Background

While there is not a clearly outlined definition of relational practice it is generally understood as an approach that gives priority to interpersonal relationships in both in relation to external (organisational contexts) and internal (how this is received by workers and service users) aspects. It is the foundation upon which effective interventions are made, and it forms the conditions for a healthy relational environment [1]. Notions of relational practice are not new. Systematised relational, psychosocial approaches to mental health care have a lengthy heritage, for example in the development of therapeutic communities [2]. Building on such traditions, Haigh and Benefield [3] describe the importance of relational practice in working toward a unified model of human development, with cross-sector implications. Within their work, they describe the importance of a ‘whole-person, whole-life perspective in the field of human relations’ with the quality of relational activity defined as being central to positive human outcomes and effective service provision [3]. The term relational practice is increasingly described and applied across different service contexts, including health, education, criminal justice and social work. The ways in which relational practice is described varywidely but include Psychologically Informed Environments, Enabling Environments and Psychosocial Environments, as well as other environments and work practices that use the relational practice label to describe their provision.

The importance of relationships and ways of connecting and being with others cannot be underestimated with respect to positive health, wellbeing and other outcomes (such as mental health recovery, overcoming social challenges, rehabilitation in criminal justice services and learning). However, practitioners, people with lived experience, academics and policy makers have not yet articulated a shared understanding of relational practice [3]. Consequently, there is a potential for interdisciplinary and interagency miscommunication, as well as a risk of policy and practice being disconnected. Further, inconsistency in terminology between disciplines is likely to result in separate knowledge bases being developed in parallel, complicating and compromising transfer of evidence into practice across fields.

While there are some systematic or scoping reviews of relational practice in specific service provision, such as acute care settings [4] or after-school provision [5], to date, there has been no comprehensive synthesis or mapping of the extant relational practice literature, across disciplines. Largely absent from the literature are reviews that focus on organisational practice using relational approaches, rather than focused on individual and/or therapeutic relationships. This scoping review maps and combines literature across a range of disciplines (Health, Education, Criminal Justice, and Social Care/Work) to provide clarity and direction, charting and summarising existing understandings. As we aimed to examine evidence from disparate or heterogeneous sources, rather than seeking only the best evidence to answer a specific question, a scoping review methodology was considered appropriate [6]. This methodology enables an examination and synthesis of the extent, range and nature of research on relational practice across health, criminal justice, social care/work and education, to inform future systematic reviews, and to identify gaps in the literature [7]. The four chosen sectors (health, criminal justice, social care/work and education) were included as these are all people facing public service contexts where relationships and relational practices are of crucial importance. We used the service provision being provided or discussed in the papers as criteria for inclusion rather than academic discipline.

The review focuses specifically on the relational practice used in an organisational context rather than in one-to-one approaches (i.e., individualised therapeutic approaches). We used the following definition: relational practice from a systemic and organisational perspective, defined as practice and/or intervention that prioritises interpersonal relationships in service provision, in both external (organisational contexts) and internal (how this is received by workers and service users) aspects. This approach was adopted owing to the ambitious and broad scope of this review, but also to add a focus as there is a wide range of relational approaches that are focused upon individualised interventions, such as therapeutic relationships and other evidence-based therapeutic/psychological approaches, but less is known about relational approaches at an organisational level. Within the review, we also scoped the extant literature for any reported impacts and benefits of relational practice.

Research question

How is relational practice used, defined and understood across different academic disciplines, professional practices and contexts, focussing on Health, Education, Criminal Justice, and Social Care/Work, and what are its reported impacts and benefits?

Method

This scoping review was conducted in accordance with the best practice guidance and reporting items for the development of scoping reviews [6]. The Preferred Reporting Items for Systematic reviews and Meta-analyses extension for Scoping Reviews (PRISMA-ScR) is provided in Additional file 1. Prior to commencement, the review protocol was registered with PROSPERO (registration number: PROSPERO2021CRD42021295958) and is available at: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021295958.

A multi-disciplinary core research team was brought together made up of academics, clinicians and people with lived experience of service provision with representation from health, education, social care/work and criminal justice experiences. A steering group committee was also convened with similar representative experience. This group provided oversight of the project, informed by subject matter expertise complimenting cross-sector and occupational/lived experience among the membership and supported with the search strategy, identifying search terms and the synthesis of the literature.

Search strategy

Searches were conducted on eight electronic databases (EPIC, SocIndex, Criminal Justice Abstracts, Education Abstracts, PsycInfo, CINAHL, Ovid MEDLINE and Criminal Justice Database) on 27 October 2021. Keywords for database searches included the following:

  • Relational focussed OR relational based OR relational work OR Relational social work OR Relational centred OR Relational centered OR relational practice* or relational informed OR relational theory OR relational approach* OR relational perspective* OR relational model OR relational strategy or relational strategies OR relational environment* or relational justice* OR relational education* or relational health OR relational therapy OR relational thinking OR relational inquiry OR relationship focussed OR relationship based practice OR relationship informed OR interpersonal system OR interpersonal environment* OR interpersonal practice OR interpersonal approach* or interpersonal perspective OR interpersonal strategy or interpersonal strategies OR psychosocial environments OR enabling environments

The full search strategy for each database is included in Additional file 2.

Inclusion and exclusion criteria

The inclusion and exclusion criteria for the review are displayed in Table 1. In order to encompass a broad range of approaches, the relational practice was broadly defined as practices and/or interventions that prioritise interpersonal relationships in service provision, in relation to both external (organisational contexts) and internal (how this is received by workers and service users) aspects. Articles were included where relational practice was seen as the foundation upon which effective interventions are made and form the conditions for a healthy relational environment. Because the focus of this review was on organisational processes, articles exclusively about the therapeutic relationship and/or therapeutic approaches were only included if they informed a systemic and organisational approach.

Table 1 Inclusion and exclusion criteria
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All types of studies (qualitative, quantitative and mixed methods), conceptual or theoretical papers/reports and all types of reviews (i.e., systematic, scoping, meta-analysis) were included, reported in peer-reviewed journals, grey literature and book and book chapters fully available online. Only articles published in English were included; however, there was no limit on the country of origin. Only articles published from 2000 were included to focus on current/recent practice and service delivery.

Study/paper selection

All records identified from the database searches were downloaded to EndNote and duplicates were removed using Systematic Review Accelerator [8]. Any remaining citations were transferred to Rayyan for screening, and any further duplicates identified were removed. Title and abstract screening were conducted in Rayyan independently by five reviewers (PB, RN, MM, GL, JP), with 20% of the papers screened independently by at least two reviewers. Inter-rater reliability was 84.09% at the title and abstract stage. Once title and abstract screening were complete, selected full-text papers were sourced and checked against inclusion criteria by six reviewers independently (PB, RN, MM, GL, JP), with at least 20% of the papers screened by at least two reviewers. An inter-rater reliability of 85% was achieved at the full-text screening stage. Reasons for exclusion were noted at this stage. Agreement at all stages was made by consensus, and any disagreements regarding inclusion were discussed with a third member of the research team where necessary.

Data extraction

Data were extracted from all selected texts using a data extraction sheet designed by the research team in collaboration with the steering group committee. The data extraction tool was piloted and refinements made. Following this authors completed data extraction for a sample of 10 studies as sufficient agreement was reached the authors then applied to tool to the remaining studies independently. Data extraction included key study/article characteristics (e.g., country), people facing service type, sector type, aims of study, study/article type, including key information for empirical studies (i.e., participants, design, data collection methods), underlying theories, key terms and definitions of relational practice and reported impacts and benefits. The research team collectively carried out calibration testing of the tool with a sample of articles prior to the assignment of independent data extraction of research team members [9].

Data synthesis

Data extracted from selected articles was charted, and a mapping of the scope of the literature was conducted using narrative synthesis. Narrative synthesis is an often-used approach within systematic and scoping study literature reviews. This approach enables the synthesis of large bodies of literature and looks to explore the relationships in the dataset collected and analyse commonalities, conflicts and relationships that assist us to reach conclusions and make recommendations for practice [10]. Consultation with the steering group committee throughout the data synthesis stage supported the interpretation and synthesis of the review findings.

Results

The results of the systematic search and screening process are displayed in a PRISMA flow chart (see Fig. 1). A total of 11,490 articles were initially identified from database searches. After the removal of duplicates, 8010 were retained, and 521 remained for full-text review. Overall, 158 articles met the eligibility criteria and were included in the synthesis. Table 2 displays the characteristics of the studies/articles included.

Fig. 1
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PRISMA flowchart

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Table 2 Characteristics of included articles/studies
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Country

Country relating to the service or organisation discussed was extracted from the included articles, where this was not identified the author’s affiliated country was noted. Figure 2 displays the countries represented in the included articles. Most of the included articles were from the UK (n = 48, 30.38%), followed by the USA (n = 32, 20.25%) and Canada (n = 25, 15.82%). There was however a broad and global spread of literature across the rest of the included literature.

Fig. 2
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Frequencies of countries represented in the included articles/studies

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Sector type

In relation to the four sector types, health has the highest proportion of included literature (n = 60, 37.92%), followed by education (n = 41, 25.95%), social work/care (n = 39, 24.68%), and criminal justice (n = 17, 10.76%), with 1 paper that was across the 4 sectors [3]. Table 3 displays the frequencies of the sector types across the included articles/studies alongside the specific service/focus within each sector.

Table 3 Frequencies of articles/studies for each sector type with specific service type or focus
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Study/article type

Study/article types were categorised as scoping or systematic reviews, empirical studies (either qualitative, quantitative, mixed methods), case studies, critical/narrative or opinion pieces/theoretical arguments. There was some overlap between the last three categories (e.g., some publications emphasising opinion or theoretical argument may also have included some brief details about application in a specific site/s). Where there was overlap the coders recorded the category that was closest to the authors’ stated intention (i.e., the aims of the article).

Descriptions of these articles were as follows:

  • Case study—a discussion or examination of relational practice or application of a delivery model in a specific site/s.

  • Critical/narrative review—generalised critique of relational practice or a particular philosophical approach and/or critical review of literature

  • Opinion piece/theoretical argument—where authors are proposing a particular approach or theoretical model for relational practice and/or an opinion of how to apply relational practice in a specific sector or the importance of relational practice in a specific sector

A large proportion of publications were opinion-based or theoretical argument papers (n = 61, 38.60%), with a further 6 (3.80%) critical or narrative reviews. These publications tended to propose models of relational practice or make arguments for the use of the relational practice in a specific service or organisation (see Table 2 for a summary of the aims of these studies/articles). An additional large number of included publications reported qualitative studies (n = 45, 28.48%) or case studies (n = 27, 17.09%). There was a lack of effectiveness trials or quantitative studies, with only 6 (3.80%) using a quantitative design and 9 (5.70%) using a mixed methods design.

Of the included publications, 27 were categorised as case studies, and 16 were descriptions of a practice or organisation and did not include any empirical data, although some did provide literature review and/or citations of other evidence sources relating to effectiveness [21, 101]. In these publications, the focus was predominately on explaining the relational practice being used in an organisation or a specific intervention and its components, rather than conducting an evaluation or examination of the effectiveness of the service. Four of these case studies were related to criminal justice services; one discussed the application of democratic therapeutic communities in the prison service [21], a further two discussed transition programmes for female offenders [28, 74] and one a community wealth-building project to promote successful re-entry for people released from prison [129]. Five of these articles related to an education setting and discussed applying the relational practice in the provision of faculty support [73], mentoring [108], delivery of a CPD course in community development [128], approach in a special school for adolescents with emotional, behavioural and educational issues [90] and using co-inquiry to form a partnership between students and lecturers in a university [160]. Six studies were health-related describing interventions for women with substance use problems and mental illness [72, 119], community-based nursing service for children and families [126] and a school obesity programme [107]. A final case study of a large UK local authority adult care department to describe a new practice model for social care [118].

The other 11 case studies included numerically informed quantitative data evaluating the service, intervention or practice described and are included alongside the studies using qualitative, quantitative or mixed-method study designs in Table 4. Most of the empirical evidence relating to the case studies is qualitative and focussed on the perceived impacts and benefits of the provision/intervention (see Table 4). Findings also relate to the importance of an institutional buy-in to the practice and support and training of staff in the approach to ensure success [41, 57, 135].

Table 4 Descriptions of empirical studies (qualitative, quantitative and mixed methods, including case studies with empirical data)
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Approaches used in the included mixed method studies varied widely (see Table 4) and often highlighted or focussed on the benefits of relational practice, rather than assessing effectiveness. Across the articles, the multi-component and complexity of relational practice is demonstrated (see Table 4).

Qualitative studies were mostly from health and social care/work sectors and highlight the time investment needed with relational approaches; noting the importance of staff motivation in order for relational practice to occur (see Table 4). The importance of trust was regularly mentioned across the articles and the importance of sharing stories and developing narratives, particularly around marginalisation to promote inclusion was highlighted.

Quantitative studies were fewer and varied; some focussed on examining the frequency or prevalence of relational practice and others examined the associated impacts (see Table 4).

A further 4 (2.53%) of the included publications were systematic or scoping reviews. There were two systematic reviews and one scoping review where relational practice was discussed. One systematic review synthesised qualitative research into older people’s experiences of acute healthcare [33], another synthesised research in adult acute inpatient mental health units, which focused on nurse-patient interaction [43] and a further systematic review used a meta-ethnography approach and explored studies of parent-school relations which impact positively on parents, regarding empowerment, parent voice and social capital [44]. The scoping review mapped health and social care and broader management literature to identify and extract important behaviours, processes and practices underlying the support of high-quality relationships [82].

Definitions and underlying theories

The commonly used terms for defining relational practice and the underlying theories mentioned across the included articles are featured in Table 5.

Table 5 Relational practice terms used, with underlying theories, across the 4 sectors
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The table shows that within the cross-sectoral terms being used to define relational practice that there are some certain commonalities, but equally there are different terms used aligned more to those specific sector types. For example, psychologically informed planned environments seem to be unique to criminal justice, relational learning and relational pedagogies to education, relational care to health and relational social work practices within social care. In contrast, enabling environments cross over criminal justice and health sectors, but are not mentioned within education or social work. Interpretation of the comparison of the cross-sector underlying theories however has fewer commonalities which is likely owing to the different sectors having more generally underpinning theoretical frameworks that are sector-specific.

Reported impacts and benefits of relational practice

A total of 76 (48.10%) articles reported impacts and/or benefits of relational practice. Over half (n = 47, 61.84) of these articles noted workforce impact or client impacts (n = 41, 53.95%). A further 12 (15.79%) reported organisational/systemic impacts.

Health impacts could be seen across all sectors but rarely were they directly noted as a health impact, these have been broken down as workforce and client impacts.

In relation to workforce impacts, it is apparent that the workforce, when this way of working is embraced, benefit from the enhanced knowledge, insights, healthy working environments, and enhanced understanding of interpersonal dynamics. The use of relational practice also appears to enhance team cohesion and shared experiences [49, 63, 65, 72, 81, 89, 100, 118]. Some articles also reported skills enhancements from the adoption of relational practice with the enhancement of interpersonal skills including communication and empathetic listening [2, 34, 48, 50, 59, 60, 65, 72, 83, 85, 90, 101, 120, 139]. Personal benefits relating to confidence, increased employee satisfaction and more effective impact upon the progression and achievements of clients were also described [11, 12, 15,16,17, 20, 21, 26, 32, 33, 35, 58, 59, 63,64,65, 67, 72, 75, 76, 80,81,82,83,84,85, 90, 100, 108, 120, 125, 129, 130, 140, 145, 148].

Client health impacts included enhancement of wellbeing [16, 82, 139], physically, psychologically, socially, improved child custody [13] and physical health outcomes [74], mental health outcomes [81, 114, 139] and various educational attainments/outcomes [11, 18, 20, 24, 25, 75, 79, 80, 108, 140]. Recovery from client difficulties substance use difficulties, physical health, mental health and criminal justice outcomes were reported alongside enhanced interpersonal relationships with service providers and carers/families [44, 45, 63, 64]. Positive impacts of relational practice were reported in the reduction of health inequalities and engagement with society which included a reported sense of community belonging [28, 37, 86, 120]. From a health impact perspective, reports of reductions in trauma and re-traumatisation [81], emotional regulation skills and buffering of stress impacts were reported as was the reduction in re-offending and violent incidents in criminal justice contexts [21]. Promoting a sense of belonging was considered to have an important impact on health, and where relational approaches were not being used this could be overlooked [28, 139].

Whilst impacts from a more organisational perspective were less likely to be reported, when they were these referred to poignant and important learning and included the development of healthy sustainable communities [47, 129, 148]. The literature also referred to the development of insights into what works and what is important, with ideas shared such as the replacement of coercive controlling environments to negotiated engaged environments [50]. The invisibility of relational and interpersonal work was often described but its cruciality to working with people facing services and the importance of collaboration was also emphasised [48, 49, 85]. The relational practice was deemed to go beyond traditional working, having the potential to create environments with a focus on interagency working, emotional availability, enhancing the wellbeing of clients and the workforce alike.

Discussion

This scoping of the literature identified a lack of articulation of a clear definition of relational practice within and across sectors. Rather, there is a more diffuse acknowledgement that various service provision settings enhance experiences and outcomes for the people who occupy these settings, be they designated as staff or service users. Whilst there is a view that there is an implicit knowledge of what relational practice is, this review demonstrates the lack of an explicit consensus and clarity across the sectors.

Whilst highlighting some commonalities in relation to what is meant by relational practice across the four sectors, the review also identifies certain unique differences. From an organisational level, there were very few explicit definitions of what relational practice is, or it consists of, but instead, a complex and multi-facetted complicated picture emerged that warrants some further synthesis using a different methodology, such as a conceptual review (currently being undertaken by the authors). There is a need for consensus and a unified model of understanding that Haigh and Benefield [3] have started to attend to, however, what has not been achieved previously is the scoping of the literature across the world and in the ambitious cross-sector approach we have adopted. This cross-sector approach adopted identified areas of agreement and conflict, but also enabled a shared learning approach to this important but lacking clarity concept of what relational practice is in an organisational context.

Equally through this review, we have discovered that whilst there are some sector-specific models of practice being proposed, there is a lack of empirical evidence relating to the implementation of relational practice and its effectiveness as we found no controlled trials and appropriately designed evaluation studies. Currently, most of the literature across the sectors identified was focussed upon opinion-based or qualitative studies. Owing to the lack of effectiveness trials and appropriately designed evaluations, we are also unable to examine impacts and effectiveness.

This review highlights that whilst the adopted use of ‘relational practice’ is increasingly being used in a variety of guises across sectors, the lack of definitional precision and clarity of understanding is problematic. There is however a sense that positive human relations can be aggregated within a setting harnessing a systematic, collective, rather than individual, approach to providing care, support or education across a variety of settings. Similarly, various theoretical perspectives are drawn upon without necessarily furnishing a unified conceptual basis for the described relational practice.

There is a tradition of practice-oriented rhetoric valuing so-called therapeutic relationships within health and social care systems, often associated with professional nursing [187] or social work practice [188]. More often than not, however, such commentary and theory-building are focused upon individual encounters rather than systemic interventions. A notable exception is the therapeutic community tradition that in turn developed out of a radical, innovative social psychiatric movement that has waned in influence in recent times but, nevertheless has offered an important legacy in initiatives such as psychologically informed planned environments (PIPES) [189] and the enabling environments kitemark in inpatient mental health services [190]. Recent scandals of abuse and neglect within inpatient mental health settings arguably expose the stark need for more organisationally defined approaches to therapeutic and supportive caring relations [191].

Albeit not exclusively, adult nursing appears more focused on technical aspects of care in contrast to forms of interpersonal and relational care more likely to be emphasised in mental health and addictions practice. The appeal of relational practice speaks to recent professional contestation of a perceived shift to the genericisation of mental health nurse education, where arguably core relational skills are poorly served in curricula that now prioritise adult nursing competencies [192]. In this regard, affinities for more relational approaches to care are associated with a preferred professional identity [193], and such affinities are often shared by service users seeking alternative forms of care and support to more narrowly defined bio-psychiatry, especially where this collides with coercive social control rather than consensual care and support [194].

Limitations

Our findings represent the first scoping of the extant literature focusing on organisation and systemic relational practice across the four key sectors of service provision: health, social care, education and criminal justice. However, this review is not without limitations and hence the results whilst not conclusive should be also treated with caution. This is the first review to broadly scope relational practice across 4 sectors. There were clear overlaps across the sectors explored and a lack of clarity and consensus made this review challenging. The lack of a clear definition resulted in the broad search strategy and reaching a consensus within the research team at each stage required much deliberation.

We also chose to focus our review specifically organisational practice using a relational approach. We could equally have chosen to conduct this review from an individualised interaction perspective; however, to ensure that the review had focus and was feasible to conduct within our existing resources, we determined organisational and system-focussed relational practice would provide the greatest examples of this increasingly described way of working and enhancing practice in people-facing services.

Even with this narrowed focus, the size of the review across the 4 sectors remained ambitious and included a wide range of different types of publications. We were not able due to the scale of included papers to conduct a thorough quality appraisal as suggested by Levac et al. [195] enhanced scoping study methodology, so we have not reported on the quality/reliability of the articles included. There is also a risk of bias due to paper heterogeneity both within and across the disciplines; however, this can also be seen as a strength of the study as there are many benefits of adopting such a broad approach.

Conclusions

The review shows that the concept of relational practice has good applied value, as evidenced by impact, yet the underpinning empirical evidence is limited and hence there is a need for clarity of understanding and more scientific effectiveness studies within this increasingly growing and important field of practice across sectors.

Ultimately, there is a need for conceptual standardisation of relational practice that draws upon the cross-sector intelligence. This in turn will facilitate a movement towards conceptual standardisation across the sectors. Conceptual inconsistencies hamper attempts to empirically investigate the relational practice constructs as is seen in the lack of research to test effectiveness, not least because this leads to a multitude of operationalisations of one construct.

This scoping review was necessary not merely to capitalise on what appears to be a cross-sector growing practice movement, which is highly valued, but also to avoid more ideologically based ways of practising which, potentially, are dependent on individual characteristics and intuition. It is perhaps not surprising that ‘relational practice’; however, it is defined and is highlighted in many papers as having organisational benefits. This scoping review has mapped available research on relational practice across four key fields. Despite certain definitional ambiguities and conceptual complexities, a number of positive benefits are claimed for the various relational approaches deployed within respective organisations.