Physiotherapy Student Experiences of Developing Therapeutic Relationships whilst volunteering with the Action after Stroke Charity

Objectives: To explore physiotherapy students’ experiences of patient-student relationship development, gained through volunteering with the Action after Stroke charity, with reference to usual placement experience, and to identify any changes in students’ thoughts and feelings towards patients, and subsequent effect on relationship development. Design: An exploratory qualitative study, utilising field diaries and a focus group interview. Participants: Nine students who had volunteered with the charity for 11 weeks participated in the focus group. Intervention: Students began recording their experiences in a field diary after 3 consecutive treatment sessions with a stroke patient and then participated in a focus group interview once volunteering had ended. Field diaries informed development of the focus group topic guides. Focus groups were audio recorded and transcribed verbatim. Thematic analysis of transcripts was undertaken. Findings: The following themes emerged from the data analysis: Time and continuity; Clinical education; Environmental factors; Trust, and Empathy. Students reported experiencing a qualitatively different and more satisfying therapeutic relationship with patients whilst working in the charity. They believed that patients benefitted from this enhanced therapeutic relationship. The time and space enabled trust and empathy to develop which helped them develop insight into their patients as people. Conclusions: Participation in the Action after Stroke charity gave students a greater opportunity to develop positive therapeutic relationships compared to traditional placements, by increasing their confidence, independence, empathy, patient-centeredness and knowledge of patients’ situations. Levels of trust also increased within the student-patient relationships. These findings suggest that involvement in non-standard practice placements, such as the charity, within a physiotherapy degree programme, may prove useful to students’ professional development.


Introduction
The relationship established between patients and therapists is an important determinant of treatment outcome and central to the therapeutic process [1]. However there is limited evidence regarding therapeutic relationships in physiotherapy [2], with little focusing on students' experiences. Available literature identifies that, in order to form a positive therapeutic alliance, physiotherapists should act in a patient-centred manner, be attuned to their patient's wellbeing, and possess characteristics such as empathy, sensitivity, and warmth [3]. Furthermore, it has been demonstrated, in other professions, that therapists who possess positive feelings towards their patients are more likely to develop positive therapeutic relationships [4].
Following recent publication of the Francis Report, the UK government has called for a greater focus on the development of caring and compassionate behaviors during healthcare professional education [5]. Evidence suggests that student's feelings and emotions are rarely considered, during training, despite their strong influence on behavior and relationship development [6]. This might explain

Research Article
Physiotherapy Student Experiences of Developing Therapeutic Relationships whilst Volunteering with the Action after Stroke Charity Aisling Byrne, Andrew Soundy and Carolyn Roskell* opportunity to volunteer with the Action after Stroke charity which provides specialist neurological rehabilitation in a supervised setting. Students working as volunteers in the charity are not assessed, their performance remaining unknown to the University. It was hypothesised that this environment might lead to a less pressurised and hurried encounter between students and patients enabling the development of a different kind of professional relationship. The present study therefore aimed to explore physiotherapy students' experiences of patient-student relationship development in the charity, compared to the usual practice placement experience. It also aimed to explore any changes in students' thoughts and feelings towards patients, and how this affected relationship development.

Design
An exploratory qualitative study, utilising a focus group interview, was chosen as the main method of data collection. This method captures in-depth and rich information through group interaction [14]. As some participants may dominate and others feel inhibited in focus groups, field diaries were also used to provide background information and encourage disclosure from less confident participants prior to interview [15].

Participants
Thirteen second and third year physiotherapy students who had volunteered with the charity agreed to participate. Eligibility criteria included having completed a minimum of three sessions with the same patient, so that some sort of relationship may have been established, and a willingness to complete a field diary and participate in a focus group.

Procedure
Students volunteered with the charity for eleven weeks, supporting patients with MS or who had experienced a stroke. During this time, 2 females and 1 male with MS, and 2 females and 7 males with stroke were seen.
Patients were offered a weekly exercise rehabilitation session for 45 minutes across an 11 week period. The rehabilitation sessions took place in a private fitness studio and a small separate rehabilitation area within the University grounds. Volunteers supported the patients carrying out their exercises, in the role of assistant, often working in pairs. This allowed students the space to bounce ideas off each other, sharing their knowledge to support peer-assisted learning. Students were provided with training in preparation for volunteering, run by an exercise professional and a neurological physiotherapist. A qualified exercise professional attended each session and where possible, a qualified physiotherapist. Participants were requested to begin making entries in their field diaries when they had worked with their patient for three sessions, recording their experiences for all patients that they had seen three times or more. During the 11 week volunteering period, students were able to fully experience the development of a therapeutic relationship with their respective patients due to the extended period of contact. Diaries were submitted one week before the focus group so that the findings could be used to inform development of the focus group topic guide.
In spite of email reminders, four students dropped out before data collection was complete, resulting in ten field diary submissions and nine students present at one focus group interview. This number of participants provided detailed insight from a variety of perspectives, yet was small enough to avoid the group becoming disorderly or fragmented [16,17]. The topic guide for the focus group was developed from themes extracted from the diaries and the literature [1,2]. The interview took place at the University and was facilitated by the researcher (AB), lasting an hour. All data was recorded by a digital voice recorder which was later transcribed verbatim by the researcher (AB).

Data analysis
The transcript was subjected to the low-technology, rigorous "long table method" of data analysis by the primary researcher (AB): an approach recommended for novice researchers due to its systematic and visual nature [16]. Transcripts were printed and cut into participant's answers and then categorized to relevant questions. Descriptive summaries were written to characterise the emerging themes from the data.

Ensuring rigour
Triangulation of field diaries and focus group interview data enhanced study credibility [18] and attention was paid to negative cases within the data, ensuring that these were reflected within the thematic structure. For example, an 'Advantages and Disadvantages' sub-theme was derived within one theme, to capture negative and positive responses. Consequently the range of participant responses was able to be captured by the identified themes. Reflexivity was addressed by discussion of the study design and analysis findings with the second (AS) and supervising researchers (CR) leading to modifications to the initial themes [19].

Ethics
Ethical approval for this study was obtained from the University of Birmingham, School of Health Sciences Ethics Committee (Ref: DEPEC 1209). Each participant gave written informed consent to take part in the study and pseudonyms were used to ensure anonymity.

Findings and discussion
The characteristics of the study participants are displayed in Table  1.
Five global themes, with associated sub-themes, relating to how participants experienced therapeutic relationships whilst volunteering in the charity, emerged from data analysis. The thematic structure is displayed in Table 2. The following section will present and discuss themes and sub-themes sequentially.

Time and continuity
This theme related to the impact on therapeutic relationship development of having longer treatment sessions, over a more prolonged period of time, whilst working in the charity, than they were used to during clinical education placements.

Quality of relationships
Hour-long treatment sessions and treating the same patient for ten weeks allowed students to take more time with their patients and get to know them better, aiding bonding and relationship development.

"You kind of build a relationship through the weeks." Pete "You definitely have a better quality relationship and its longer term with the same person."-Amy
Relationship continuity has been shown to be related to the development of quality patient-provider relationships [20]. Patients are more likely to like their practitioners in longer-term relationships, and experience higher satisfaction levels when consistently treated by the same physiotherapist [1]. This may be due to increased time permitting the development of the components necessary to form positive therapeutic alliances. Patient continuity such as that offered by the charity should therefore be encouraged in students' curriculum.

Patient-centredness
This sub-theme emerged with participants reporting how it was easier to adopt a more patient-centred model of practice whilst working in the charity. Having only one patient to see once a week reportedly enhanced participants' ability to focus their attention, tailor treatment, and reflect on their patient. Some felt this was an advantage compared to placement where they were used to seeing patient after patient.
"By having that time with the patient and then having the week, you've got a long time to reflect… They've got a lot of your attention, undivided. You're not thinking oh I've got to go and see this patient next." Sarah As clinical education placement experience has been associated with a decline in empathy [21,22], it is possible that students may begin to view patients as numbers and lose a sense of their individuality. However the charity permits students to focus holistically on one patient. Understanding the context of a patient's whole situation, as opposed to just treating their physical problem, has a recognized influence on patients' experience of care, reinforcing the establishment of positive therapeutic alliances 2 . Students also had time to reflect on previous experiences, aiding patient-centredness. This is beneficial since time constraints in the clinical setting can often present a barrier to reflective practice [23]. This type of patientcentred behavior should be particularly encouraged in students' practice as it provides higher patient satisfaction and adherence to treatment, through development of better therapeutic relationships [24].

Students' emotions
Respondents experienced a range of emotions arising from the impact of consistency on their patient relationships. Some students felt proud of their patient's improvements. Others felt excited and looked forward to the sessions each week.
"Because you're seeing them [patients] over such a long time period and become quite close with them as well it's really exciting and you feel really proud like when they actually make big improvements." Fran Patients' feelings are often emphasised in the consideration of therapeutic relationships, with most papers exploring patients' perspectives and little focus on the therapist's. However therapists' feelings drive their behavior, affecting relationship rapport [25]. The charity provides opportunity for students to independently explore their emotional responses towards patients so that they become aware of how their emotions can influence their behavior and practice. Feeling proud may increase students' passion for treating patients and is likely to enhance their dedication and absorption while preventing exhaustion and cynicism [26]. Ultimately, caring and feeling excited about practice in this way can motivate students to improve their therapeutic relationships [27].

Skill development
Some students felt that volunteering gave them the opportunity  to further develop their skills through working with a chronic neurological patient group and seeing patients outside of a clinical setting, which they may not have had the opportunity to do on placement.
"We've got to be hands on to actually feel… what tightness is really like rather than just practicing on each other." -Sarah "It keeps the clinical skills and like practice with patients ticking over before we go out on placement again." -Kim The charity offers opportunity to supplement clinical experience in a different setting enabling neurological-specific skill development such as clinical and communication skills [28].

Clinical education
This theme emerged as participants reflected on how this nonstandard placement experience compared with their previous clinical placement experience.

Advantages and disadvantages
Students reported advantages and disadvantages of the level of supervision they experienced. Some respondents felt that they missed talking through treatment options with a clinical educator to develop their thoughts and treatment plans, and gain reassurance, preferring more supervision and advice, especially initially, to point them in the right direction.

"I sometimes find that talking through with your educator they give you like ideas… and just confirm that what you're doing is beneficial to the patient." Georgina
By contrast, some students felt that the presence of a clinical educator made them feel pressurised or intimidated and hindered their ability to independently work and interact with patients.

"If you've got your educator there it's a bit like I don't want to talk…." -Claire
Although qualified members of staff were present, the lack of a formally identified 'educator' helped some students feel more comfortable talking to and getting to know patients in the charity. Others felt they had more control than on placement and felt happy taking the lead with their patient, something they may have been reluctant to do in the presence of an educator. This allowed students to gain confidence in their own capabilities.

"I definitely feel like we have got a lot more independent. It's really helped my confidence… not having someone lingering over you that technically you're the one in control." Sarah
Working in the charity appears to have provided opportunity for the development of student autonomy and self-confidence.

Peer-assisted learning
This sub-theme emerged as students reported being able to draw on their own resources for development through peer-assisted learning. Although initially some felt they would appreciate more supervision, as time passed, individuals felt that working as a pair of students compensated for not having an educator, as they could learn from one another.

"The fact you've got two people as well working together its two to one. So that sort of gave me confidence to do stuff together so I didn't miss having an educator at all really." Amy
The benefits of peer-assisted learning have been widely reported. Students working alongside peers are encouraged to be more honest regarding gaps in their knowledge [29] and seeing someone similar to oneself succeed can enhance personal self-efficacy [30]. By observing others in the charity, students may learn how to interact with patients, and have increased confidence to do so themselves, aiding relationship development.

Environmental factors
This theme related to participants' perceptions of specific environmental factors in the charity that supported therapeutic relationship development.

Relaxation
Many students felt that they were more relaxed participating with the charity than they were on placement.
"I do feel more relaxed than I was on placement because when you're on placement you've got to try and please the educator." Laura Levels of stress have been found to be higher in physiotherapy undergraduates than the average male worker, 27% of students suffering from psychological morbidity, with health care students experiencing higher levels of stress during clinical practice as compared to learning in a classroom [31]. Such anxiety experienced in clinical setting scan hinder learning, impairing cognition while trying to perform [32]. Consequently, students practicing in an environment where they feel less pressurized, such as the charity, may experience decreased levels of stress and thereby improve their learning experience when working with patients.

Implications on therapeutic relationships and professionalism
Students agreed that the relaxed and less busy environment aided student-patient relationship development compared to placement, being more conducive to socializing.

"I think just not wearing tunics and uniforms it's more relaxed." -Pete
Nevertheless students were keen to state that the more relaxed setting within the charity did not compromise their professionalism, providing their finest care when delivering exercises, but participating in social interaction during breaks. An individual suggested that this was beneficial since placement often permits purely professional dialogue with no opportunity for social interaction, whereas the charity allowed for both.
"You can be in a relaxed environment and you can feel relaxed in yourself but you can still give the patient the same amount of treatment and care as you would under more pressure." -Georgina Soundy et al. [33] suggest that patients can develop emotional attachments to physiotherapists with some misinterpreting the professional relationship as a friendship. The social aspect of the charity has the potential to challenge professional boundaries within the patient-student relationship. These students however felt that they were able to maintain their professionalism while providing treatment. Combining a professional approach within a supportive social relationship is advocated as social support has been associated with positive health outcomes and may mediate patients' responses to stress [34]. The charity offers a unique opportunity for students to develop therapeutic relationships through both social and professional avenues.

Trust
This theme defined trust as an important factor that participants felt strongly facilitated therapeutic relationship development. Some students felt that the level of trust in their patient-practitioner relationship grew over the course of the sessions. Patients became more willing to try challenging and 'scary' activities and, as trust grew, became more comfortable being treated by students. Students felt that the increased trust helped patients to open up, confide in them and trust their judgment.
"As the weeks have gone on he's [the patient] been willing to try harder things than to start off with… so I think he has had more trust". Claire Long-term relationships are believed to promote interpersonal trust between patients and practitioners resulting in increased patient satisfaction and treatment adherence [35] and conversely, the absence of a long-term relationship inhibits characteristics such as trust and empathy from building over time [36]. Students and patients appeared to benefit from the continuity and trust offered within the charity through the quality of the relationships they experienced.

Empathy
Empathy has been identified as an important element in therapeutic relationships [3]. This theme defined how working in the charity promoted student empathy.

Knowledge of how patients feel
Students reported that patients in the charity became more open to telling them how they felt and what they wanted to achieve compared to patients on placement. Some felt that this was because patients were volunteers so were open to begin with, whereas others felt that patients became more comfortable opening up as patientstudent relationships developed. Knowledge of how patients felt and what they wanted from their therapy allowed students to work towards specific patient-centred targets while taking into consideration factors that affected their patient's performance.
"When you're on a hospital ward you don't get the chance to speak about how you both feel… whereas we can work towards things that they [patients] want to be able to do… rather than being generic for everyone." Sally Effective listening increases patient satisfaction and decreases risk of litigation [37] facilitating higher trust and satisfaction with their practitioner [38]. Due to patients' increased openness within the charity, students felt better able to consider the needs of their patients and thus develop and work collaboratively with them towards personalized goals. This type of approach has been shown to increase patient adherence, satisfaction, and goal attainment [39] and may ultimately improve rapport.

Relating and responding compassionately to patients
Most students felt that participating in the charity gave them an insight into how conditions affect patients' lives physically, emotionally and socially. This experience was felt to be significantly more valuable than lecture-based learning in enhancing their compassion and empathy. Importantly, students did not feel sorry for their patients but instead appreciated how they felt. Some felt that although they gained similar insight when on practice placements such as in the community and rehabilitation placements, it was harder to relate to patients in this way in a hospital setting. Others felt that having the experience with the charity changed how they will relate to patients in the future. According to Gerdes et al. [40], empathy consists of three main components: Knowledge of how patients feel; feeling what another person is feeling and, responding compassionately to another person's distress. The charity gave students exposure to all three components, providing them with a complete toolkit for their empathetic development.

Discussion overview
This study has revealed that students volunteering within the charity were able to experience conditions that appeared to facilitate the development of richer therapeutic relationships than they had experienced during formal clinical education placements. It highlights the importance of having time to make a connection with the patient; seeing them as a person, rather than as a condition, and being able to engage emotionally with each encounter. These elements have been identified as characterizing a more patient-centred model of care [41]. This way of being was more easily achieved due to the absence of pressure from external judgment through presence of a formal clinical educator, thereby promoting autonomy. Interestingly, student learning appeared enhanced through being liberated from an external locus of control, seeing students turn to peer-assisted learning and their own reflective capability for their own professional development. This suggests that the constraints of formal clinical education settings may militate against students being able to develop capability to deliver patient-centred care and may explain why empathy has been found to decline in healthcare students following exposure to clinical practice [7,22]. These findings suggest that the charity has provided a useful addition to traditional clinical placements, which has potential for helping students become more patient-centred practitioners.

Study limitations
Use of a convenience sample from one university may have introduced selection bias limiting generalizability to students from other universities. The researcher (AB) did not have a prolonged and varied field experience and may have held a personal bias due to their similar background to participants. However a second analyst was used, during data analysis, to aid rigour. This research focused on the student perspective and has not accounted for how patients experienced these relationships limiting any conclusions drawn.

Conclusion
This study has demonstrated that participation in the Action after Stroke charity gave students a greater opportunity to develop positive therapeutic relationships compared to traditional placements, by increasing their confidence, independence, empathy, patient-centeredness and knowledge of patients' situations, and by increasing levels of trust within the student-patient relationships. These findings suggest that involvement within the charity alongside the physiotherapy degree programme may prove useful to students' professional development. Since the present study only provides information from the students' perspective, it would be of interest to study patients' experiences of therapeutic relationships in the charity in comparison with their experiences of patient-practitioner relationships in the NHS.

Ethical Approval
Ethical approval for this study was obtained from the University of Birmingham, School of Health Sciences Ethics Committee (Ref: DEPEC 1209).