Concept analysis of trust: a coronary care perspective

Concept analysis of trust: a c o r o n a r y

care perspective Steven P. Hams Patients admitted to the coronary care unit following either myocardial infarction, severe left heart failure or rhythm disturbances frequently have difficulty conceptualizing a 'broken heart'. The aim of this paper is to provide a greater understanding of the term 'trust' in relation to patient care, utilizing the concept analysis framework of Walker & Avant. Trust has been identified as an essential element in the nurse-patient relationship; due to its abstract nature it would appear that we as critical care nurses have been naive and have over-simplified the concept. Indeed, it is suggested that we could learn from our patients, in order to contribute to an effective nurse-patient relationship.

Steven P. Hams RN Dip. Applied Health Studies, Staff Nurse,

Coronary Care Unit, Wiltshire Cardiac Centre, Princess Margaret Hospital, Okus Road, Swindon SN I 4JU, UK

(Requestsfor offprintsto SPH) Manuscript accepted September 1997

Patients admitted to a coronary care unit (CCU) following either acute myocardial infarction (AMI), severe left heart failure or rhythm disturbances frequently have difficulty conceptualizing a 'damaged heart'. Unlike a patient with a fractured femur who, when the plaster cast is removed, is able to see a positive restoration o f health, cardiac patients are left feeling vulnerable and disempowered as they are unable to see, physically, the 'damaged heart' getting better. It is in such situations that a combination of trust, positive reinforcement and adaptation of health are seen as essential facets in the delivery of effective health care; a delivery that encourages the patients to respond positively to their situation, although some aspects are somewhat difficult to demonstrate following cardiac arrest or myocardial reinfarction. In a patient-related context, trust has been identified as an important element in the nurse-patient relationship (Wallston et al 1973, Pask 1994), and as prerequisite for patient empowerment (Gilbert 1995). Studies have shown that the concept of trust is a major c o r n -

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ponent in patients' acceptance of treatment from health care professionals (Semmes 1991). Trust can be seen as an important element in improving patient care, and the continual development o f the traditional nurse's role. Furthermore, trust provides patient empowerment, which ensures that the responsibilities for patient care are shifted towards the patient (Trojan & Yonge 1993). Nurses have a strong interest in developing and enhancing a relevant knowledge base, with the aim o f clarifying and challenging conceptual foundations (Rodgers 1989), thus providing evidence that encourages a critical review of nursing practice. A clearer understanding o f trust and its relative concepts may indeed both provide clarity and act as a catalyst for a change in nursing practice. The purpose here, therefore, is to provide a greater understanding of the term 'trust' in relation to patient care, utilizing the concept analysis framework o f Walker & Avant (1995). Walker & Avant (1995), suggest that concept analysis is useful for several reasons: to refine ambiguous concepts in a theory; to help to clarify over-used vague nursing concepts; as an instrument for research development and evaluation; to produce a precise operational definition; and finally, to help to develop and evaluate nursing diagnoses. Walker & Avant's (1995) framework consists of eight steps usually completed in sequential order. However, the authors stress that many of the steps can occur simultaneously, the first step being uses of the concept.

USES OF THE CONCEPT Most of the time, people trust without being consciously aware of doing so, for none of us are seN-sufficient; we rely on person(s), object(s) and institutions to help us obtain and retain those things in life that are important to us (Pask 1995). Trust essentially involves the capacity to put our faith in the goodwill of others towards us, and to accept an element o f risk that not all can be known. As nurses, appreciation of the risks involved when we trust will, to some extent, be influenced by those beliefs that are a product of our own past experiences. As well as nurse-patient trust, it is also important to recognize that a certain degree of trust must exist between members o f the health care team, for as Farmer (1993) suggests, without trust, communication necessary for the planning and coordination o f competent patient care may be lacking, and this in turn may promote distrust rather than trust among patients. The dictionary is identified by Walker & Avant (1995) as a potential source for identifying

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uses o f a concept. Interestingly, the dictionary provides a list o f the way that words are c o m monly used, rather than providing a definitive definition. The Oxford Quick Reference Dictionary (Thompson 1996) was used to examine the concept o f trust. The English noun 'trust' is derived from the Icelandic w o r d 'traust', which means trust, and the verb from the associated w o r d 'trusten'. The emerging four elements from the noun form o f trust are reliability, strength, confident expectation and responsibility. There are also more specific uses o f the word 'trust' in both a legal and a business context. These vary, but include commercial credit (obtained goods on trust), reliance, to accept (on trust) and confident expectation o f a positive behaviour by an individual. Trust has been cited as an element essential to a successful nurse-patient relationship, and a concept that provides patient empowerment and self help (Thome & Robinson 1989, Gilbert 1995). There has been much work related to trust and nurses practising within a critical care sphere. Washington (1990) indicated that trust had not been clearly conceptualized, and so a clear definition had not been operationalized. Nurse--patient trust is described as a continual process within critical care nursing, and as such it has undoubted uses in assisting patients in regaining and maintaining an optimum level o f health following a period of critical illness. Trust within the health care context may be influenced by time (Pask 1994). The longer people trust, the stronger the sense o f trust; this relationship may, however, take time to establish. This clearly highlights a potential difficulty within a coronary care setting, as patients are discharged from the unit after 48 hours. Therefore, nurses have to ensure that the foundation building blocks for a trusting relationship are laid as soon as a patient is admitted. In some instances, this process starts before the arrival o f patient, when a nurse will brief the immediate family as to their loved one's condition and treatment programme whilst in the C C U . The ability to trust ourselves as nurses is also important in the building o f a trusting relationship (Thorne 1988). Those who have developed a view o f themselves as being somewhat inadequate may have difficulty in placing their trust in others. As nurses, we need to be sensitive to those occasions when our own, or our patients', low self-esteem may inhibit the ability to trust. The demonstration o f competence could overcome potential difficulties due to short length o f stay influencing the degree to which a trusting nurse-patient relationship can develop. Gilbert (1995) discusses competence, a concept related to trust, in that it is possible to gain the trust o f patients by exhibiting an aura ofprofes-

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sionalism and competence. A familiar example is given: that o f individuals who entrust their loved one, who may be critically ill due to AMI, to the care o f health professionals. Because such individuals do not apparently, have a full understanding o f the situation themselves, they may feel forced to place their trust in others; and because they are unsure o f their }~eehngs, their behaviour may indicate distrust, for example checking the details o f care that has been given. This perspective is reinforced by Morse's (1991) view o f trust as an attitude, in which one relies with confidence upon someone or something, although such a cognitive process can also be seen as fragile. To gain further insight into the conceptualization o f trust, the author asked for and noted nursing colleagues' personal concepts o f trust. The overwhelming theme expressed by many nurses was the need for a therapeutic relationship, within which trust was an integral part. T h e y also suggested that having time to talk with patients and relatives appeared to reassure them, thus instilling confidence and trust in what was described as a ' t w o - w a y partnership'. Going that extra mile has been well documented within the nursing literature (Fosbinder 1994). Being a friend and providing nursing care beyond minimal expectations, 'tuning into the same wavelength' as the patient and wanting to get involved at both a practical and an academic level provide positive reinforcement for a collaborative trusting relationship. A recent personal experience highlighted that trust is indeed an attitude, with which one relies with confidence upon someone or something in the development o f a trusting nurse-patient relationship. Around the time o f the U K general election in 1997, a 45-year-old gentleman was admitted with an AMI. H e was settled in bed and the named nurse received a handover report from the accident and emergency nurse. During the handover, the named nurse was informed that the gentleman was a local prospective parliamentary candidate for the Labour party. The named nurse introduced herself and in conversation asked the patient h o w his canvassing was going for the Labour party. The reply was somewhat amusing: the patient abruptly corrected the nurse stating that he was a Conservative party candidate, and as such did not want a nurse who appeared to support his opposition party! This experience highlighted the difficulty the named nurse had when attempting to gain her patient's trust and the fragile nature o f such trust. A simple mistake had a significant impact upon her relationship with the patient, w h o requested a change o f named nurse. Several colleagues highlighted their discontenX, with the patient-doctor relationship, in

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Concept analysisof trust 353 that doctors tend to assume respect and trust from patients. It is not u n c o m m o n to overhear patients talking about their general practitioners (GPs), suggesting that they do not trust their GP because, for example, 'she was treating me for a gastric ulcer, although what I really had was angina'. McKenna (1997, p 90) suggests that as ward staff we frequently use the language of symptoms to describe patient behaviours, and indeed classify patients into diagnostic groups. For example, rather than assessing a patient's problem as 'unstable angina', a medical term, we should focus on the problems concerning the effect that the unstable angina has on the individual and his or her family. This ultimately highlights the constraints and conflict encountered when attempting to jointly apply both nursing and medical models of care: such an approach may lead nurses to ignore aspects of patient care that do not fit neatly into the boundaries of the medical model. Much work has been completed in the nonnursing arena with regard to trust. Trust was recognized as a key leadership function in a discussion by Carr (1994) on empowering leaders; and trust, though not specifically conceptualized, was identified as a prerequisite for empowerment. An international study o f subcontracting firms focused upon inter-firm trust, with the conclusion that the concept of trust was demonstrated as a state o f mind or expectation of one that another will behave in a predictable and mutually acceptable manner (Sako 1992). Trust was also found to enhance information flow between Japanese industrialists (Dodgson 1993). Finally in a debate on building trust within the Royal Air Force leadership structure, trust was identified as a crucial element of leadership, which must be built in ways that are applicable to specific situations (Cassel 1993).

CRITICAL ATTRIBUTES The critical attributes are those characteristics o f a concept that appear consistently. Having reviewed the available literature, the author has identified the following consistent critical attributes o f trust: self; willingness; relationship; vulnerability; reliance on thing(s) or person(s); performance; expectation; and empowerment. Having identified the critical attributes of trust, trust can be defined as:

a willingness to engage onese/fin a relationship that has reliance upon either a person(s) or thing(s), with an expectation that vulnerability may arise from either the trustee's or truster's

performance. The primary aim, however, is to provide empowerment to both parties.

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A M O D E L CASE The following model case of trust is aimed at promoting a clearer understanding o f trust as a core concept: Patient A, a 65-year-old man was admitted to the C C U following an inferior AMI. Due to the nature and instability of his medical condition, it was essential that two peripheral venous lines of access were established (venflon). The author, as the named nurse, explained the imminent procedure, identifying that m o m e n tarily a sharp scratch would be felt on the back of the patient's hand. This feeling would, h o w ever, subside after a few seconds. Patient A understood and agreed to have the venflon inserted. He perceived the experience as it had been described, and so was less anxious when the second venflon was inserted.

B O R D E R L I N E CASE Borderline cases include some of the critical attributes of the concept of trust, as previously identified. Patient B, a 78-year-old woman was admitted to the C C U following an acute anterior myocardial infarction. W h e n asked if she would mind a nurse inserting a venflon, she appeared puzzled and confused. The nurse explained what a venflon was and its function, and then proceeded with the insertion. In this instance, the nurse failed to describe the entire procedure and the potential for pain when the venflon was inserted, so patient B was unable to make an informed choice regarding the intervention required, thus reducing the empowerment component of the relationship and increasing vulnerability; and her expectation o f care differed from that of the nurse.

RELATED CASE Related cases are those instances of concepts that are related to the concept o f trust, but which do not, however, contain the critical attributes. During identification of the uses of the concept of trust, competence appeared to be related as discussed by Gilbert (1995). There n o w follows a practice example o f competence. A nursing colleague preparing a patient for permanent pacemaker insertion explained what would happen before insertion, during the procedure and after insertion, and the importance of the patient minimizing the movement of her

354 Intensive and Critical Care Nursing left shoulder when she got back to the C C U . O n return to the C C U the nurse asked the patient if she felt that she was given enough information about the procedure. The patient replied: 'Everything was explained step by step...You were aware o f what was going to happen...there were no nasty surprises'. Forsbinder (1994) would identify the previous interaction as a method o f translating the necessary processes to the patient as a basis for informing on what is either happening n o w or about to happen in the near future.

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C O N T R A R Y CASE The final stage offered by Walker & Avant (1995) is the construction o f a contrary case, a clear example o f 'not the concept'. A contrary case o f trust is described below. The setting is identical to that o f the model case. In this instance the nurse explains to patient A that the insertion o f the venflon will not under any circumstances hurt, and that there is absolutely nothing to worry about. W h e n Patient A sees the venflon, he becomes concerned with a notable increase in heart rate. Patient A, believes that the insertion o f the venflon will hurt and that the nurse has been dishonest and lied to him. Patient A becomes visibly distressed and the attempt is abandoned until he has calmed down. In all four o f the previous cases, to a lesser or greater extent, a perception o f vulnerability was evident. In the four cases, the patients considered the information that was available at a given moment in time and weighed it against the perceived potential benefits o f engaging in a given relationship. In the model case, the nurse was deemed sufficiently trustworthy to enter into a trusting relationship. The consequences o f a positive outcome were perceived to be understood by the patient, and this was demonstrated in a manner indicating trustworthiness; thus, the trusting element of the relationship was reinforced as the continuation o f a positive nurse-patient relationship. During the contrary case, patient A did not believe the information regarding the insertion o f the venflon to be true, and following initiation o f the procedure he did not feel that the nurse had been trustworthy. So a trusting relationship was not established.

social contexts in which a concept is generally used. The core concept o f trust can be applied to a wide variety o f situations, in both everyday situations and within a nursing context (Thorne 1988). The generalized antecedents o f trust include reliability, perception o f competence, past experience and trustworthiness o f the trustee. Risk and expectation o f positive consequences associated with the situation are included. The truster must believe that the trustee is competent to perform as expected and will be sufficiently reliable and trustworthy to do so. In order to assume a risk, a positive outcome should be expected (Johns 1996). These antecedents are thought to increase in specificity as the core concept is applied in context specific situations, for example in the model, related, and contrary cases o f trust. As in the instance o f antecedents, consequences associated with the core concept o f trust have a low level o f specificity to accommodate their generalizability. The consequences for the core concept o f trust are the realization o f expected benefits, unanticipated results and the formation o f either a stable or a varying level o f trust.

EMPIRICAL REFERENTS Several modes ofbehaviour by a truster may be considered to be empirical referents o f the core concept of trust. These include sharing o f information considered by the truster to be confidential with the trustee, and manifestations of willingness o f the tmster to maintain vulnerability with respect to the trustee (Kristjanson & Chalmers 1990). Walker & Avant (1995) suggest that empirical referents are classes or categories o f actual phenomena that by their existence demonstrate the occurrence o f the concept. T h e only literature found by the author that contains discussion o f measurement o f trust, is a paper by Wallston et al (1973). T h e y cited two existing scales for measuring generalized trust in society, but considered them to be marginally related to the nurse-patient context, with insufficient breadth to discover the true meaning o f trust.

IMPLICATIONS FOR PRACTICE

ANTECEDENTS AND CONSEQUENCES Walker & Avant (1995) identify that antecedents and consequences are useful in illuminating the

O n the whole, most patients entrust their safety to nurses; at the very least they trust that they will not be harmed. O t h e r than entrusting their safety, patients may vary as to what else they entrust, and this therefore requires careful assessment.

Concept analysisoftrust

It is suggested in a study by Mangold (1991) that nurses lack insight into the care that is entrusted to them. Mangold found that a significant difference existed between nurses' and patients' ranking of most and least important nursing behaviours. It would appear that nurses cannot assume that they know what is entrusted to them, especially when nursing patients with cultural backgrounds different from their own. Nurses need to consider the way in which personal life experience may affect that which patients entrust to them (Pask 1993). This clearly requires careful consideration of the influence of differing cultural norms and values upon our expectations. A further implication for nursing within the critical care field is the existence of 'blind faith'. Trust in the existence of God is an example, or the unquestioning trust that patients with acute myocardial infarction may place in their doctor. W h e n such trust exists, the suggestion that one might question and judge the wisdom of one's trust may be seen (as with intimate trust) as a betrayal of what is demanded. The sense of obligation within such a relationship is simply to trust without question (Sumners 1990). However, since 'blind trust' can be an important element affecting well-being in such instances, it is important for nurses to identify the responsibilities of those who would see themselves as advocates of those who trust in this way. Whilst forming close trusting relationships with patients, nurses are accountable in law for the quality of care they give. The professional body, the United Kingdom Central Council for Nursing, Midwifery & Health Visiting (UKCC), also requires nurses to deliver care that is in keeping with stated standards ( U K C C 1992). The U K C C would argue that the aim of 'the Code of Pr@ssional Conduct' is to enable and support nurses in their endeavours to achieve particular standards of care for which it holds them accountable. It may reasonably be asked why such a code of conduct is necessary, if it is assumed that all nurses have goodwill and are altruistic. To some it might appear that the code exists because nurses cannot be trusted; this is further reinforced by the U K C C being represented by nurse managers and nurse educators who wait on the sidelines to accord blame when things go wrong (Walsh & Ford 1994). The U K C C is rather an example of institutional distrust. It constitutes what Lumann (1979) has called a distrust agency, which is designed for the benefit of society as a whole and therefore need not be viewed as a statement about one's trustworthiness or 'goodwill' in particular. It is evident that trust is fundamental to a successful, effective health care relationship.

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However, nurses' traditional approach to this relatively abstract p h e n o m e n o n has been somewhat simplistic and naive. As health care professionals we have much to learn from our patients and other recipients of nursing care. Patients can teach us how to engage in a trusting relationship, so that we as nurses can make a meaningful contribution towards their efforts to maintain independence and well-being following an episode of critical illness. The process of concept analysis, particularly the identification of model, related, contrary cases and the determination of antecedents and consequences, can be useful in suggesting hypotheses regarding concepts and provoking research in other ways (Walker & Avant 1995). This is especially evident with the concept of trust, as such conceptualizations may provide the basis for both independent and dependent variables to be studied through quantitative research. Research that associates trust with nursing can offer a wide range of opportunities for further exploration of the concept. Because of the pervasive and essential nature of trust in nursing, such research has the potential to contribute to the body of nursing knowledge. Future concept analysis of trust may indeed promote a greater understanding of the concept and help to solidify nursing both as a discipline and as a profession.

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