Concept Analysis of Trust

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The antecedents, attributes and consequences of trust amongnurses and nurse managers: A concept analysis

T.J. McCabe a,*, Sally Sambrook b,1

a National College of Ireland, Mayor Street, IFSC, Dublin 1, Irelandb Bangor Business School, Bangor University Hen Goleg, College Road, Bangor, Gwynedd, LL57 2DG, UK

International Journal of Nursing Studies 51 (2014) 815–827

A R T I C L E I N F O

Article history:

Received 5 March 2013

Received in revised form 3 October 2013

Accepted 6 October 2013

Keywords:

Concept analysis

Nurses

Nurse managers

Trust

A B S T R A C T

Background: Although trust has been investigated in the health context, limited research

explores nurse and nurse manager perceptions of trust.

Objective: To explore the concept of trust amongst nurses and nurse managers at

individual, interpersonal and organisational levels.

Design: Our paper reports the findings from an interpretivist study conducted within the

British National Health Service, involving thirty-nine semi-structured interviews with

nurses and nurse managers.

Settings: Large acute and small community organisation within the British National

Health Service.

Participants: 28 nurses and 11 nurse managers working within an Acute and a Community

sector organisation – 20 and 19 in each organisation. Participants were selected through a

process of purposive sampling, reflecting variations in terms of age, grade, ward and

tenure.

Methods: We utilise a concept analysis framework in exploring the antecedents, attributes

and consequences of trust amongst nurses and nurse managers at individual,

interpersonal and organisational levels.

Results: Key findings suggest that trust is formed within the immediate ward

environment, and is significantly influenced by the role of line manager. Other positively

influencing factors include professionalism and commitment to the nursing profession.

These form the basis for the teamwork, delegation, support, open communication systems,

confidentiality and discretion essential to delivering quality patient care. Negatively

influencing factors include new management concepts, practices and styles overseen by

managers recruited from the private sector. New management concepts were associated

with reductions in the number of qualified nurses and increasing numbers of untrained

nursing staff, reduced direct patient contact, less opportunities for professional training

and development and deteriorating terms and conditions of employment.

Conclusions: Our findings offer insight for managers, nurses and human resource

practitioners to help build high trust relationships in a health care context. Of particular

import is the need for managers to communicate more effectively organisational and

financial constraints, in a manner that does not ‘alienate’ nurses and nurse managers, by

highlighting their value and acknowledging their role in delivering high quality patient

care.

� 2013 Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: +353 1 4498550.

E-mail addresses: [email protected], [email protected] (T.J. McCabe), [email protected] (S. Sambrook).1 Tel.: +44 1248 38 2046.

Contents lists available at ScienceDirect

International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

0020-7489/$ – see front matter � 2013 Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.ijnurstu.2013.10.003


What is already known about this topic

� General management was introduced into the publicservices as the basis for more effective governance andbetter representation of service users. This saw theintroduction of new concepts such as privatisation,quality, customer service and performance management.� Trust is a multi-dimensional concept linked to notions of

vulnerability based on the goodwill, benevolence andcompetence of another party.� Trust often tends to be developed through individuals

with particular characteristics rather than abstractnotions of the organisation or generalised others.� Change in healthcare organisations on trust has resulted

in declining levels of trust in management but increasinglevels of trust in ‘nurse managers’.

What this paper adds

� Trust is formed within the immediate ward environmentamongst nursing professionals and is significantlyinfluenced through the nurse manager role.� Evidence of professionalism was significant in the

development of trust amongst nurses and nurse man-agers. This formed the basis of the teamwork, delegationand support required for an efficient work environment,considered as the main consequence of trust.� Communication systems and styles, linked to confiden-

tiality and discretion influenced the development oftrust. Nursing professionals were more likely to trustmanagement with open styles of communication, whowere approachable and accessible.� New management concepts, practices and styles, intro-

duced by managers recruited from the private sector, hada negative impact on trust levels. New managementconcepts and resource management were viewed asresponsible for lower numbers of qualified nurses,increasing numbers of untrained nursing staff, reduceddirect patient contact, professional training and devel-opment and poorer terms and conditions of employ-ment.

Implications for policy and/or practice

� Offers insights and opportunities for health care man-agers, nurses and human resource practitioners toconsider the influencing factors of trust in building hightrust relationships.

1. Introduction

Traditionally employment within health and socialcare has tended to attract and favour individuals with astrong occupational or professional commitment (Bar-tlett, 2007, p. 126), to organisations with ‘‘a crediblecommitment and support’’ for their ‘‘professional com-petence’’ (O’Donohue and Nelson, 2007, p. 554). However,in response to increasing conflicts with state and serviceusers (Rose, 1996; Gilbert, 2005), ‘managerialism’ wasintroduced as the basis for effective governance of public

services (Doolin and Lawrence, 1997; Calnan and Gabe,2001; Jommi et al., 2001; Pollitt, 1993). Concepts such asprivatisation, free choice, quality, customer service andperformance management became widespread, reflectingthe increasing use of the discourses and practices of themarket (Nordgren, 2008), and a move towards a compe-titive business culture (Davies and Mannion, 2000).‘Managerialism’, in terms of its rhetoric, has tended toposition itself as ethically opposed to the professionaldiscourses, that were viewed as guilty of ‘paternalism’ andarrogant self-interest, raising the wider issue of trust(Traynor, 1999). Trust is managed by positioning ‘man-agerial governance’ in opposition to ‘professional exper-tise’, with both claiming to represent the best interests ofservice users (Traynor, 1999).

Trust has become a valuable and scarce commodity inlate modernity (Brown, 2009), and plays a major role inhealth care, an environment characterised by ‘uncertainty’.It is crucial in managing vulnerability (Hall et al., 2001) andcomplexity (Luhmann, 1979), where patients are bothvulnerable and reliant upon the competence and inten-tions of the practitioner (Brown, 2008; Williams, 2007;Alaszweski, 2003; Hall et al., 2001). It is consideredessential in the nurse-patient relationship (Mechanic,2004; Peter and Morgan, 2001), where nurses ‘interface’between patient and ‘hospital’ (Bolton, 2004), and act asthe main signifier of patient satisfaction (Arthur and James,1994; Attree, 2001; Mahon, 1996). Trust and associatedbenefits such as ‘commitment’ and ‘goodwill’ are alsorequired to ensure the maintenance of service quality(Skinner et al., 2004; Hau, 2004; Walsh, 1995; Halliday,2004), particularly in an environment driven by servicedemands and technology (Williams, 2005). It is particu-larly essential in achieving extensive structural, philoso-phical and value changes (Moye and Henkin, 2006; Kiffen-Peterson and Cordery, 2003).

2. Background

The multi-dimensional nature of trust has made itdifficult to define (Hosmer, 1995), with definitions rangingfrom commodity (Dasgupta, 1988) to an emphasis on asocial reality (Lewis and Weigert, 1985), vulnerability (Hallet al., 2001; Mollering, 2007) and a basis for bargaining(Coleman, 1983). Trust has been defined as ‘‘one’swillingness to increase one’s vulnerability to anotherwhose behaviour is not under one’s control’’ (Zand, 1972, p.230). It is conceptualised as a process involving vulner-ability (Brockner et al., 1997; Laschinger and Finegan,2005; Mayer et al., 1995) and risk (Sellman, 2007), wherethere is an expectation of others and a giving of self.However because trust involves vulnerability there shouldbe ‘good reasons’ when entering into a ‘trust relationship’(Laschinger and Finegan, 2005). Trust is fragile, it can beeasily undermined and ‘destroyed’ (Owen and Powell,2006). The consequences of trust are the realisation ofexpected benefits or continued trust (Johns, 1996; Hams,1997). Drawing on a concept analysis framework (Walkerand Avant, 1988; Rodgers, 1989) we now review thetheoretical antecedents, attributes and consequences oftrust.

T.J. McCabe, S. Sambrook / International Journal of Nursing Studies 51 (2014) 815–827816


2.1. Antecedents of trust

Calnan and Sanford (2004) emphasise the importanceof individuals in developing trust, rather than widersystems and processes. Brown (2009) found that direct‘tangible’ experiences had a more profound influence ontrust, as opposed to more remote, abstract notions of theinstitution – yet notes a lack of supporting theory as to whyindividuals act as a more compelling basis for thedevelopment of trust. Meize-Grochowski (1984) andStewart (1996) found that trust involved having con-fidence in ‘someone’ or ‘something’.

In addition to competence and reliability (Sellman,2007; Poortinga and Pidgeon, 2003) trust is also influencedby beliefs regarding the ‘good-will’ and benevolence ofothers (Baier, 1985, 1986, 1994; Robinson, 1996). Trustarises from the perception of another’s competence, theirtechnical and social skills, and the belief that the ‘trustee’ isworking in the ‘truster’s’ best interests (Hupcey and Miller,2006; Rowe and Calnan, 2006). Reciprocal gesturesdemonstrating ‘goodwill’, giving others the ‘benefit ofthe doubt’ (Owen and Powell, 2006) tend to reinforce trustas they reduce the level of uncertainty amongst partici-pants (Fox, 1974; Brockner et al., 1997; Kramer, 1999).Sanders and Schyns (2006) found that supervisors whotrusted their subordinates were more likely to gain theirtrust in return.

Trust is influenced by previous experience (Lewickiet al., 1998; Saunders and Thornhill, 2003), based on theperceived personality traits and qualities of others(Mollering et al., 2004; Smith, 2005). It is increasedthrough positive communication and interaction over time(Brown, 2009; Meize-Grochowski, 1984). Communication,openness, listening to others and keeping employeesinformed through open communication channels (Bowenand Lawler, 1995; Shaw, 1997; Weatherup, 1997; Ran-dolph, 1995) all positively influenced trust (Barnes, 1981;

Brann and Foddy, 1988; Morgan and Hunt, 1994). Schutz(1932/1972) also discusses the vital role played by the‘truster’ in actively interpreting knowledge, as it wasmeant and ‘‘intended by the communicator’’ (Schutz,1932/1972, p. 127). This literature on the antecedents oftrust can be summarised as tangible experiences withspecific individuals, Reciprocal gestures of benevolenceand goodwill, and open communication systems, whichare illustrated in Fig. 1.

2.2. Attributes of trust

Within health care, the concept of trust is consideredfundamental to a supportive relationship between staffand managers (Rowe and Calnan, 2006), where clinicalnurse managers demonstrate good leadership, areapproachable, flexible and available. This is also linkedto the development of professional and personal compe-tence amongst nursing staff (Galvin and Timmins, 2010).Trust also needs to occur at all levels within theorganisation, particularly at ward level for the effectivedelivery of quality patient care (Saunders and Thornhill,2003; Gilson, 2006) and safety (Tallman, 2007).

The first component of a trustworthy individualinvolves a willingness to engage in relationships (Hams,1997). Other components include listening skills, respect,caring, honesty and confidentiality (Hupcey and Miller,2006; Rowe and Calnan, 2006). Martins (2002) suggeststhat managers need five specific characteristics; emotionalstability, resourcefulness, outgoing personality (extraver-sion), agreeableness and conscientiousness. Other char-acteristics of ‘trustworthy’ managers and colleaguesinclude; predictability, dependability (Holmes andRempel, 1989), reliability (Johnshon-Geroge and Swap,1982; Zucker, 1986) and loyalty (Butler and Cantrell,1984). Managers considered ethical, fair and predictablewere also more likely to be trusted (Errol and Bruce, 2005).

Anteceden ts

Organisational

• Tang ible exp eriences with

spec ific ind ividu al’s - rather

than wider systems and

process es.

• Rec iproca l ges tures of

benevo lence and good will .

• Open commun ication systems.

Consequence s

Organisational and Individual

• Eff iciency.

• Adap tabilit y.

• Good leade r-member exchang e.

• Low trust link ed to poo r qu alit y

pati ent ca re.

Att ribu tes

Individual

• Profess ion al competence .

• Authenti c leade rship.

• Good commun ication styles.

• Con fidenti alit y.

Fig. 1. A summary of the theoretical relationship between the Antecedents, Attributes and Consequences of Trust – Individual, Interpersonal and

Organisational.

T.J. McCabe, S. Sambrook / International Journal of Nursing Studies 51 (2014) 815–827 817


Other studies suggest that characteristics of trusted nursemanagers include an ability to build good relationships,motivate others, remain positive and press on with theirvision (Johns, 1996; Hams, 1997; Doucet, 2009). SimilarlyWong and Laschinger (2010) found that increased‘authentic leadership’ in nurse managers led to increasedtrust levels in the nurse manager concerned, which in turnplayed a role in fostering organisational trust, workengagement, voice behaviour and perceived quality ofcare. The relationship between the line manager role inexplaining employee behaviour, issues of trust, loyalty,commitment and performance have been discussed andhighlighted in nursing and health care (Laschinger et al.,2000). This literature on the attributes of trust can besummarised as Authentic Leadership, Professionalism,Communication styles and Confidentiality, which areillustrated in Fig. 1.

2.3. Consequences of trust

Trust has a positive relationship with efficiency,adjustment, communication, openness, organisationalcommitment, adaptability and survival (Kiffen-Petersonand Cordery, 2003; Moye and Henkin, 2006). It is positivelycorrelated with problem solving (Zand, 1972), individualand collective performance (Earley, 1986; McAllister,1995), citizenship behaviour (McAllister, 1995), co-opera-tion (Fine and Holyfield, 1996) communication (Robertsand O’Reilly, 1974) and employee satisfaction (Dirks andFerrin, 2002). Conversely, low trust can lead to a ‘greateramount of surveillance or monitoring of work in progress’(Mayer et al., 1995, p. 728). Surveillance reduces the levelof innovation and cooperation amongst employees, andcan undermine the relationship between managers andemployees (Brann and Foddy, 1988; Kramer, 1999).

Following the ‘restructuring’ and ‘downsizing’ in theCanadian health service, Laschinger and Finegan (2005)discussed how declining levels of trust amongst nurses andtheir managers resulted in declining levels of morale,commitment, and organisational performance withincreasing levels of work related stress. They identifiedthe development of trust as a crucially important leaderactivity. Good leader-member exchange, between line-managers, and subordinates, resulted in better workattitudes (Chiaburu and Marinova, 2006) and led to greatertrust in head nurses (Chen et al., 2008). Tallman’s (2007)research reinforces Mayer et al.’s (1995) three factor modelof trust, demonstrating that changes in health careorganisations impacted on trust in management, whichwas low, with significantly higher levels of trust insupervisors. Calnan and Rowe (2006) attribute the erosionof trust primarily to the introduction of the ‘health servicesmanager’. The important role played by nurse managers inpositively increasing the general level of trust in manage-ment has also been highlighted in previous studies (Chenet al., 2008; Tallman, 2007). Skinner et al. (2004), suggestthat ongoing change, with an increased focus on theorganisation away from the profession, offers a lesseffective basis upon which to establish trust. While trustand mistrust has frequently been mentioned in the nursingliterature (Calnan et al., 2006; Sellman, 2007), we note a

limited focus on trust between nurses and colleagues,suggesting that trust in these relationships is not believedto be problematic or significant to the outcome of patientcare (Mullarkey et al., 2011). However, where mistrustexists between nurses the results often do negatively affectpatient care (Calnan et al., 2006; Rowe and Calnan, 2006).This literature on the consequences of (high) trust can besummarised as Efficiency, Adaptability, and Good leader-member exchange, while Low trust is linked with poorpatient care. These are illustrated in Fig. 1.

While trust is increasingly important within the healthcare context, and is frequently highlighted in the nursingliterature (Calnan et al., 2006; Sellman, 2007), we note thelimited research regarding perceptions of trust betweenmanagers and nurses. Our study attempts to address thesegaps and gain further insight into this complex concept.Our paper reports the findings of a study exploring theconcept of trust amongst nurses and nurse managers. Weprovide an initial summary of the theoretical relationshipbetween between the Antecedents, Attributes and Con-

sequences of Trust (Fig. 1). We subsequently analyse theantecedents, attributes and consequences of the concept oftrust amongst nurses and nurse managers, and considerthe implications they may have for nursing practice. Theseare highlighted at individual, interpersonal and organisa-tional levels. The concept of trust transcends nationalborders, thus the findings have international relevance.

3. Aim of the study

Nurses in organisations make judgments regarding theextent to which they trust their line-managers, and theorganisation in which they work. Although trust has beeninvestigated in health as well as other contexts, limitedresearch explores nurse and nurse manager perceptions oftrust. The aim of the study was to explore the antecedents,attributes and consequences of the concept of trustamongst nursing professionals, at individual, interpersonaland organisational levels.

4. Methodology

This is an inductive study on the social construction oftrust, based on the premise that organisational phenomenaare socially constructed and sustained through ongoinginteraction between participants (Berger and Luckmann,1966; Morgan and Smircich, 1980). By exploring phenom-ena through the eyes of the participants, their meaningsand interpretations, we sought to clarify and developframeworks for understanding the references used (Burrelland Morgan, 1979; Daft and Weick, 1984). This study seeksto provide a contextually relevant understanding of theconcept of trust (O’Neill, 1995), in this case the antecedents,attributes and consequences of trust. Antecedents includepersonal and organisational factors influencing how theconcept is enacted (Walker and Avant, 1988; Rodgers,1989). Attributes can be considered as the defining‘characteristics’ or ‘attributes’ of a concept (Walker andAvant, 1988). Consequences are the outcomes of enactingthe concept (Walker and Avant, 1988; Rodgers, 1989).



4.1. Sample/participants

The interviewees were selected through a process ofpurposive sampling to reflect varying age, grade, ward andtenure. They were informed about the study through theirline manager and participated on the basis of availabilityon the day and level of interest. The nurse managers andnurses participated voluntarily, with confidentialityassured. Interviews were conducted in private roomsclose to the ward where the nurses were working for theirconvenience.

Thirty-nine participants were selected, 20 from theacute hospital and 19 from the community hospital. Thesample included 28 staff nurses (a mix of D and E grades)and 11 nurse managers (consisting of a mix of F, G and Hgrades). These included 12 nurses and 8 nurse managersfrom the acute organisation and 16 nurses and 3 nursemanagers from the community organisation (Table 1).

The mean age of participants in the acute organisationwas 38.5 years old – ranging from 25 to 54 years old. Themean age of the participants in the community organisa-tion was 40.7 years old – ranging from 27 to 57 years old.The abbreviations in Table 1 represent years spent innursing and highlight the organisation, Acute or Commu-nity (A or C), Nurse (N, e.g. N1, N2, etc.), Nurse Manager(NM, e.g. NM1, NM2, etc.), the gender of the interviewees(F or M) followed by their age.

4.2. Data collection tool

Semi-structured interviews were employed to educethe experiences of nurses and nurse managers, to learn asmuch as possible about the concept of trust from theirperspective. Given that managers have key interpreta-tional roles (Bennis and Nanus, 1985; Smircich andMorgan, 1982), the views of both nurses and nursemanagers are presented to elicit their collective inter-pretations. The interview schedule was informed by anextensive literature review and piloted amongst fournurses. It comprised a detailed set of open-endedquestions, including: (1) how the participants conceptua-lised trust and the level of trust within their working

environment; (2) the characteristics and attributes of trustand trustworthy managers; (3) the consequences of lowtrust.

Each nurse and nurse manager was asked to describeand discuss trust. They were initially asked, ‘‘What do youmean when you think about and talk about trust?’’ Thisenabled the interviewees to reflect and articulate theirown concept of trust. While reflecting on the meaning oftrust, the participants were then asked about the nature oftrust between themselves, their colleagues and line-managers on their ward, and trust within the widerorganisation. They were then asked to discuss factorscontributing to trust, characteristics of trust and ‘trust-worthy’ managers, and possible consequences of thebreakdown or absence of trust.

The interviews lasted approximately 45 min to 1 h andwere recorded through note taking and audio cassette (forreference purposes). They were recorded and transcribedin full text format.

4.3. Ethical considerations

Two British National Health Service (NHS) organisa-tions were selected: one acute and one communityhospital. Access to participants was negotiated andapproved by Human Resources, who also acted as theinitial point of contact between the interviewer (firstauthor) and interviewees. Approval was granted by bothorganisations’ ethics committees.

4.4. Data analysis

The study used a concept analysis framework. Thisinvolved a thematic analysis (Easterby-Smith et al., 2008)of the qualitative interview data in identifying anddeveloping the main themes and sub-categories. We usedthe theoretical relationship between the Antecedents,Attributes and Consequences of trust as a framework toguide our analysis of the qualitative data (Fig. 1).

Each interview transcript was analysed, verbatimsections that corresponded with the various categorieswere selected with interviewee details and placed into a

Table 1

Participant demographics.

Acute <5 5–10 11–15 16–20 21–25 26–30 31+

Eye Infirmary ANM1-F26 AN1-F48

Child Health AN2-F42 AN3-F45

Cardiac ANM2-F33 AN4-F38

Midwife AN5-F46 AN6-F26 ANM3-F54

Neurology AN7-F30

Haematology AN8-F25

Anaesthetics AN9-F34

ANM6-M37

ANM4-F39

Renal ANM8-F36 AN10-F47

Orthopaedic AN11-F49

AN12-F43

Oncology ANM5-F35

Surgical ANM7-F38

Community CN1-F48 CN9-F27

CN10-F32

CN13-F27

CNM1-F29

CN5-F41

CN6-F33

CN11-F31

CN14-F35

CN16-F42 CN2-F42 CN3-F39

CN4-F40 CN15-F54

CNM3- M50

CN7-F48

CN8-F48

CN12-F57

CNM2-F51



qualitative table under the corresponding category.Approximately 240 such excerpts were recorded. Thecoded categories were examined for their relationshipswith one another for patterns, emerging themes to ensurethat all categories were identified in the data.

We found considerable similarities comparing theresponses across the acute and the community organi-sation, amongst nurses and nurse managers. In manycases nurse managers echoed what nurses were saying.While the interviewees in the acute organisation sharedmany of the issues experienced by their communitycounterparts, their feelings were not as negative, norwere they as critical of their managers in relation to poorcommunication and the management of organisationalchange.

4.5. Findings

We present the antecedents, attributes and consequences

of trust as perceived by nurses and nurse managers,summarised in Table 2. There is some overlap betweenorganisational and individual factors in our conceptanalysis of trust. Analysis of our findings suggested thatthe discourses and the perceptions of nurses in relation tothe concept of trust focused mainly on the characteristicsof trustworthy managers. While antecedents of trust focusprimarily on organisational factors such as immediate

work environment, communication systems and newmanagement, the attributes of trust focused on individualcharacteristics of trusted individuals such as leadership,professionalism, communication styles and confidential-ity. Finally we present consequences both as the presence oftrust and the absence of trust or mistrust, amongst nursesand nurse line-managers. The consequence of ‘high trust’was the benefits and outcomes associated with the conceptof trust, professionalism, efficiency and the delivery of highquality patient care. These were underpinned by team-work, delegation and support. The consequence of ‘lowtrust’ or ‘mistrust’, was the absence of the benefits of trustresulting in reduced ‘efficiency’ and increasing surveil-lance. Low trust work environments were associated withreduced levels of teamwork, delegation, support andpatient care quality. They were also associated with higherlevels of work-related stress, conflict, absenteeism andlabour turnover.

4.5.1. Immediate work environment – leadership

The participants discussed a high level of trust amongstnurses and nurse managers within their immediate wardenvironment. They said that they were less likely to trustthose outside their immediate work environment.

‘‘There is an element of trust within the smallerenvironment in which I work. However within the

Table 2

A concept analysis of Antecedents, Attributes and Consequences of trust: nurse and nurse manager perspectives.

Immediate work

environment – Leadership

‘‘I trust my immediate superior but I have very little to do with the rest of the other managers. . . Presumably if

my immediate superior trusts them (management) then I would trust them’’ (ANM3)

‘‘‘‘Management’’ don’t come down to the ward and say hello. . .They are the ones that will come down jumping

on our heads if something goes wrong and say ‘I didn’t know what was going on’’’ (CN9)

‘‘You trust them (line-manager) to know what the right thing is. You trust their judgement. . .she (line manager)

taught me an awful lot, and yes I would trust her’’ (ANM5)

‘‘My Supervisor supports us which makes us a good team. That is what she does and that is what makes you feel

that you can trust people’’ (AN3)

New Management Concepts,

Practices and Styles

‘‘Nursing staff are seen as commodities. Patients are also viewed as commodities. They don’t think of us as

human beings. This does not make people feel valued. Being valued is very important because it motivates you

to work’’ (AN3)

‘‘I trust my direct managers completely but only because I am currently involved in the decision-making. I know

exactly what is going on’’ (AN1)

‘‘If something goes wrong the general feeling is that management (middle and senior level) won’t support you’’

(CNM2)

Communication Systems

and Styles – Involvement,

Confidentiality and Discretion

‘‘We have a thing called ‘clinical supervision’. There is a lot of trust involved in that. That is about staff of the

same grade, supervising each other, being a sounding board, saying things like ‘I think you don’t do that well’.

You have to have a high degree of trust in someone else to allow them to say those things to you’’ (CN16)

‘‘If you are not coping with things, or you have a problem with your team, you need to talk it over with your

manager and work out some way that you can sort it out. It makes for a better relationship and a better working

environment’’ (AN12)

Professionalism – Efficiency,

Teamwork and Support

‘‘I think people recognise commitment is a form of trust, a part of ‘professional trust’. If you are committed then

you are not going to give up easily and run away from your professional responsibilities’’ (AN7)

‘‘You cannot work efficiently; you don’t feel as if you are working as part of a team’’ (AN3)

‘‘I think it makes you feel good about yourself if you know that your superior trusts you. That has got a ‘knock on’

effect with everyone else. Like I say if I trust my team, and they know I trust them, they feel better as well’’

(CNM1)

‘‘It would be the patients that would suffer in the long run, then myself (a climate of ‘low trust’). If things weren’t

done as they should be, or were just missed out because somebody didn’t know how to do a certain procedure. If

I am doing 101 other things I haven’t got the time! You can only spread yourself so far!’’(CN5)

‘‘If you cannot trust your fellow workers it is not a very nice place to work. It would make my work

harder. . .People would be going off sick, the stress levels would hit the roof. If you couldn’t trust the people you

were with you would just be so stressed. We have had situations when you felt you weren’t supported by some

members of the team’’ (CN16)



larger, wider organisational context I think there is a lotof distrust. . .you tend to employ people (nurses) on theward who you would naturally warm towards’’ (ANM8)

As most nurses had limited contact or involvement withsenior management, they tended to base their views on theattitudes of their line manager. The attitudes of nursemanagers towards ‘senior management’ tended to ‘rub off’on their subordinates. The nurse manager role wasconsidered highly significant in developing trust, in theimmediate work environment and in the wider organisa-tional context.

‘‘If there is conflict between myself and my managers,the way I then come back to the ward and present it willeither make them (nurses) trust or mistrust manage-ment’’ (ANM8)

Individuals that showed ‘leadership’, who led byexample and demonstrated ‘good’ judgement, were morelikely to gain the trust of others. Nurses were also morelikely to trust managers they considered accessible,approachable, involved and ‘hands on’, which theyassociated with feeling supported, respected and valued.

‘‘I will say that one of managers has come and workedon the ward and that went down really well. She ‘rolledup her sleeves’ and helped’’ (CN12)

They were less inclined to trust managers perceived as‘inaccessible’, ‘removed’ or those managers higher upwithin the organisational hierarchy.

‘‘I think he (line-manager) could maybe become a moreactive member of staff. That is when he is on duty he canbe counted on. He needs to work on the ward ratherthan do managerial tasks. He should be involved on theward’’ (CN13)

‘‘How can you trust someone you don’t know?’’ (CN12)

Many nurses considered senior management as ‘dis-tant’ figures who were removed from the work they did.

4.5.2. New management concepts, practices and styles

The introduction of new management concepts, prac-tices and styles, previously associated with the privatesector, created considerable mistrust. Many participantssaid that managers recruited from the private sector hadlittle or no experience in health care, and did not sharetheir sense of professional commitment to best practicenursing or patient care. They felt that management’sconcern with resource management and quantitativeperformance indicators such as patient throughput clashedand conflicted with their professional nursing values andtraining. They felt that this perceived lack of support frommanagement limited their ability to administer bestpractice patient care.

‘‘The introduction of new management practices hasseen the introduction of business people, businessculture and private sector managerial jargon, a custo-mer service ethos and an attempt to set in placemechanisms to measure and control quality. There is amove to breakdown and erode the power of medical

professionals and other groups of employees within theNHS’’ (CNM3)

‘‘We used to care for people, now we treat them!’’(CNM3)

The participants perceived the issue of ‘resourcemanagement’ as having impacted upon them in a numberof respects. They perceived resource management ashaving reduced the number of qualified nursing staffworking on the hospital wards, many of whom hadsubsequently been replaced with health care assistants(HCAs). They also perceived resource management aslimiting the scope and the resources available for patientcare, professional training and development. Finally theyfelt that resource management was responsible for theirdeteriorating terms and conditions of employment. Thesewere viewed as the main reasons why many nurses lefttheir respective hospitals or quit the profession altogether.

‘‘This (nursing staff turnover) was mainly due to thepoor introduction of the ‘new system’, low staffinglevels and patients who were really poorly coming ontothe ward through the Medical Assessment Unit. All thestaff left this Ward. Everyone was leaving, getting jobselsewhere and getting off that ward. You could not feelthat you could commit yourself to the patient, becauseyou had so much work. . .you just felt that. . .‘I cannotcope with this!’’’ (AN10)

‘‘Things are missed out. . ..The basic things are done, thethings that make a difference to whether someone livesor dies. But the important things. . .The little things. . .

Like being able to spend time with somebody and talk tothem. Listen to their fears and anxieties, being able to sitwith a relative who is distressed. That is very oftenmissed out because there is not enough time for it’’(ANM6)

4.5.3. Communication systems and styles – involvement,

confidentiality and discretion

Regular communication that was ‘open’, ‘honest’ and‘clear’, was discussed as an antecedent, attribute andconsequence of trust. Appropriate communication channelsand styles resulted in increased levels of understanding,clarity and cooperation. Nurses highlighted ward meetingsas a form of ‘peer support’, where staff could openly andconstructively discuss how they ‘functioned as a team’.Communication also helped diffuse the potential forconflict.

‘‘She (nurse line-manager) has been very good through-out the ward closure. Obviously she had to work withhigher level management but she always kept usinformed, and has always came back to us and told uswhat was happening throughout the meetings’’ (CN11)

‘Poor communication’ was discussed as the main factorundermining trust between nursing professionals and‘management’.

‘‘If you trust somebody you will communicate withthem. If there is no communication between all the



different areas then you are not going to have mutualtrust, because no one understands anyone else. Peoplewon’t know what they are working towards, andproblems set in. This happened previously. No onetrusted the manager. . .Very often conflict arisesbecause of a lack of knowledge and understanding ofaspects of work, and what other peoples’ roles are’’(AN11)

Many participants did not understand the supportingrationale behind organisational change, particularly whenit came to ward closures and staff relocation. Theyexpressed frustration at the lack of any meaningfulinvolvement in the change process, and felt that greaterinvolvement could reduce feelings of insecurity andmistrust. They also felt that they were been kept ‘in thedark’ in relation to management planning and decision-making.

‘‘I wouldn’t trust them (management) further than Icould throw them! Because of the way they havehandled some situations! They have just handled somesituations appallingly’’ (CN2)

A history of negative experiences, characterised bybroken promises and commitments, also made trust moredifficult to establish. Linked to communication was thetheme of confidentiality and discretion. While the majorityof participants felt that they were able to confide in theircolleagues and line-managers, they stressed the impor-tance of knowing that they could confide in theircolleagues and managers in resolving any problems orissues they were experiencing. They also said that theirtrust levels would be undermined if their confidentialitywas in anyway broken or compromised.

‘‘If they have gone and talked to everyone it is veryundermining. I got so angry with that person, andbecause she was my manager I had absolutely norespect and never really gave her the time of dayafterwards. . . If you go to someone and they respectconfidentiality it can enhance your working relation-ship a lot more’’ (AN4)

4.5.4. Professionalism – efficiency, teamwork and support

Evidence of having a strong commitment towardsprofessional nursing values, best practice nursing andpatient care were considered very important in contribut-ing towards the development of trust. It was alsoimportant that ‘trusted parties’ acted in the best interestsof the nursing profession, as an ‘advocate’ for nurses andthe work that they did. Peer support and teamwork fromcolleagues and managers was considered very importantin developing trust, and delivering high quality patientcare.

‘‘You have to rely on other people to help. You can’t do itall by yourself. You have to trust your colleagues, theirwork and their abilities’’ (AN5)

‘Professional competence’, ‘consistency’, ‘accountabil-ity’ and ‘objectivity’ in decision-making and behaviourwere viewed as attributes of ‘trusted’ line-managers and

colleagues. It was important that nurses and nursemanagers were ‘fair’ and ‘objective’. Perceptions of‘favoritism’ and the absence of ‘professional impartiality’undermined trust. Many nurses considered professionalcompetence of greater importance than personal liking.

‘‘Its whether or not you have faith in that person’sability to do their job. Whether you like the individualconcerned is not important. You can actually dislikesomeone intensely, but at the same time you can trustand work with them so it is not personal’’ (AN3)

Many nurses and nurse managers discussed thedifficulties they had in developing trust with ‘agencynurses’, nurses on short-term contracts and untrainednursing staff. They felt that they did not have enoughknowledge of their qualities and attributes, nor did theyhave the time necessary in order to get to know them.

‘‘When you allocate patients to nurses you do on thebasis of trust - that they can look after that patientadequately. It is based on your previous knowledgeabout them, where you have spent time and have hadexperience working with them. So you can trust them inparticular situations’’ (ANM6)

The main positive consequence of trust was that itsupported the professionalism of nurses and nursemanagers. It provided the peer support and teamworknecessary for an ‘efficient’, healthy and positive workenvironment, considered essential to maintaining goodnursing care standards.

‘‘I would definitely trust my immediate superior. . .Sheis honest. I have known her a long time. She iscommitted to the organisation. She is a caring person. Ihave never known her to lie. She has high standards’’(ANM7)

While some nurses were less trustful than others, mostparticipants felt that they were initially ‘trusting’ of others.They only became less trusting when the parties involvedacted in a manner that undermined or broke their trust.

‘‘If you have got someone who will listen to you, andyou know that it is not going to go any further, whetherit is work based or not it is nice to have a person to talkto about it. If the trust is broken then you would nevergo to them again. They are more likely to get the bestout of you if you can develop a trusting relationship’’(AN7)

Conversely, it was equally important that individualnurses felt trusted, and given the autonomy necessary toconduct their tasks according to their professionalrequirements.

‘‘One because I know that they have got the skills to dothe job, and two I know that they have got thecommitment. If they undertake it (the job) they will seeit through’’ (AN11)

The absence of trust undermined teamwork, andassociated benefits such as support, delegation, commu-nication and confidentiality - where participants felt they



could not take the professionalism of their colleagues andline-managers as a ‘given’. This resulted in increasedsurveillance and ‘checking up’ on others, the mainconsequence was a less productive and ‘efficient’ workenvironment.

‘‘I could not do my job as a manager. I would becontinually going around and checking up on people. It(mistrust) would lower the standard of nursing care.This would prevent me from doing my own work’’(ANM7)

A climate of low trust resulted in increased conflict. Thiscontributed further towards ‘mistrust’ and resulted inreduced cooperation and isolation. It was felt that thiswould have a ‘knock-on’ effect in terms of increasedabsenteeism and labour turnover.

‘‘I just had to get off that particular ward (as a result oflow trust). The situation had become what I wouldconsider ‘‘dangerous’’, both for staff and the patientswithin their care. I did not feel that I could commitmyself to the patient because I had so much work. I justfelt that I could not cope. . .I felt stressed so I looked for ajob else where. I quickly got a transfer onto anotherward’’ (AN7)

Many participants felt that this would undermine theirmorale, confidence and ability to administer good practicenursing care standards and deliver quality patient care.

‘‘The team spirit would go (as a result of low trust). Theefficiency, the morale would go. It did go at one pointhere (within the ward). About eighteen months agothere was a problem of trust between the nursemanager and a senior nurse and it split the ward. Ittook a whole year to sort that out. There was dishonesty

and lying and a lack of trust and the ward justdisintegrated into two’’ (ANM1)

5. Discussion

Our findings provide evidence to support the view thattrust is an important leader-member exchange activity inhealthcare organisations, particularly at nurse managerlevel. They highlight the importance of the nurse managerrole in significantly increasing or decreasing trust levelswithin their immediate ward environment, the widerorganisational environment, in senior management andthe strategic leadership of healthcare organisations. Ourfindings support the work of Tallman (2007), Mayer et al.(1995) and others (Wong and Laschinger, 2010; Laschingerand Finegan, 2005; Calnan et al., 2006; Chen et al., 2008;Chiaburu and Marinova, 2006) who suggest that whilechange within healthcare organisations has had a negativeimpact on trust levels in ‘management’ it has resulted insignificantly higher levels of trust in nurse managers(Tallman, 2007; Calnan and Rowe, 2006; Laschinger et al.,2000). Our findings also support the work of Skinner et al.(2004), who suggest a continued focus on ‘professionalism’within the changing organisational environment, in thiscase the role of nurse manager, as a more effective basis forthe establishment of trust.

We present a summary of our findings in Fig. 2,illustrating the perceptions of nurses and nurse managers,which differ slightly from the theoretical relationshipbetween antecedents, attributes and consequences (Fig. 1).The consequences, in Fig. 2, refer to the consequences ofhigh and low trust amongst nurses and their line managerswithin their work environment. Participants however didoften identify those factors that diminished or prevented

Anteceden ts

Organisational

• Imm ediate w ork env iron ment –

Lea dership.

• Commun ication systems.

• New manage men t.

Cons equence s of tr ust

Organisational and Individual

Positive

• Profess ion ali sm and eff iciency

• Enh ance d tea mwork, delegation and suppo rt.

• Delive ry of high qu alit y pati ent ca re.

Negative

• Reduce d ‘eff iciency’ - Reduce d levels of tea mwork, delegation and suppo rt.

• Highe r leve ls of work-related stress , con fli ct, absentee ism and labou r turnov er.

• Lower pati ent ca re qu ali ty.

Att ribu tes

Individual

• Lea dership.

• Profess ion ali sm.

• Commun ication styles.

• Con fidenti alit y.

Fig. 2. The perceived relationship between the Antecedents, Attributes and Consequences of Trust – Individual, Interpersonal and Organisational – by nurses

and nurse managers.



trust-building and subsequently led to undesirable out-comes. Also, it is important to note that these are theperceptions and beliefs of nurses, as there is no evidence inthe paper to link a lack of trust with reduced efficiency,absenteeism, turnover and lower patient quality. Given theimportant implications of our findings for nurses, man-agers, and patients, there is a need to further explore theconcept of mistrust in relation to trust (p.11). For example,do nurses perceive low trust and mistrust to be the same orperhaps low trust or broken trust lead to mistrust? Donurses’ past experiences with trust in their nurse-managerrelationship influence their willingness to trust theirmanager? These questions need further consideration tocreate a more nuanced model of trust among nurses andtheir managers.

The perceived positive consequences of high levels oftrust included beneficial outcomes such as professionalismand efficiency. These in turn were underpinned byteamwork, delegation and support, all of which wereassociated with high trust work environments. Theseformed the basis for the delivery of high quality patientcare, in an environment were participants could take thecommitment and competence of their colleagues and linemanagers as a given.

The nurses and nurse managers who participated in ourstudy conceptualised trust as an ‘intimate’ rather than a‘public’ phenomenon. The study’s participants were lessinclined to trust management outside their immediatework environment. They suggested that direct interactionwith specific individuals played a greater role in determin-ing the outcome of trust, rather than any abstract notion oftrust in generalised others within the wider organisationalenvironment. This reinforces the salience of direct‘tangible’ experiences with specific individuals as thebasis for developing trust over time, through positiveinteractions amongst participants. This is also discussedand highlighted in the literature reviewed (Brown, 2009).Our findings also highlight the importance of participantsfeeling that they themselves were trusted. This involvedbeen given the autonomy necessary to get on with theirown tasks and duties and to do so in a professional manner.The ‘reciprocal’ nature of trust is also discussed in theliterature reviewed (Owen and Powell, 2006; Sanders andSchyns, 2006).

The attributes of trust, emerging from our studyincluded leadership, particularly in relation to the nursemanager role, professionalism and communication. Ana-lysis of the interview findings highlighted a link betweencommunication, involvement and the ability to maintainconfidentiality. Nurses in both organisations felt that therewas little communication, or meaningful staff involvementin organisational decision-making and organisationalchange. Our findings showed that nursing professionalstend to trust managers with ‘open’ styles of communica-tion, who they considered ‘hands on’, ‘approachable’ and‘accessible’. This is also supported in the literature on trust(Bowen and Lawler, 1995; Shaw, 1997; Weatherup, 1997;Randolph, 1995).

While the participants discussed the importance oftrust in the wider organisation, it was consideredparticularly important amongst nursing professionals

and nurse managers at ward level in delivering qualitypatient care. Professional competence was frequentlymentioned amongst the study’s participants as anattribute of trustworthy managers and colleagues. Pro-fessionalism was discussed as forming the basis for theteamwork, cooperation, delegation and support that wereall considered essential to an ‘efficient’ work environ-ment. This has also been highlighted and discussed inprevious studies (Gilson, 2006; Saunders and Thornhill,2003; Poortinga and Pidgeon, 2003; Walsh, 1995). Aconsequence of trust was the ability to take the profes-sionalism of managers and colleagues as a given. Ourfindings suggest that the main consequence of low trust,characterised by an absence or a breakdown of trust, wasthat it undermined the perceived level of professionalismamongst nurses and nurse managers. The replacement ofqualified nursing staff with agency and untrained nurses,combined with less resources for the purposes ofprofessional training and development did not createthe basis for a ‘high trust’ work environment, wherenurses could take the professionalism of their colleaguesand managers ‘as a given’. Previous studies suggest thatlow trust often results in increased monitoring andsurveillance, which is time consuming, expensive andinefficient (Mayer et al., 1995; Kramer, 1999). Theliterature also associated low trust work environmentswith higher levels of stress, conflict, absenteeism, labourturnover and most worrying of all lower standards ofpatient care (Calnan et al., 2006; Tallman, 2007; Skinneret al., 2004; Halliday, 2004). While the findings of ourstudy confirm that of previous studies we have exploredand clarified the importance of trust in a nursing, healthcare context, particularly in relation to positive healthcare outcomes.

Many participants did not feel ‘valued’ by managementfor the work they did. They said that direct patient contactand feeling ‘valued’ were their main sources of jobsatisfaction. They felt that these had been ‘lost’ throughthe introduction of new management systems andprocesses. They felt that managers who had originallycome from the private sector brought with them under-lying concepts, practices and styles that conflicted withthose of nursing professionals, particularly in relation topatient care. This finding is also supported in previousstudies (Bolton, 2002; Laschinger and Finegan, 2005;Newman et al., 2002; Nordgren, 2008; Davies & Mannion,2000). Gilbert (2005) has also discussed the ‘polarisation’of professional and managerial discourses in relation totensions around costs and care.

6. Limitations

Walker and Avant (2005) note that one of the mainobjectives of a concept analysis is to examine the definingattributes of a concept. Our study has presented theattributes of the concept of trust that emerged from nurses’perceptions of trust, based on the characteristics that makemanagers trustworthy. Thus, it would appear that theseare antecedents, rather than defining attributes of trustitself. However, when asked to define trust (attributes),nurses focused on individual characteristics of trusted



individuals such as leadership, professionalism, commu-nication styles and confidentiality.

This study is limited to two NHS organisations,involving 39 nursing professionals, nurses and nursemanagers selected at random across various departmentswithin their respective hospitals - acute and community.A further limitation of this study concerns the long-termimpact of organisational change and new managementpractices on perceptions of trust amongst nurses andnurse managers. This warrants further longitudinalresearch.

While our study explored perceived trust amongstnurses and nurse managers in two UK hospitals, ourfindings resonate in other similar healthcare contexts bothnationally and globally. Following on from our rich insightother researchers may consider testing our findings inlarger scale studies. This could be done through aquantitative research methodology, involving larger sam-ple sizes that examine relationships between trustvariables amongst nurses and nurse managers.

7. Conclusion

We have presented findings from interviews withthirty-nine nurses and nurse managers in two British NHSorganisations. Employing a concept analysis, we havehighlighted the antecedents, attributes and consequences oftrust from a nurse and nurse manager perspective. Theseoccur at individual, interpersonal and organisationallevels.

Key findings suggest that trust is formed within theimmediate ward environment and is significantlyinfluenced by the role of line manager. Other positivelyinfluencing factors include professionalism and commit-ment to the nursing profession. These form the basis forthe teamwork, delegation, support, open communicationsystems, confidentiality and discretion essential todelivering quality patient care. Negatively influencingfactors include new management concepts, practicesand styles overseen by managers recruited from theprivate sector. The perception amongst many nurses wasthat the introduction and greater use of resourcemanagement practices were associated with reducednumbers of qualified nurses and increasing numbers ofuntrained nursing staff, reduced direct patient contact,with less opportunities for professional training anddevelopment and deteriorating terms and conditions ofemployment.

Our concept analysis offers insights and opportunitiesfor managers, nurses and human resource practitioners toconsider these influencing factors in building high trustrelationships amongst nursing professionals. Of particularimport is the need for managers to communicate moreeffectively organisational and financial constraints, in amanner that does not ‘alienate’ nurses and nursemanagers, by highlighting their value and acknowledgingtheir role in delivering high quality patient care.

Conflict of interest

None declared.

Funding

Bursary/PhD studentship – University of Plymouth.

Ethical approval

The ethics committees from the Hospitals involved andfrom the University of Plymouth.

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Dr. T.J. McCabe is a Lecturer in HRM and Research Methods at the NationalCollege of Ireland. He leads a number of post-graduate and undergraduatemodules, including Research Methods, Strategic Human Resource Manage-ment, Employee Relations and HRD. His research interests extend to trustand commitment amongst nursing professionals, and human resourcemanagement issues in the health sector. He has presented this work atnational and international conferences, and co-chaired the HRM track for the14th Annual Conference of the Irish Academy of Management. He has

published papers in both academic and practitioner journals, and recentlyreceived The Best Paper Award, Healthcare and Public Sector ManagementTrack, Irish Academy of Management: McCabe, T.J., Sambrook, (2011), ADiscourse Analysis of Managerialism and Trust amongst NHS Nurses andNurse Managers, 14th Annual Irish Academy of Management Conference,National College of Ireland, Dublin. Previous published papers include;McCabe, T.J., & Sambrook, S.A., (2012), Psychological contracts and commit-ment amongst nurses and nurse managers: A discourse analysis, Interna-tional Journal of Nursing Studies, published online Dec 2012; McCabe, T.J., &Garvan, T.N., (2008), A Study of the drivers of commitment amongst nurses:The salience of training and development and career issues, Journal ofEuropean Industrial Training, Volume 32, Issue 7, p. 528–568; McCabe, T.J.,Cotter S., Ryan F., Hegarty H., and Keane E. (2003), Immunisation: The viewsof parents and health professionals, Euro Surveillance, Vol. 8, No. 6, June 2003.

Sally Sambrook is a professor of Human Resource Development, DeputyHead of School and formerly Director of Postgraduate Studies in Businessand Management at Bangor Business School. Sally leads the Business andManagement team, and the School’s research and teaching in HumanResource Management/Organisational Behaviour. Sally is a member of theUniversity Forum for HRD and elected a Board member of the AmericanAcademy of HRD. She is Associate Editor of Human Resource DevelopmentInternational and on the editorial boards of the Journal of European Indus-trial Training and the International Journal of Management Education, and areviewer for numerous other journals, including Personnel Review, Quali-tative Research In Organisations and Management, Journal of Health Orga-nisation and Management, and Journal of Advanced Nursing andInternational Journal of Nursing Studies (HR/managerial issues). Sally haspublished over 40 international journal articles and 20 book chapters andedited texts on HRD and has received awards for her work on critical HRD.


Concept Analysis of Trust

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