stroke rehabilitation, in order to determine how this construct contributes to treatment efficacy.