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Patient Centered Care | Unit 5b Lecture
1. Patient-Centered Care
Unit 5: Patient-Provider Communication
Lecture b â Trust and Respectful Interactions
This material (Comp 25 Unit 5) was developed by Columbia University, funded by the Department of Health and
Human Services, Office of the National Coordinator for Health Information Technology under Award
Number 90WT0006.
This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International
License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.
2. Patient-Provider Communication
Learning Objectives
⢠Objective 1: Explain the importance,
elements, and processes of patient-physician
communication (Lecture a)
⢠Objective 2: Discuss the concept of trust in
the context of health care interactions
(Lecture b)
⢠Objective 3: Describe various informatics
tools and the practical considerations to
support patient-provider communication
(Lecture c)
2
3. What is trust?: definitions
⢠âTrust relationships are characterized by one
party, the trustor, having positive expectations
regarding both the competence of the other
party (competence trust), the trustee, and
that they will work in their best interests
(intentional trust)â
⢠âconfidence in and reliance upon others,
whether individuals, professionals, or
organizations, to act in accord with accepted
social, ethical, and legal normsâ
⢠(Institute of Medicine, 2001)
3
4. Characteristics of trust are specific
to health care context
⢠Stronger affective component
(vulnerability)
⢠Altruism, or working in best interests of
patient (honesty, confidentiality, caring and
showing respect)
⢠Competence (social and technical)
4
6. Trust: Does it matter?
⢠Those seeking health care are frequently
experiencing uncertainty
⢠Patients are vulnerable and dependent on the
provider for quality care
⢠There is an indirect influence on health outcomes
through a direct therapeutic effect of empathy and
caring
⢠Trust is also an important characteristic of
employees and health care staff in the workplace
⢠Trust exhibited on the part of the employer
contributes to job satisfaction and a culture of trust
⢠(Calnan and Rowe, 2005)
6
7. Transactional Trust Model
⢠Competence Trust
â Trust of capability
⢠Contractual Trust
â Trust of character
⢠Communication Trust
â Trust of disclosure
⢠(Hoylton-Rushton, Reina, & Reina, 2007)
7
8. Developing a trusting and
connected relationship
⢠Understanding the patientâs needs
⢠Displaying caring actions and attitudes
⢠Providing holistic care
⢠Acting as the patientâs advocate
⢠(Mok and Chiu, 2004)
8
9. The costs or dangers of trust
⢠Abuse of trust with vulnerable patients,
particularly those with limited resources
⢠Easier to trust if powerful and wealthy
⢠Tension between development of trust and
patient empowerment
9
10. Drivers of change
⢠Top down policy initiatives
â E.g. performance management
⢠Wider social and cultural change
â E.g. decline in deference to authority
⢠Negative media coverage of âmedical
scandalsâ
â E.g. the Tuskegee study by U.S. Public Health
Service
10
11. How are trust relations changing?
⢠There is high trust in professional self-regulation,
such as the American Medical Association (AMA)
⢠Patients trust clinical recommendations for
treatment
⢠Patientsâ passively trust primary care providers to
determine access to specialist services
⢠Greater external regulation and monitoring
decreases trust
⢠Increased expectations of patient self-care
requires more clinical trust
11
12. New forms of trust relations
⢠Shift from affect to more cognition-based
⢠Greater interdependence in trust relations
⢠Role of information in trust creation
⢠Importance of institutional trust
⢠More informed, but conditional, trust
12
13. Conceptual framework for explaining
trust relations
Relationship Trustor
(Affect-
Based)
Trustor
(Cognition-
Based)
Trustee
(Reputation
Based on
Status)
Trustee
(Reputation
Based on
Performance)
Context Type of
Trust
Traditional
clinician â
patient
X X
Paternalistic
medicine
Embodied
Traditional
clinician-
clinician
X X
Autonomous
self-
regulation
Peer
Traditional
clinician-
manager
X X
Professional
autonomy /
expertise
Status
New NHS
clinician-patient
X X X X
Expert
patient
Informed
New NHS
Clinician-
clinician
X X
Shared care Earned
New NHS
Clinician-
manager
X X
Clinical
governance
Performance
5.7 Table: Calnan, M, and Rowe, R. (2005).
13
15. Conditional trust behavior (Contâd)
⢠High trust behavior
â Minimal checking
â Informal, unwritten rules
â Significant professional
autonomy
â Willingness to take risks
â Willingness to divulge
information
â Passive, deferent role
â Advice is accepted
unquestioningly
(Calnan and Rowe, 2005)
⢠Low trust behavior
â Constant monitoring
â Detailed and prescriptive
regulations
â Intense supervision and
little delegation of
authority
â Information is withheld
â Questioning, possibly
skeptical, role
â Request for a second
opinion or alternative
source of treatment
15
17. Patientsâ beliefs and behaviors if
there is embodied trust
⢠Patients have a more passive,
deferent role
⢠Information is valued for the
respect it shows rather than its
content
⢠Advice / recommendations are
accepted unquestioningly
⢠Trust relates to âfamilyâ /
âpersonalâ experience of doctor
⢠There is an association
between the level of direct
contact and level of trust
(Calnan and Rowe, 2005)
⢠There is minimal checking or
monitoring with managers and
clinicians being given
considerable autonomy in
decision-making
⢠Rules are unwritten and
informal and processes are not
prescriptive
⢠There is an assumption that
the other party is well-
intentioned towards you
⢠A clinicianâs altruism is
unquestioned
⢠Willingness to take risks is
based on the reputation of the
organisation or individual
17
18. Patientsâ beliefs and behaviors if
there is informed trust
⢠Information is used to
calculate whether trust is
warranted
⢠Careful monitoring,
supervision, and checking
(possibly covert)
⢠Patients want to play a
more equal role in decision-
making
⢠Patients expect doctors to
trust their ability /
competence to self-manage
(Calnan and Rowe, 2005)
⢠Patients may be more
questioning of treatment
recommendations
⢠They may express greater
suspicion and scepticism
about otherâs intentions
⢠Willingness to take risks is
based on careful weighing
up of the situation
18
19. Providersâ beliefs and behaviors if
there is peer trust
⢠An individual clinicianâs
authority and reputation are
based on their position in
the medical hierarchy,
personal networks and word
of mouth recommendation.
⢠Senior cliniciansâ views and
decisions are unquestioned.
⢠Clinical freedom is
unquestioned
⢠Performance is self-
regulated, individually
assessed and not publicly
reported
(Calnan and Rowe, 2005)
⢠Complex patients are only
seen by senior doctors
⢠âSuccessfulâ relations
between clinicians are
based on conforming to
traditional roles
⢠Trust is generally higher
between clinicians of the
same profession and
specialism
19
20. Providersâ beliefs and behaviors if
there is âearnedâ trust
⢠An individual clinicianâs
authority and reputation are
based on their proven skills
and competence, and being
up-to-date with medical
technology
⢠Clinical freedom may be
limited and trust gained by
following agreed protocols
and an ability to work well in
a team
⢠Careful performance
monitoring against targets
⢠Both complex and easy
patients may be seen by
junior clinicians on the basis
that they are following
agreed protocols
(Calnan and Rowe, 2005)
⢠âSuccessfulâ relations
between clinicians are based
on mutual respect for their
different skills
⢠Trust may be higher between
clinicians who have
experience of working
together, irrespective of their
profession or specialism
⢠Communication skills and
providing information are
important in building trust.
⢠Junior clinicians may
question the views of their
seniors.
20
21. Managersâ beliefs and behaviors if
there is status trust
⢠A clinicianâs authority relates to their position and
role within the hospital / organization
⢠Rules are unwritten and there is minimal
monitoring of clinical activity
⢠Trust is one way â clinicians have little need to
trust managers, whereas managers have to trust
clinicians
⢠In decision-making, managers act as
administrators, trusting clinicians with strategic
decisions about service development
⢠Managers are not involved in monitoring or
checking clinical activity
⢠(Calnan and Rowe, 2005)
21
22. Managersâ beliefs and behaviors if
there is performance trust
⢠A clinicianâs authority relates to their ability to meet targets, as
well as their position within the organization
⢠Trust is likely to be higher in those clinicians who have some
managerial role
⢠A willingness to provide information on clinical activity and to
engage with managerial agendas creates trust
⢠In âsuccessfulâ clinician-manager relations trust is important
because it reduces the need for checking and monitoring
⢠Trust is two-way â clinicians need to work with managers to
secure resources and to develop services
⢠In decision-making, managers work with clinicians to make
strategic decisions about services
⢠An evidence-based approach to clinical practice using
guidelines and protocols encourages trust
⢠(Calnan and Rowe, 2005)
22
24. Unit 5: Patient-Provider Communication,
Summary â Lecture b, Trust and Respectful
Interactions
⢠Listen carefully; patients will feel understood
and cared for
⢠Treat patients respectfully; patients will feel
like valuable human beings
⢠Be honest and consistent; patients will feel
that providers are trustworthy
⢠Follow through on commitments; patients will
feel their care is predictable and dependable
⢠Have an accepting attitude; patients will be
more comfortable sharing information about
themselves
24
25. Patient-Provider Communication
References â Lecture b
References
Calnan, M, & Rowe, R. (2005). Trust relations in the ânewâ NHS: theoretical and
methodological challenges.
https://www.kent.ac.uk/scarr/events/Calnanand%20Rowe%20paper.pdf
Institute of Medicine. (2001). Crossing the Quality Chasm: A New Health System for the
21st Century. Committee on Quality of Health Care in America.
Mok, E, & Chiu, PC. (2004). Nurse-patient relationships in palliative care. J Adv Nurs..
48(5):475-83.
25
26. Patient-Provider Communication
References â Lecture b (Contâd)
Charts, Tables, Figures
5.6 Figure: Calnan, M, and Rowe, R. (2005). Trust relations in the ânewâ NHS: theoretical
and methodological challenges. âTaking Stock of Trustâ E.S.R.C Conference London
School of Economics December 2005.
https://www.kent.ac.uk/scarr/events/Calnanand%20Rowe%20paper.pdf
5.7 Table: Calnan, M, and Rowe, R. (2005). Table 1: Conceptual framework for explaining
trust relations in the new âNHSâ. âTaking Stock of Trustâ E.S.R.C Conference London
School of Economics December 2005.
https://www.kent.ac.uk/scarr/events/Calnanand%20Rowe%20paper.pdf
5.8 Table: Calnan, M, and Rowe, R. (2005). Table 2: Attitudes that reflect felt trust.
âTaking Stock of Trustâ E.S.R.C Conference London School of Economics December
2005. https://www.kent.ac.uk/scarr/events/Calnanand%20Rowe%20paper.pdf
5.9 Figure: Axium Healthcare. (2014). http://www.axiumhealthcare.com/patient-provider-
trust/
26
27. Unit 5: Patient-Provider
Communication, Lecture b â Trust
and Respectful Interactions
This material was developed by Columbia
University, funded by the Department of
Health and Human Services, Office of the
National Coordinator for Health Information
Technology under Award Number
90WT0006.
27
Hinweis der Redaktion
Welcome to Patient-Centered Care, Patient-Provider Communication. This is Lecture b.
The objectives for this unit, Patient-Provider Communication are: 1) Explain the importance, elements, and processes of patient-physician communication; 2) Discuss the concept of trust in the context of health care interactions; and 3) Describe various informatics tools and the practical considerations to support patient-provider communication. In this lecture, we will discuss trust and respectful interactions in health care between provider and patient and between health care team members.
Trust is defined by the Institute of Medicine as âconfidence in and reliance upon others, whether individuals, professionals, or organizations, to act in accord with accepted social, ethical, and legal normsâ.
A clear understanding of trust and values of trust is important to both health care and lifelong learning. The building of a trusting provider-patient relationship is based on communication. The patient must see the provider as someone that he or she can be open with about their concerns and not feel judged. If a provider seems uncaring or disinterested, the patient may feel not comforted and may feel depressed from that. Sometimes this condition can make the patientâs situation more stressful. Trust is a part of everyday life and relationships, but there are characteristics of trust that are specific to a health care context. Those are vulnerability, altruism, and competence.
Health care organizations may demonstrate their trustworthiness by putting into place integrated systems with a clinical, educational, and administrative infrastructure that can enable health care professionals to practice in accordance with professional competencies to achieve the desired patient outcomes. In routine care delivery setting, trust must be present in each encounter with patients and families, among interdisciplinary health care professionals, and across all levels of the health care organization to achieve optimal patient outcomes and create a healthy work environment.
Trust and betrayal are two dichotomous forces that affect the quality of relationships at the interpersonal, intrapersonal, team, and organizational levels. These two forces coexist in human interactions and are considered fundamental to developing and maintaining relationships, achieving outcomes and goals, and ensuring the integrity of individuals, processes, and structures. Vulnerability creates the necessity for interpersonal trust. Illness carries an element of risk. There is an uncertainty of outcomes and also an information imbalance between provider and patient. All of these factors play into vulnerability, and trust is an essential factor in the patient-provider relationship at this vulnerable and helpless point in their life. Although the focus of the patient-provider relationship is on the patient in their vulnerable state, everyone in the health care setting experiences risk, uncertainty, and information imbalance which should provide the foundation for empathy and caring.
Here is the component of transactional trust of the Reina Trust and Betrayal Model. According to Rushton, Reina, and Reina, there are behaviors that build trust and offer guidance in creating a trustworthy environment for care. Since the trust is transactional in that it exists in relationships between at least two parties, it involves a mutual exchange, and it is created incrementally over time. âThese components include: competence trust (trust of capability), communication trust (trust of disclosure), and contractual trust (trust of character). For each type of trust, the model specifies behaviors that are essential for building that trust and suggests ways to interact with patients and families." Transactional trust comprises of competence trust, contractual trust, and communication trust. Competence trust is one of capability. Contractual trust is one of character. And communication trust is one of disclosure.
According to Mok and Chiu, there are four themes in the development of a trusting and connected relationship: "(1) understanding the patientâs needs; (2) displaying caring actions and caring attitudes; (3) providing holistic care; and (4) acting as the patientâs advocate".
When a provider responds to a patientâs needs in a trustworthy way, a relationship of trust is developed, and in all conditions the provider strives to be fair and consistent with each patient. This intentional attitude of responsiveness inspires trust, amplifies professionalism, and enhances the credibility of the provider. However, a trusting relationship by its very nature leaves both parties vulnerable to abuse of the trust. In addition, the patient can become less empowered do to the nature of the trusting relationship and providers need to encourage both exploration of empowerment as well as nurturing trust.
The importance of clear, straightforward communication is vital to trust. In as much as patients can relate their symptoms without fear or caveat, so too must providers lose jargon and explain what they know and understand about those symptoms in plain language. Being able to risk saying âI donât knowâ or showing uncertainty about the outcomes of treatment, are part of balanced interpersonal interactions. In this respect, not only must patients trust their providers, but also, providers must trust their patients. This shift could be attributed to top-down policy initiatives, negative media coverage of âmedical scandalsâ, and wider social and cultural change.
When clinical care professionals become aware of the myriad ways that trust can be built, they are able to alter their communication, decision making, and behaviors in trustworthy ways. This awareness can lead to the development of intentional strategies that can be integrated into each patient care encounter by becoming more aware of the impact of trust on the relationship. The more that a patient is responsible for their own complex care, such as managing wounds or insulin doses, the more the health care professionals must trust the patient. The more the provider is managing and in control of patient care, the less the provider has to trust the patient. Conversely, the more the provider adheres to clinical recommendations, the more the patient trusts the provider, and the less aligned the provider is with professional standards, the less the patient trusts the provider.
Acknowledging peopleâs skills and abilities became an essential component of trusting relationships. Medical care professionals demonstrate competence trust when they work closely with patients and families to clarify their intentions and assess their preferences. Trust includes the act of engaging the patient and family in exploring and understanding the implications of certain decisions on the whole person and the family.
Competence trust supports patients and families in their own decision-making process and involves others who can support and facilitate patientsâ or familiesâ own internal resources. Inquiring about how they can be helped and supported, the strengths that serve them as they navigate through difficult times, and practices that support their well-being acknowledges the inner capabilities of patients and families. The framework on this slide shows the variation in types of trust based on the context of the relationship of the provider to the patient.
Trust can be developed and nurtured by providing the right conditions that promote and support trust. These conditions include behaviors on the part of the person seeking to grow trust that are addressed towards both the trustee and the trustor. The behaviors that build conditional trust include: managing expectations, establishing boundaries, delegating appropriately, encouraging mutually serving intentions, and keeping agreements and consistency.
One key behavior to foster conditional trust is to work with patients, families, and colleagues to clarify the meaning and conditions of the relationship. Establishing therapeutic and professional boundaries, and identifying shared intentions about the relationship, helps avoid unintentional betrayals and creates a shared understanding of expectations and of responsibility that are essential to building trust. Clear boundaries, the limits of the professional relationship that allow for a safe, therapeutic connection between the professional and the patient, are essential for trustworthy relationships. The beginning of a therapeutic relationship is the best time to establish respectful boundaries with patients and families. Later, circumstances marked by increasing vulnerability may make maintaining a balance of engagement and separateness more difficult, especially if either party has a diminished capacity for trust. Boundary violations, either constricted or diffuse, can undermine trustworthiness.
Contractual trust, another dimension of transactional trust, is based on the confidence that promises that are made will be kept. Promises may concern the expectations patients or their families have about outcomes, treatment processes, or potential complications to the boundaries and tenor of their relationships with healthcare professionals.
Clinical care professionals, patients, and families may employ constrictive or controlling behaviors to create a sense of safety from the uncertain and unpredictable events that are inherent to all patients. Constrictive or controlling behaviors are manifested in multiple ways, such as rigidity in the individualâs actions and thought or criticism of others not sharing the same values. It can also be manifested as distancing behaviors, ranging from emotional withdrawal, physical isolation, and superficial interactions to raging, hostility, or distraction in a flurry of activity.
Informed trust is important, especially within the context of shared decision-making. Informed trust includes both the patientâs affect and cognition, as well as the providerâs status and performance for the basis of trust. With this type of trust, the patient has an active role in the relationship. Information weighs heavily in the trust between the patient and the provider and could encourage a collaboration between patient and provider when it comes to decision-making.
Peer trust is between providers and is based on cognition and status. Patterns of âoverinvolvementâ may be the clinicianâs attempt to relieve feelings of loneliness by establishing connections. Inappropriate disclosures and interactions, including breaches of confidentiality, may also be a manifestation. Whatever form they take, boundary violations can undermine relationships and break trust in every sphereâpersonal, professional, and community.
Earned trust is another type of trust between clinicians. It is also based on cognition, but instead of status, it is dependent on performance. In other words, actions and outcomes are highly valued. This encourages collaboration and team-based practice between providers so that one could experience the performance of other providers. Trust is key in the performance of a team when delivering care. There are other units that go further into detail regarding teamwork, relationships, and communication.
Status trust is between a provider and administration and relates to authority. There is a symbiotic relationship between the two roles because they rely on the other to make decisions and perform work. Contractual trust also involves matching the needs of patients and families to participate in care with appropriate opportunities, resources, and support. Clinicians must be mindful to consider ways to engage patients and families in meaningful participation in treatment and caregiving. Understanding how patients and families wish to participate and their own assessment of their capacities to do so is the foundation for delegating appropriately.
Performance trust is a bi-directional relationship between clinicians and administrations because again they depend on each other to perform. Administration makes decisions about resources and services and clinicians affect the performance goals, targets, and outcomes. In broad terms, trust is a relational notion or psychological state that influences individualsâ willingness to act on the basis of the words, motives, intentions, actions, and decisions of others under conditions of uncertainty, risk, or vulnerability. Workplace trust in health care settings is a phenomenon that involves fair treatment and respectful interactions between individuals. Workplace trust in health care settings entails the providerâs trust in colleagues (linked to teamwork and shared experiences), trust in supervisors (related to personal behaviors and which do have an impact on trust in the organization), and trust in the employing organization (influenced by leadership and human resource management practices). Such trust relationships enable cooperation among health care workers and their colleagues, supervisors, managers, and patients and may act as a source of intrinsic motivation.
At the surface, trust may be a simple concept, especially since we encounter it in our everyday lives and relationships. However, there are various kinds of trust between different people and positions. There is transactional trust, which implies that trust is between two parties and there is a mutual exchange of trust. Competence, contractual, communication, and conditional are types of transactional trust. We also discussed embodied trust, which is between a clinician and a patient and is more reflective of a paternalistic type of relationship. The shift from a paternalistic relationship to a mutual relationship between patient and provider reflects informed trust and more of a partnership and collaboration. Then there are types of trusts between clinicians. Peer trust is one type and is traditional, in the sense, that it is dependent on status. Earned trust is another type of trust between clinicians and instead of status, it is due to performance. Additionally, you can have trust between clinicians and administrators. One type is called status trust and is dependent on authority. The other type is trust due to performance. As you can tell, trust is a simple, but yet also, a complex concept. Trust is very important, especially in the context of health care.
This concludes Lecture b of Patient-Provider Communication. To summarize, there are behaviors that facilitate trust and respectful interactions, such as listening carefully, treating patients respectfully, being honest and consistent, following through on commitments, and having an accepting attitude. Patients must be able to trust their doctors with their lives and well-being. Trust is a central element in the provider-patient relationship and the trust that patients have in their provider to act in their best interest contributes to the effectiveness and quality of medical care.
