Rapport between nurses and adult patients in ambulatory oncology care settings: a scoping review protocol : JBI Evidence Synthesis

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Rapport between nurses and adult patients in ambulatory oncology care settings: a scoping review protocol

Koppel, Paula D.1; Ledbetter, Leila2; De Gagne, Jennie C.1

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JBI Evidence Synthesis 19(6):p 1433-1443, June 2021. | DOI: 10.11124/JBIES-20-00102
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Research demonstrates that patients with cancer value nurses not only for their skillful and knowledgeable delivery of treatment but also for their support and guidance.1-5 Rapport, or nurse–patient bonding, is strongly associated with patient satisfaction,6 and both patients2,4,5 and nurses7 perceive this connection contributes to positive patient outcomes. Although the importance of the nurse–patient relationship in oncology nursing is well established, there is not a consolidated body of research describing attributes of rapport or how it is cultivated, especially in ambulatory care where the majority of cancer treatment is delivered.8,9 Because cancer is often life-threatening and chronic in nature, it impacts all aspects of a patient's and their family's lives. Nurse–patient relationships are often intimate and extend over many years through diagnosis, treatment, relapse, and either survivorship or death.5 Mapping the available evidence on rapport is critical to understanding the relationship between nurses and patients with cancer. The unique quality of the cancer journey and the prevalence of this disease make a thorough review of the research on rapport essential.

Globally, 17.8 million new cases of cancer and 16.3 million cancer deaths were recorded in 2018 with cancer burden expected to increase over the next two decades.10 Caring for the growing number of patients with cancer presents a significant challenge for the US health care system, with over 1.8 million new cases projected in 2020.11 Rapport is increasingly important given the growing incidence of multimorbidity that increases symptom burden within this patient population; among the most common types of cancers, comorbidity rates range from 30% to 53%.12 Trusted and sensitive health care professionals provide guidance and advocacy for patients navigating complex systems and treatments.1 In addition, the establishment of rapport facilitates an accurate assessment of patient needs, responses, and adaptation to cancer, thus allowing the nurse to better personalize care.1,13

Rapport, defined as a connection established with another person based on respect, acceptance, empathy, and a mutual commitment to forming a relationship,1 is considered an important attribute of quality care in oncology nursing.2 Nurse–patient bonding (another term used to express rapport) has been demonstrated to be an important mediator for patient satisfaction.6 Studies of patient perspectives demonstrate that the quality of their relationships with clinicians involved in their routine care impacts their emotional and physical well-being throughout the course of their disease process.1,14 In an analysis by Thorne et al.4 consisting of face-to-face interviews with 200 patients with diverse experiences with cancer, respondents so frequently identified a patient–provider human connection as highly valued that the researchers classified it as a universal need. For the oncology nurse, creating rapport or connection with patients is an essential step in building a strong therapeutic relationship.5,7 Studies document that for cancer patients, feeling personally known and connected with nurses and health care providers on a level beyond just their diagnosis or disease process facilitates satisfaction, positive health outcomes, increased quality of life, and decreased levels of suffering.1,4,13,15

Although the importance of therapeutic nursing relationships has been established, far less is known about specific attributes of rapport or the process of nurturing rapport, especially in ambulatory oncology care settings. The factors influencing the cultivation of rapport between oncology nurses and patients in ambulatory care, such as verbal and non-verbal behaviors, affective qualities, and patient preferences, are discussed in the literature but do not appear to have been systematically studied.7-9 Studies demonstrate that both patients2,4,5 and nurses7 perceive that a connection characterized by feelings of trust, hope, support, comfort, and safety contributes substantially to patient well-being; however, the mechanisms explaining the association between these specific feelings, the development of rapport and well-being, are complex and have not yet been adequately studied.1

Biomedical technology and information system interfaces often interfere with rapport-building.15 In addition, rising system-level demands, such as high patient-to-nurse staffing ratios, visit quotas, and documentation requirements, are obstacles to the time that a provider must invest to know patients individually.16 Although cancer treatments are now primarily delivered in an ambulatory setting,8 little research has focused on how the ambulatory environment impacts rapport. In a systematic review, Prip et al.9 discovered only nine studies; they concluded that the patient–provider relationship is important to patients’ ability to cope, and that the outpatient environment impacts the formation of patient–provider relationships.9 Practice guidelines do not consider the context of the ambulatory setting, where care encounters are brief, intermittent, highly focused on task-based delivery of chemo or radiation therapies, and often lack adequate privacy.17,18 This can leave patients feeling isolated and unsupported; numerous studies show that patients’ needs are often either not identified or not addressed.19,20 For example, patients receiving chemotherapy have reported unmet needs resulting in unplanned hospitalizations.21

An initial review of the literature including searches in MEDLINE (Ovid), CINAHL (EBSCO), JBI Systematic Review Register, and Cochrane Database of Systematic Reviews revealed that knowledge about the development of rapport in ambulatory oncology is sparse. Studies that were identified lacked specific research questions focused on rapport within this population, often having a broader focus on communication or quality care in general with providers including but not limited to nurses.8,9,17,18 A scoping review will help survey the landscape of what is known about rapport, and clarify the existing state of knowledge and gaps. This will provide necessary direction for future research questions.

The primary goal of this scoping review is to explore what is known about cultivating and sustaining rapport, or connection, between adult patients and their nurses in ambulatory oncology care. Because our initial scan of the literature, in addition to a systematic review by Prip et al.,9 found limited research regarding ambulatory oncology care, we will include a bibliometric analysis of written publications to search for and map potential connections among the studies that meet our criteria. This will also allow us to explore whether bibliometric analysis has utility and enhances the mapping of the current literature.

Review questions

Which nurse-related attributes, behaviors and interventions, and system- and patient-related attributes and behaviors are identified in the literature as influencing rapport between nurses and adult patients in ambulatory oncology care?

Inclusion criteria


The review will consider studies that include nurses from all levels of practice working with adult patients (18 years or older) undergoing treatment (palliative or curative) for any form of cancer. The search strategy will use the terms “nurse,” “nursing,” “nurse-patient relations,” “patient,” and “client.” Unlicensed nursing students, assistive personnel, or unlicensed health care providers (ie, nursing assistants) will be not be included in this review.


There are numerous words and theories used to describe the concept of rapport experienced between patients and nurses. This scoping review will utilize the definition of rapport from the National Cancer Institute: “a perception of connection with another individual based on respect, acceptance, empathy, and a mutual commitment to the relationship.”1(p.18) “Nurse-patient bonding” refers to the expression of this concept within nursing practice. Some of the many related concepts within nursing and other health disciplines include “connection,” “caring moment,” “empathy,” and “caring behaviors.” To ensure that all relevant works are captured, the search strategy will employ a variety of terms, including “rapport,” “bonding,” “empathy,” “psychosocial support,” emotional support,” “respect,” attentiveness,” and “caring behaviors.” A full list of terms is presented in Appendix I.

The studies identified relating to rapport between nurses and patients in ambulatory oncology care will be included in the review. Definitions related to system, nurse, and patient-related attributes, behaviors, and interventions influencing the cultivation of rapport will not be used to determine the inclusion or exclusion of articles since they do not appear to have been systematically studied. Definitions of these terms, however, will be used to categorize these factors during data extraction.


This scoping review will consider studies focused on the interactions and relationships between nurses and adult patients within ambulatory oncology care. Oncology care settings such as acute care, inpatient care, and community-based hospice care are not considered because their context differs significantly from that of ambulatory care, where encounters are more likely to be brief, intermittent, highly focused on task-based delivery of therapies, and lacking in privacy. There are no geographic restrictions to the context.

Types of sources

This scoping review will consider both experimental and quasi-experimental study designs including randomized controlled trials, non-randomized controlled trials, before-and-after studies, and interrupted time-series studies. In addition, analytical observational studies including prospective and retrospective cohort studies, case-control studies, and analytical cross-sectional studies will be considered for inclusion. This review will also consider descriptive observational study designs including case series, individual case reports, and descriptive cross-sectional studies for inclusion. Consideration will be given to qualitative studies that focus on qualitative data including but not limited to designs such as phenomenology, grounded theory, ethnography, qualitative description, action, and feminist research. Systematic reviews and dissertations that meet the inclusion criteria will be considered. Conference abstracts and posters will be excluded due to their brevity. Editorials, commentaries, and opinion papers will be excluded due to potential bias.


The proposed scoping review will be conducted in accordance with JBI methodology.22

Search strategy

The search strategy will follow a three-step approach aimed at identifying both published and unpublished studies. First, a draft search will be conducted in MEDLINE (Ovid) and CINAHL (EBSCO), followed by an analysis of text words in the titles, abstracts, and index terms. Second, the search strategy for MEDLINE (Ovid) and CINAHL (EBSCO) will be finalized and tailored according to each additional database (see Appendix I). Third, reference lists of the final selected studies will be screened for additional eligible studies.

The databases to be searched include MEDLINE (Ovid) and CINAHL (EBSCO). The search for unpublished or gray literature will include the ProQuest Dissertations and Theses Global database, PapersFirst, and EThOS. While studies in all languages will be included in the search, only those in English will be included in the review and there will be no time limits. Non-English studies with abstracts in English will be listed in an appendix in the final report.

Study selection

All identified citations will be imported into Covidence (Veritas Health Innovation, Melbourne, Australia) for screening. Two independent researchers will screen titles and abstracts of all retrieved citations and determine eligibility for inclusion, after which the full text of selected studies will be retrieved and assessed. Full-text studies that do not meet the inclusion criteria will be excluded, with reasons for exclusion provided in an appendix in the final review. Lack of agreement between researchers during the screening process will be resolved through discussion or by a third reviewer. Included studies will undergo a process of data extraction. The results of the search will be reported in full in the final article and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist.23 A formal assessment of methodological quality or confidence assessment will not be performed as the purpose of this research is to map existing evidence as opposed to selecting evidence to answer our research questions.22

Data extraction

The data extraction instrument will be adapted from the standardized JBI data extraction tool22 to answer the research questions. Two research members will initially read and chart data on at least two sources piloting the extraction form as recommended by Valaitis et al.24 Once this trial is complete, data will be extracted from the included studies by two independent researchers using the data extraction instruments (Appendices II and III). The data will include details about study methods, population, concept, context, and key findings. If there is a lack of agreement between the researchers, it will be resolved through discussion or with a third researcher. Texts pertinent to the review questions will be recorded in a data extraction form, and each document will be coded, analyzed, and synthesized to allow the main themes to emerge. The draft data extraction tool will be revised as necessary during the process. Modifications will be detailed in the full scoping review.

A definition of nursing intervention from the International Council of Nurses will be utilized: “intervention means literally ‘a coming between’ the patient and the problem in order to modify or influence the problem … limited to treatments and procedures.”25(p.110) This definition excludes assessment and evaluation nursing activities. Categorization of the specific interventions during extraction will be guided by the International Classification of Nursing Practice Catalogue for Nursing Intervention Statements established in 2019.26 As suggested by Bartz et al.,27 intentionally using this standardized terminology will support the review's ability to provide meaningful data for nursing practice and future research initiatives. Items from the revised Caring Behavior Inventory7 will be used to guide the identification of nursing behaviors. The Cambridge Dictionary defines attribute as, “a quality or characteristic that someone or something has.”28(para.1) This definition will guide the identification of system attributes (eg, staffing ratios, documentation requirements, technology interfaces, privacy) as well as nurse and patient-related attributes (eg, age, gender, perceived similarity, acuity, likeability).

Data analysis and presentation

A bibliographic mapping analysis will be performed on citation data retrieved from both databases using VOSviewer (University of Leiden, The Netherlands). Bibliometric analysis is largely dependent on the dataset; therefore, specific criteria for inclusion or exclusion is not necessary. A co-author network will be constructed to discover persons writing about the concept of “rapport” and to determine how they may be connected. Additionally, we will generate a co-occurrence term map, using data from the search based on text mining of titles and abstracts, to determine the terms being used to describe the concept of rapport and how these terms interconnect with other concepts. A corpus analysis of the full text of papers may be performed from the final set of selected articles in order to map terms used to discuss the concept of rapport.

The extracted data will be presented in tabular form and as a narrative summary that aligns with the objective of this scoping review. This table (Appendix II) will report study characteristics including location, sample size and characteristics, design, outcome measures, and main results. In addition, data on system-, nurse-, and patient-related attributes and behaviors, as well as nurse-related interventions, that influence rapport will be extracted and entered in the extraction instrument (Appendix III). Graphic representations may be used (eg, bar charts, charts, pie charts, diagrams) if they facilitate presentation of the results.


This review may be considered part of the doctoral dissertation for author PDK.

Appendix I: Search strategy


Searched on July 8, 2020



Searched on July 8, 2020


ProQuest Dissertation & Theses

Searched on July 8, 2020


Appendix II: Data extraction of study characteristics


Appendix III: Data extraction of review findings



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ambulatory care; bonding; nurse; oncology; rapport

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