The fragile frontiers of trust in healthcare

Have you ever been in the situation of vulnerability, perhaps as a hospital patient, in which you felt able to trust some clinical staff more than others? As I have previously studied trust in the nursing context (see. ), I have decided to explore whether there are any recognisable patterns at the personal level in feelings of trust or distrust. What leaps out at me more than anything else is my observation that the issue of trust doesn’t become relevant until the moment you encounter someone you feel you can’t trust entirely.

As this is a sensitive issue, I am keeping my personal sources private. And I should make clear that this blogpost, being drawn from highly personal experiences, cannot claim to be generalisable. Despite these caveats, I hope that my observations find resonance with readers.

I have tried to find useful starting points in the trust literature. The most helpful source I have found is an academic paper by Liz Bell and Anita Duffy published in 2009 in the British Journal of Nursing.

They identified the following four characteristics of trust in a nursing context:

  • Expectation of competence
  • Goodwill of others
  • Fragility/vulnerability
  • Element of risk.

I’ll organise my thoughts around this list.

Expectation of competence

It is not easy for patients to know whether the people caring for them are competent. One patient might be impressed that a care worker is wearing gloves to do finger-prick tests, and another might be very concerned to notice that the gloves are not changed between patients.

Healthcare Support Workers (HCSWs) and housekeeping staff are the people who have the most sustained contact with patients, maintaining the routine ‘servicing’ work. Between them, they make sure the beds, bodies, floors and so on, are clean. They serve up food and drink. They maintain the routine patient observations of ‘vital signs’, enquire whether patients have any pain, and record food and drink intake and bowel movements. In a recent hospital stay, I was surprised that the only person who asked me how I was feeling ‘in myself’ was a doctor.

From the vantage point of a patient, it is hard to know whether or not someone is good at their job. So much of the work happens out of sight. With the divisions of labour on a hospital ward, it is difficult even to know what people’s jobs are. How do you know if someone is stepping outside the boundaries of their competence? Some members of the housekeeping staff might be very keen to engage the patients in conversation about their conditions and their anxieties, and others quietly get on with cleaning tasks. Which is more competent? Can you trust a housekeeper to handle your anxieties sensitively as much as you can a nurse?

Much of this expectation of competence is an expression of hope. Expecting confidence and goodwill from those who care for you is based on hope for a good recovery and/or the best possible care at a time of need.

Goodwill of others

Do healthcare staff have the best interests of their patients at heart? Are they diligent? Do they have the personal capacity to care?

Body language

Why would a patient sense a lack of trust in someone who, as far as they can tell, is perfectly competent? Part of the answer here is that healthcare is not just about getting things done, although this is of course vital. Trust is important because people are not simply machines to be serviced and repaired. Trust also hinges on attitude. Body language could give clues.

Some people look as though everything is just too much effort. Perhaps they are preoccupied with their own tiredness, discomfort, or boredom. If they are in a caring role in these circumstances, it can be difficult for a patient to feel confident about their capacity to care.

By contrast, some people exude a kind of flamboyance clearly aimed at cheering patients and colleagues with their sunny and congenial disposition. Whilst it’s reassuring to know that people are putting positive energy into their work, patients may be left wondering whether this behaviour is masking a lack of knowledge or a fundamental lack of confidence. Most concerning – is this flamboyance a sign of over-preoccupation with ‘jollying people along’ at the expense of the more sober work of caring for people who are in a vulnerable position? Now, I suddenly realise this perceived capacity to care could be at the root of trust.


Diligence and capacity to care

I am starting to feel some better insight into the elusive nature of trust. Patients need to know that a person who has a key role to play in their care is taking a solicitous and diligent approach to their work. A telling proxy for care and diligence is hand hygiene. Who do you trust better? A flamboyant high-octane worker who does not change gloves between patients, or a very reserved care worker, who has a downtrodden air about him, going quietly about his work, sanitising his hands in a well-rehearsed fashion at all the appropriate times? Perhaps the more concrete concerns about cross infection can override the initial impact of body language.

The strange thing is, if you trust someone intuitively, you probably wouldn’t bother to monitor their hand hygiene. I remember the badges that were all the rage just a little while ago – the ones that stated ‘Clean hands? It’s OK to ask’. Whatever happened to them?

If body language sparks distrust, I know that trust is repairable. The person just needs to show that patient’s recovery, dignity, or relief of suffering is their prime concern as they carry out their work. Patients don’t want to feel that we are inconveniencing the staff. On the whole, they want to be ‘good’ patients – not excessively demanding, grateful for the care and thankful that the NHS still exists. In return, they want the staff to see them as individuals.


To encourage a trusting relationship with patients, staff need to let down their defences just a little.


Imagine I’m lying in a hospital bed. You appear at my side. I’ve never seen you before, I don’t recognize your uniform, I don’t know on what basis I can trust you. Tell me who you are when you first come to my bedside. What is your name? What is your role? Are you qualified for the tasks you are performing? Are you responsible for my care today, or are you just performing the one task? It makes a difference. Without this knowledge, I am left wondering. I don’t understand how the team fits together and how the communication is working behind the scenes. I don’t know whether I should trust you or not.

Does someone have my back?

Now I feel I’m really getting somewhere in my efforts to understand the trust or distrust felt by hospital inpatients. They want to know that someone has their back. If things aren’t getting done properly, they want to know that someone in a position of authority will notice. They need to know where the accountability lies. A clear sense of leadership is missing sometimes. Patients need to know who is in charge. Managers and leaders need to be making some visible effort to communicate with patients person to person.

If I said to a nurse that I am expecting a blood sample to be taken today and am concerned that it hasn’t happened, it is only mildly reassuring to be told that the phlebotomist will turn up at some point if they want the blood. I want the nurse to check. Perhaps I misunderstood what the doctor said yesterday. Taking initiative at this one-to-one level would go a long way in restoring trust. Patients are afraid of appearing too bossy, too interfering, too self-important. They want nurses to be able to ‘read’ situations and respond appropriately.

Will you respond appropriately in an emergency?

It takes a position of vulnerability to raise your sensibilities regarding trust. If you’re not feeling vulnerable, trust isn’t important. Sudden life-threatening events expose vulnerability at its most extreme. If a patient observes a care worker not responding with sufficient urgency, either to a patient’s call for help, or a dangerous change in vital signs, any trust they have in that worker is likely to crumble.

Element of risk

There is an element of risk on both sides of a relationship based on trust. From a worker’s point of view, letting down one’s defences could open the way to overfamiliarity. Worse, giving away ‘too much information’ could lead to misinterpretation on the part of a patient. Healthcare staff are constantly aware of the risk of litigation. Taking time to follow up the concerns of one patient will have to be balanced with competing priorities – something has to give.

From the viewpoint of a patient, their very vulnerability adds an element of risk. For example, they have to trust nurses to administer medications correctly. Any routine medications they could normally manage themselves are now in the hands of someone else. Hospital acquired infections loom large as constant threats. Invasive treatments such as surgery or the insertion of needles, cannulas and tubes carry risk. Sick patients are at risk of developing pressure ulcers. I can go on.

Patients want to trust

I’ll conclude by drawing together the strands I have woven here. Patients want to trust healthcare staff. It goes with the hope they hold at a time of extreme need: hoping for recovery, or simply tender loving care. Body language gives important signals, but perhaps the more concrete demonstration of diligence and capacity to care hold sway. The vulnerability of patients can make them look for signs that someone has their back. They need to know that there is a trustworthy figure who is accountable. They need to see that staff respond appropriately in an emergency. Healthcare is a risky business. Risk is present on both sides. Everyone, including patients, needs to pull together to minimise these risks. I hope the steady, caring, trustworthy people get the recognition they deserve.