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Journal of Nursing

Building Trusting Work Relationships in Healthcare and Beyond

Pablo Velez, PhD, RN, Sherry Nooravi PsyD. [email protected]


Introduction


The healthcare environment is constantly and rapidly changing with new regulations, new technology and workforce transformations. Now more than ever, it is critical to build organizational trust to foster employee and physician engagement, improve patient care, and boost financial performance. According to Twibell & Townsend (2011), broken trust takes both a human and economic toll, causing the entire healthcare organization to suffer. According to Galford & Drapeau (2013) there is a link between trust and corporate performance. If people trust each other and their leaders, they will (1) work through disagreements; (2) take smarter risks; (3) work harder; (4) stay with the company longer and (5) contribute better ideas.

In an effort to help leaders in various types of healthcare organizations learn how to build trust and work relationships within their organizations, eight CNOs of eight California healthcare organizations ranging in size from 150 beds to 500 beds, and teams of 700 employees were interviewed. All the CNOs interviewed were females. Years of experience as CNO ranged from five to more than 25. All the CNOs except for one have master’s degrees in nursing or business administration. Interviews were conducted in a private setting and participants were informed that information shared would be kept confidential, results would be incorporated into one document, and identities would remain unidentified. All the CNOs were asked the same structured questions. Interviews lasted approximately one hour. The CNOs were asked to define trust and components that build trust (see table 1 for definitions). Interviews were transcribed by the same person for consistency, and the two researchers read and highlighted themes independently of each other. These themes and dimensions were then identified and discussed between them.

Results


Our results include the definitions of trust by the eight CNOs, the dimensions of trust, the Four R’s of building trustworthy relationships and how the CNOs go about building it in their organizations. We developed an acronym of SHARE that CNOs, healthcare administrators and physician leaders can utilize in leadership development trainings and ultimately as a tool to build stronger relationships and employee engagement in their organizations. Last, we discuss what CNOs describe as “trust blockers,” actions a CNO can take that would break the employee’s trust.

Trust Definitions


Trust is having a relationship where you can put yourself, your real self, and really be intimate with someone else not like physically, but mentally. Trust is a reaction to authenticity and authenticity is a synonym that I would use for trustworthiness. Behaving in ways that are consistent and that others think are authentic. Having some sense of prediction.

Someone with whom I can be sure that I am understood and if we both agreed, I can depend on that agreement. Someone who says what they mean, means what they say and does what they say.

When two individuals establish feelings that they are both comfortable and confident that what they say and what they do are one in the same. That there is a comfort level that it’s OK to take risks and feel that you would get support.

One component of trust is independent decision-making and support within the organization for anything. Empowering your workforce and having confidence in what they do.

Trust is built on past experiences primarily, so generally, if someone keeps their word, if they follow through with something they promised.

Trust is dignity and honoring the presence of each other, including feelings, thoughts and expertise, because no one comes into this as an empty vessel.

Being trustful, for me, means that I don’t have to worry that whatever I do or say, I am going to hear back later in a negative way that you don’t believe I can do the role I was hired to do. Trust is not being second guessed.

CNOs were asked how they go about developing trustworthy relationship with staff. They discussed that this is an ongoing process and that they observe staff over time to ensure consistency of behavior and performance. The following five dimensions were identified as key ingredients to having trustworthy working relationships:

1. Authenticity
2. Work ethics
3. Communicating and sharing news
4. History and reputation
5. Creating a supportive and empowering environment

Authenticity was defined by one CNO as “being congruent – in other words, having who you have inside and who you express yourself as being and wanting the same.” The following is an example of what being authentic meant to another CNO: “State your position and why you feel a certain way: ‘I feel that my requests don't get the same attention that others' requests do. Is there something wrong in our relationship?’ or be specific about what you observed and that you'd like to understand the person's thinking. Be authentic and non-judgmental when telling the person you'd like to understand his or her point of view.” She spoke about the importance of ensuring body language is open and inviting.

From the interviews, the “four Rs of building trustworthy relationships” were identified:

1. Real self: As one CNO put it, “Say what you mean, do what you say and own what you do.”
2. Respect: “How does someone behave, how do they talk to other people? Do they talk behind their back? Do they say one thing and do something different?”
3. Relationship: “Engaging with staff on a personal level and having a willingness to listen.”
4. Risk-taking: “Encouraging risk-taking and supporting staff if things go wrong. Knowing I can always depend on that person.”

One of the CNOs conveyed the thought succinctly: “I think you could be the smartest person in the world, but if you don't have trusting relationships at work, what can you accomplish? I have no tolerance for employees who are not kind to our patients. I trust when I see my employees rounding, washing a patient’s hair, and doing all the little things we do that show we actually care for people. That shows me that they are trustworthy and not just here for the job. These employees are engaged, present and have a protective nature for their patients.”
Work ethics was defined as doing whatever it takes to get the job done, doing it well and meeting deadlines. As one CNO put it, “When I delegate a job, I don’t have to worry about it. I know it’s going to get done.” Another component of work ethics that was raised was staff demonstrating good decision-making processes, competency, a strong skill set and a high level of commitment.”

The theme of communication and sharing news was consistently mentioned by all CNOs, who spoke about the importance of clear communication, “telling it like it is” and honesty. The CNOs indicated that it is important not only to learn from mistakes, but to admit to them when they have been made. They indicated that transparency and communicating with staff are important, and that explaining “the why” and two-way engagement are key. They also shared the value of providing staff with sensitive and accurate information so they feel a sense of ownership, and being accessible to them. The CNOs discussed that when they provide information, they look to see if that information has been kept confidential. One CNO shared, “Sometimes problems that need to be corrected would never surface until something really bad happens. Trust is essential so that anybody can highlight areas for improvement and problems can be corrected without fear.” As another CNO indicated, “I think a lack of trust breeds a lot of misinformation, gossip, fear, and redirects away from our purpose, which is to take care of patients.”

We developed an acronym based on the responses for how the CNOs said they build trust as S.H.A.R.E.
S: Share the vision and values
H: “How can I help you? How are you?” The key here is really knowing your people, including their strengths, challenges, and about their home lives when appropriate.
A: Authenticity
R: Role modeling and being consistent
E: Engage for change and seek input, open the door more frequently and lend an ear

As one CNO said, “Be absolutely transparent. Be more curious than certain. Don't ever assume. There are no cookie-cutter cultures or environments. Every healthcare institution has its own rhythm, culture and pain point. You need to meet with as many of your people as possible and validate that everyone makes a difference. We have an obligation as leaders to help people see that something would be missing if they weren't in this world doing what they do best. We all have a common calling and it’s our responsibility to tell people about that and find out where we need to support them.”

On the subject of history and reputation, the CNOs shared they observe staff over time to see if they keep confidential information confidential. They validate information before jumping to conclusions and taking action. They look for a history of a proven track record and past behaviors. As one CNO shared, “I watch staff over time for their patterns of behavior and consistency of those behaviors. You can hear a rumor or something the person said, but then you come to learn they did not ‘walk the walk.’ That makes you feel unsettled and causes you to question whether or not you can trust this individual because they did not follow through with something they said, saying one thing but doing something different, putting me in an embarrassing situation. I trust people, and then I look at their actions. It takes time.” The CNOs indicated that developing trust is an ongoing process in which you see a theme again and again and the outcomes match what you hope to accomplish. As one CNO stated, “I think trust is built primarily on past experiences. Generally, if someone keeps their word, if they follow through with something they promised, if they are kind and giving to other people, and if they sustain those things over time and show me that’s who they are, then I tend to trust them.”

In discussions about the value of creating a supportive and empowering environment, the CNOs mentioned the importance of praise, encouragement and “have someone’s back.” The CNOs talked about the importance of supporting and guiding staff through difficult situations. As one CNO put it, “How you approach staff and the words you use will either give you grief or hang your star. There is great value in trying to understand where staff is coming from and helping them deal with difficult situations. I think it's important to create a learning environment so staff understands there are no dumb questions and that if someone makes a mistake, it's OK as long as there is learning.” Leaders also need to learn when to apologize because doing so makes them a stronger leader.”

Trust Blockers: CNO Actions that Break Employee Trust


We believe that it is important to learn from the best practices of healthcare leaders holistically. This means it is also important to learn from the mistakes they have made or seen in others. This build on using other’s wisdom and avoiding “recreating the wheel.” The CNOs shared some of the actions that can results in breaking trust with employees. Well intentioned leaders may engage in these types of behaviors for a variety of reasons including: (1) Not taking the time to reflect on their thoughts and assumptions, (2) Not taking the time to plan change and explain what is needed from the staff, (3) Being inconsistent with their words and actions and (4) Leading from a place of fear or inability to confront behavior.

The “Trust Blockers” that CNOs shared can break employee trust were:
1. Our assumptions and assuming the worst of a person or situation based on past experiences
2. Not explaining changes to the staff
3. Unclear expectations on what the staff needs to do to be successful
4. Misinformation, gossip, leading with fear; being in constant panic mode and passing this on to employees
5. Not “walking the talk” and inconsistency with your directives and behaviors
6. Generalizing - Seeing one ineffective behavior in an employee and painting the whole person in a negative way because they have an area to work on (such as being reactionary)
7. Not confronting and/or blindly trusting curious employee behavior, for example employees with facades of being the “golden” boy or “golden” girl

Discussion


As our healthcare industry changes at an accelerated pace, it is imperative that effective relationships are built between leaders and frontline staff. Our research supports and outlines an effective model for building trusting relationships between all members of an organization. Leaders have a critical duty to facilitate this important process. The more CNOs and healthcare leaders can develop themselves with a foundation of trustworthy behaviors, the stronger, more empowered and effective their employee culture will be. Further, this research can apply to industries outside of healthcare as leaders aim to strengthen their personal leadership styles and to strengthen their workplace environments by creating and role modeling a more open communication culture.

References


Galford, R. & Drapeau, A.S., 2013. The Enemies of Trust. Harvard Business Review.
Twibell, R. & Townsend, T. (2011). Trust in the workplace: Build it, break it, mend it. American Nurse Today, November 2011 Vol. 6 No. 11.


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