Triadic Trust: Nurses, Patients, and Institutions—Implications for Critical Care Nurses

Trust is central to the delivery of health care. Nurses exhibit features of both interpersonal and institutional trust in their work. Nursing demands trust in nurse-patient relationships. And yet, the care nurses provide is a form of labor, highly professionalized, systematized, and resourced by health care institutions. Health care institutions, such as hospitals, are vested in the experiences of both nurses, their largest workforce population, and patients, their primary consumer. Health care institutions, such as health care organizations and hospitals, also play a critical role in shaping the social and physical environments in which patients receive care and nurses work. As such, the institutions are a primary participant in cultivating normative expectations around trust within the nurse-patient relationship.However, the very health care institutions that create those normative expectations also create conditions that promote trust betrayal, resulting in betrayed trust. Thus, health care institutions set expectations for trust relationships between nurses and patients that are nearly impossible for nurses to fulfill. This results in the dilemma of professionalized trust (DPT). This dilemma highlights a case of trust that is both interpersonal and institutional, and recharacterizes the nurse-patient relationship from a dyad to a triad, with institutions as a third party, one that intervenes in and shapes the nurse-patient relationship. Shifting from a dyadic to a triadic concept of trust relationships helps demonstrate that the nature of trust in institutional settings is inherently multirelational and elucidates trust-relationship dynamics in the nursing context between nurses, patients, and institutions. This triadic model offers a conceptual resource for nurses when they face challenges maintaining trust with patients and families. Understanding trust as triadic in the health care context is important because it emphasizes the pervasive role institutions have on breakdowns in trust between nurses and patients that is otherwise obscured.Sarah, an intensive care unit nurse at an academic medical center, walks onto her unit and takes her patient assignment for the shift, which is beyond the upper limit of their staffing ratio of 2 patients to 1 nurse. It includes the sickest person on the unit, Jane, a patient experiencing increasing delirium who has been challenging for staff to keep safe from falling out of bed and pulling out her intravenous catheters. Fortunately, Sarah has cared for Jane and her family often over the past several months and has developed a close relationship with them.Sarah’s shift is dangerously busy, beset further by inadequate or nonfunctional equipment. This, in conjunction with the fact that the unit is short-staffed for the number of patients in their census with no relief nurses available throughout the hospital, piles onto Sarah’s mounting stress over keeping Jane safe. Near the end of the shift, family members arrive, and Sarah reports to them that while she is increasingly agitated, Jane has not fallen or pulled out any of her intravenous catheters.When Sarah returns with the night nurse for handoff, the family angrily confronts her, pointing to Jane’s bloody restraint mittens; she had managed to pull out her central venous catheter. Because unplanned removal of the catheter puts Jane at risk for complications, Sarah takes the necessary steps to ensure Jane is safe, coordinating with the team to place a new central venous catheter and reports the event in her hospital’s safety event reporting system.Afterward, Sarah returns to discuss the event with the family. The family members are enraged, berating Sarah for nearly an hour. Sarah is crushed when the family demands she never be assigned to Jane’s care again. Later, in discussing the event with the unit and hospital leadership during a safety debrief, little attention is given to the many challenges Sarah faced during her shift to keep Jane safe.In analyzing the above case, many different features of the case details could be drawn out and emphasized. Understanding the relationships between nurses, patients, and institutions through the lens of trust, trust betrayal, and broken trust is vital to understanding these stakeholders’ shared experiences in the health care setting. This framing also affirms the existing 50-year literature on trust in a variety of stakeholder relationships in the clinical setting.1,2 In the nursing literature, trust is considered one foundational feature in the relationship between nurses and patients.3 Trust has been characterized as an essential element of all nurse-patient relationships and part of a relational process where trust can be broken and reestablished.4 More specifically, nurses’ professional competencies and interpersonal caring attributes were most important in the development of trust.5 Much of the literature also accounts for the role of health care organizations in protecting nurses’ ability to cultivate therapeutic trusting relationships with patients, which results in better outcomes for both nurses and patients.6–9 In the philosophic literature, normative features of trust are argued to include goodwill, expertise, commitments, and professionalism.10–13 In this column, I use the concept of trust used by Hawley,11 as commitment, but any other concept, such as those noted above, can fit into the triadic model. Appropriately conceptualizing relationships of trust in health care settings among nurses, patients, and institutions is one way the triadic model will contribute to the intersecting literatures on trust in nursing and philosophy.A review of the example of Sarah and Jane through 2 different dyadic models of trust illustrates how the dyadic model inadequately describes their breakdown. In the simplified dyadic model, which captures everyday trust relationship dynamics between 2 parties, the only relevant parties in the case are Sarah and Jane; Sarah has failed to uphold her commitment to patient safety, to keeping Jane safe. In this model, Sarah has a trust commitment to keeping Jane safe from harm; when she fails to reliably fulfill that commitment, there is little else to inform how that trust-betrayal occurred. The simplified dyadic model flattens our understanding of the situation and fails to reveal the more complex dimensions of trust.A more nuanced dyadic relationship model involves several dyadic relationships at a time across multiple participants, known as the stacked dyadic model (see Figure 1). In this model, 3 of the 4 possible relationships available among 3 participants are captured: the nurse-patient (N-P) dyad, the nurse-institution (N-I) dyad, and the patient-institution (P-I) dyad. The stacked dyadic model captures everyday, ordinary understandings of trust that occur between 2 parties while also allowing for the reality that people have many relationships with different trust commitments between them. In this case study, the relevant participants and their individual relationships are clear: Sarah and Jane, Sarah and the hospital, and the hospital and Jane. Within these siloed dyads, participants have distinct relationships with distinct commitments of trust between them, and each participant has 2 sets of possible commitments to negotiate at any given time. So, nurses have commitments in the N-P dyad as well as the N-I dyad, such that (1) Sarah has a specific trust commitment to Jane in keeping her safe from harm, and (2) Sarah also has trust commitments to the hospital to be a good employee and to excel in her care for patients. This is also true for institutions, such as hospital systems: (1) The hospital has a trust commitment to Sarah to ensure that she can meet her obligations to provide patient care safely; (2) the hospital has a trust commitment to Sarah in providing a safe work environment; and (3) the hospital also has trust commitments to Jane and her family to provide safe and competent patient care (through their system processes, employees, and so forth).However, a model of siloed dyadic trust relationship dynamics falls short of fully capturing the interrelationships and the social dynamics of trust that occur in the relationship between all 3 participants. What the dyadic accounts of trust cannot model and what the triadic model can, is the emergent relationship between all 3 participants of the nurse-patient-institution triad. In this model, our understanding of trust relationship dynamics is irreducible to its dyadic parts (see Figure 1). The fulfillment or betrayal of trust is grounded in both the trust expectations and trust capacities of participants that are either more or less in alignment or in competition across the triad. These expectations and capacities are not generated and siloed by any one participant or dyad but are emergently in play across and through the interconnected triad relationships.In capturing the emergent relationship between all 3 participants, we can model a range of social dynamics of trust that the stacked dyadic model cannot. Briefly, some examples of these social dynamics include the following.In the philosophical literature on trust, which often presumes a dyadic orientation, the focus lies in analyzing what ethically special feature distinguishes trust from mere reliance, whether it be goodwill, expertise, commitment, or professionalism.10–13 In the triadic model of trust, the relevant focus on trust is not necessarily which feature distinguishes trust from reliance. Rather, the relevant focus of triadic trust is in understanding how trust is formed, maintained, or eventually betrayed and repaired between participants in more than 2 interconnected relationships. In the triadic model of trust relationship dynamics, trust in nursing can only be fully understood by capturing the participants in the context of nursing, including nurses, patients, and institutions. In capturing the appropriate participants, a richer view of 4 interconnected trust relationships is possible, including the nurse-patient dyad, the nurse-institution dyad, the patient-institution dyad, and the emergent relationship of the nurse-patient-institution triad. Briefly, it is worth noting that in this model, 3 is a minimum number of participants in an institutional setting, where in general participants include an institution, a consumer or client, and a professional intermediary. Of course, many other participants and stakeholders work in institutional settings and engage and intervene on these 3 primary relationships. In the setting of nursing and health care, for example, other individuals also involved in these relationships include, but are not limited to, the patient’s family, other clinicians in the health care team, hospital administrators, insurance companies, governmental regulatory bodies, professional clinician organizations, researchers, news reporters, and the public. However, it is beyond the scope of this commentary to address the full polyadic nature of trust relationships.In sum, understanding trust dynamics in the context of nursing requires including institutions (which are made up of both individuals in leadership positions and organizational structures and processes) as a participant in the relationship between nurses and patients. Trust is not experienced by any one dyadic relationship alone but is influenced by each individual’s relationship with each of the other participants. The triadic model of trust relationship dynamics brings the emergent relationship between these participants into view in a way the dyadic models of trust cannot.When we include institutions, we identify 2 important features of how trust manifests in interconnected relationships. The first is how normative expectations of trust are set across participants and by whom. The second is how individual participants’ capacities to fulfill those trust expectations are dependent on institutional conditions. Institutional conditions can either empower or diminish participants’ capacities to fulfill or betray trust. Institutions are a vital participant in setting trust expectations for nurses and patients and creating institutional conditions that shape nurses’ capacities. Institutions are the third key participant that needs to be included to achieve better explanations of how trust manifests in the nursing and health care context.This is best exemplified through the DPT, which is generated from the triadic model. Further analysis of the case through the triadic model and the DPT will involve using primary contextual features relevant to institutional settings: (1) The role of institutions in setting trust expectations between nurse and patient participants; (2) how institutions’ conditions shape participants’ capacity to make good on the trust expectation in question; and finally, (3) how those conditions either protect against or foment trust-betrayal between participants.The triadic model presumes that both nurses and institutions make commitments to patient safety while also recognizing that these commitments bear on nurses and institutions differently. Importantly, expectations for patient safety, and how they inform the actual commitments made by nurses and institutions, originate from all 3 participants. However, health care systems, organizations, and institutions play a primary role in shaping patients’ and nurses’ experiences in care to generate both general trust expectations and specific commitments for aspects of care. Patients’ and nurses’ perspectives on the experience of care are mediated, in part, by the hospital system, which serves as both the work environment for nurses and the care environment for patients. Health care systems are invested in assessing and understanding both patients’ and nurses’ perspectives of the care experience and their satisfaction. One way health care systems assess what quality care looks like to nurses and patients is in research on both parties’ experiences of, and satisfaction with, the care environment. Assessments of nurse and patient experience and satisfaction can include measurement scores of patient and nurse satisfaction and research on their respective “essentials” of care. Each essential feature identified can be seen as a normative declaration of what good health care should involve for patients to receive high-quality care or what work conditions nurses should have to best be positioned to provide that degree of high-quality care.Health care systems regard patient satisfaction scores as an important assessment for organizational practice and patient outcomes; they serve as one indicator on the quality of care provided to patients. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is the first national, standardized, publicly reported survey of patients’ perspectives of hospital care.14 HCAHPS scores, among other assessment tools, are one view into the patient’s experience of care and might indicate what aspects of care are particularly valuable.15 Much research has been done to identify what aspects of quality care patients value most and consider essential to good health care.16,17Health care systems prioritize assessing nurses’ experience and satisfaction in the delivery of patient care. Health care systems are invested in the connection between improving nurses’ work environment for the effects it has on nurses’ job satisfaction, which in turn impacts nurse retention and, subsequently, patient outcomes and satisfaction.18,19 For example, one study found that higher odds of patient mortality, failure to rescue, and prolonged length of stay were found in hospitals that had, on average, higher nurse burnout scores.20 Considering the connections between nurses’ work environment and patient outcomes, health care systems also often partner with professional organizations to better tailor work environments to the needs of specific professional and patient populations. The American Association of Critical-Care Nurses (AACN) represents and advocates for the needs of nurses working in hospital systems. Over the past 20 years, AACN has investigated the status of work conditions for nurses and put forward 6 standards for a healthy work environment: skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition, and authentic leadership.21 In their 2021 National Nurse Work Environment study, AACN found that workplaces that actively implemented any of the 6 standards had better results across domains that include nurses’ intent to leave the job, nurses’ experience of moral distress, the degree of appropriate staffing, and perceived patient care quality.21We can compare the essentials of a high-quality health care experience as generated by patients with the essentials nurses identify as necessary in their work environment for the delivery of high-quality care. While there are many examples in the literature of essential standards or quality indicators of care for both nurses and patients, we can directly consider at least 2 specifically. These can serve as exemplars of how normative expectations are explicitly generated by health care systems, as well as by professional organizations in the research and standards they create; these exemplars also show how normative expectations are embedded within these organizations. The Picker Institute of Europe generated 8 such patient-driven essentials from research with patients in developing a model of patient-centered care.22 Research by Kramer and Schmalenberg23 found 8 nurse-identified “essentials of magnetism”—based on nurses working in Magnet-certified hospitals—that define the ideal working environment influencing the provision of quality nursing care.23 The Table summarizes these essentials.22,23 The above empirical work on essentials of care, when placed in context with the triadic model, demonstrates how institutions participate in generating trust expectations based on nurses’ and patients’ experiences.The relationship between nurses and patients is one context where the normative expectations for care are delivered. However, the normative trust expectations cultivated by institutions can be in tension with institutional conditions that shape nurses’ capacities to fulfill those trust expectations. System and organizational barriers can impact the ability of nurses to satisfy those expectations, further mediating the relationship between nurses and patients. Some examples of organizational barriers that prevent patient- and family-centered care or compassionate care include nurse shortages, no support to clinicians in achieving this care, workload, high nurse-patient ratio, overcrowded hospitals, clinician burnout, poor intensive care unit design, inconsistency between the workload and its allocated time, and inattention to the needs of the nurse by the organization.24,25 In the case example, organizational barriers for Sarah included being in an assignment beyond her unit-specific staffing ratio, a lack of staff resources such as a sitter or more nursing staff, and a significant failure at the organizational level to respond to the safety event the fact during the safety organizational barriers are one way that institutional conditions actively prevent nurses from being to fulfill the expectations for care that both patients and nurses setting up conditions for trust betrayal to This is an example of how trust dynamics among participants are across the triad, as individual participants, in this case institutions, to over the of the dyadic on the role and of a therapeutic relationship between nurses and patients can the in setting conditions. The triadic on the emergent nature of social dynamics across the triad relationship brings the of institutions over other participants into In the DPT, health care institutions actively participate in setting up both trust expectations between nurses and patients, as well as nurses and they also create conditions that nurses’ capacities to fulfill trust in either relationship. More specifically, the DPT can be understood as health care systems set up trust relationships that are impossible for nurses to expectations for trust between nurses and patients and nurses and institutions and nurses’ capacities for trust, institutions set nurses up for the case of Sarah and Jane, on a dyadic model, Sarah be for to meet her commitment to keeping Jane safe. In institutions, there be very little attention to, or of, the existing and working conditions that Sarah’s ability to meet that commitment of safety to Jane. the triadic of the impact of the organizational barriers noted in the helps our understanding of how the trust betrayal for Sarah and Jane. In a setting of poor staffing, a lack of and poor support for nursing staff, Sarah’s to fulfill her commitment to keeping Jane safe is not fully by her Rather, Sarah’s failure to uphold her commitment, while to Jane, is more understood against the of the care and work environment that the for them trust betrayal not only occur between Sarah and Jane. The triadic model also demonstrates 2 other of trust one that in this case between Sarah and the institution, as well as trust betrayal within Sarah Research by and to specific in organizational leadership that either or trust with nursing staff, with the including failure to and Sarah’s understanding of how the poor staffing model or lack of institutional or resources the betrayal might generate a further of for a shift in her as a safe nurse. that institutional conditions the betrayal, Sarah might to standards to fulfill the trust of patients and meet her of the of nurse she However, it is possible for the triadic model to be a conceptual resource for nurses like where it describes and how everyday breakdowns in trust with patients and The triadic model can also serve as a way nurses, such as can assess the institutions they work in for the quality of healthy or trust relationships between patients, and institutions. In the model can serve patients and in better understanding the way in which institutions directly shape their relationship with clinicians at the and the quality of the care they of trust in philosophical literature provide a lens to the features of relationships trust. of trust in nursing literature to how institutions trust between nurses and patients in but no existing model of trust fully describes the multirelational nature of trust in health care institutions and the practice of The dyadic of the nursing and literature can only so in understanding the relational dynamics of trust in institutional settings where relationships involve more than 2 participants. on dyadic relationships alone is less to nursing practice because of the nature of moral in nursing, where nurses are for that they not have been part of in the context of nursing, what the dyadic models cannot and what the triadic model can, is the emergent relationship between all 3 participants of the nurse-patient-institution triad. In capturing 3 key participants of trust and their the triadic model can better the social dynamics of trust across those relationships. The DPT the role institutions play in trust betrayal between nurses and patients. using the triadic model and the DPT to the case of trust-betrayal between Sarah and Jane, we how they can serve as a conceptual and resource for nurses, patients, and institutions to better and the relationship of trust between them.