Making Me Feel Comfortable: Developing Trust in the Nurse for Mexican Americans.

541519 research-article2014

WJNXXX10.1177/0193945914541519Western Journal of Nursing ResearchJones

Research Report

Making Me Feel Comfortable: Developing Trust in the Nurse for Mexican Americans

Western Journal of Nursing Research 2015, Vol. 37(11) 1423–1440 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0193945914541519 wjn.sagepub.com

Sharon M. Jones1

Abstract Trust (confianza) is an important component of patient-centered care and culturally competent care and a major element in the Hispanic culture. The aim of this study was to conceptualize the process of the development of interpersonal trust by hospitalized patients in their nurses. Using the grounded theory method, English-speaking Mexican American patients (N = 22) were interviewed. The core category was Making Me Feel Comfortable. The cyclical process included a beginning stage (Having Needs, Relying on the Nurse), middle stage (Coming Across to Me, Taking Care of Me, Connecting), and end point (Feeling Confianza) with two outcomes (Confiding in the Nurse, Taking Away the Negative). Anytime there was a negative element during the middle stage, this element halted any further development of trust with the nurse. Unique findings were related to Hispanic cultural values of familism and personalismo. The findings have implications which impact patient safety and quality care. Keywords cultural competency, grounded theory, Hispanic Americans, nurse–patient relations, qualitative research, trust

1Indiana

University South Bend, USA

Corresponding Author: Sharon M. Jones, School of Nursing, College of Health Sciences, Indiana University South Bend, 1700 Mishawaka Avenue, South Bend, IN 46634-7111, USA. Email: [email protected]

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Developing trust in the nurse is important as nurses provide patient-centered care. Trust is part of collaboration and communication in patient-centered care. Trust (confianza) is an important component of Hispanic culture (Warda, 2000) and culturally competent care with Mexican Americans (Keller, 2008; Stasiak, 2001; Warda, 2000; Zoucha, 1998). Yet Hispanics had the lowest level of trust of health care providers compared with non-Hispanic Whites and Blacks, and having a Hispanic provider was not associated with increased trust (Sohler, Fitzpatrick, Lindsay, Anastos, & Cunningham, 2007). In the United States, 17% of the population is Hispanic and expected to grow to 31% by 2060 (U.S. Census Bureau, 2013), with Mexicans as the largest subgroup. In 2008, 82% of the employed U.S.-registered nurse population was non-Hispanic White, whereas only 3.9% of nurses were Hispanic (U.S. Department of Health and Human Services, 2008). As nurses have more encounters with Hispanics, it is essential that nurses understand how to develop trust with them.

Trust and the Nurse–Patient Relationship Trust can be institutional or interpersonal (Weaver, 2006). A patient initially places trust in the institution (nursing profession) but the nurse earns interpersonal trust through the nurse–patient relationship (Carter, 2009; De Raeve, 2002). Robinson (2000) defined trust as “belief that the other will act in one’s best interest” (p. 247). Baier (1986) and Sellman (2007) identified five key components were present for trust to occur: vulnerability, risk, power imbalance, familiarity, and goodwill. Goodwill reflected caring about a patient rather than simply caring for a patient, encompassing “reflective scrutiny” with “an attitude of concern and commitment” (De Raeve, 2002, pp. 159-161). Trust has a prominent role in the physician–patient relationship from the patient’s perspective (Thorne & Robinson, 1988). In the clinic setting, Thorne and Robinson (1988) identified three stages in the relationship development process were blind (institutional) trust, loss of trust, and resolution with guarded alliance. Four types of guarded alliance were identified: (a) absolute trust of an individual health care provider with general distrust of providers, (b) trust in predictable health care provider behavior and the patient manipulates services, (c) general distrust of providers, and (d) interpersonal relationship and trust with selected health care providers including patient collaboration in care decisions (Thorne & Robinson, 1988). In a grounded theory study of the development of trust between hospitalized patients and a variety of care providers, Hupcey, Penrod, and Morse (2000) found the three stages were entering the system, interacting with providers, and evaluating. Facilitators to trust included treating the patient as an individual, clicking,


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taking action, and going the extra mile (Hupcey et al., 2000). Barriers to developing trust were having many caregivers, waiting, not being responsive to needs, and not providing explanations of care (Hupcey et al., 2000). Unfortunately, at times the trust discussed in the findings reflected institutional trust rather than interpersonal trust. In a grounded theory study, Morse (1991) interviewed nurses and identified four types of nurse–patient relationships: clinical, therapeutic, connected, and overinvolved. The outcome of the connected relationship was patient trust to confide in the nurse (Morse, 1991), reflecting interpersonal trust. In the clinical and therapeutic relationship types, the outcome was nursing competence (Morse, 1991), reflecting institutional trust. In the relationship with home care nurses and their clients, Trojan and Yonge (1993) identified the stages for establishing trust were initial trusting, connecting, negotiating, and helping. The negotiating stage likely reflected the balance of power between the nurse and the patient not found in the hospital setting where the patient is more vulnerable. Finally, in a qualitative field study exploring the process of adherence to leg ulcer treatment with patients who received a nursing intervention, an unexpected finding was interpersonal trust in the wound nurse was a central factor in patient adherence (Van Hecke, Verhaeghe, Grypdonck, Beele, & Defloor, 2011). In studies of culturally competent care with Mexican Americans in the community and outpatient settings, authors identified the importance of the nurse establishing or earning confianza (Keller, 2008; Stasiak, 2001; Warda, 2000; Zoucha, 1998). To earn trust, the nurse should spend time and show interest in the person (Belknap & Sayeed, 2003; Zoucha, 1998), be friendly and respectful (Warda, 2000; Zoucha, 1998), attempt to speak Spanish (Stasiak, 2001; Warda, 2000; Zoucha, 1998), and recognize the importance of family (Stasiak, 2001; Warda, 2000). These factors reflected key Hispanic cultural factors of personalismo and simpatia (positive, personal relationships, avoid negative encounters), respect, and familism (National Alliance for Hispanic Health, 2001; Warda, 2000). Although previously published studies have noted the importance of establishing trust between the patient and nurse, especially in care of Mexican American patients, the authors have not conceptualized how the process of trust develops in the hospital setting. The purpose of this study was to conceptualize the process of how trust develops in hospitalized Mexican American patients with the nurses caring for them.

Method Classical grounded theory method (Glaser, 2001; Glaser & Strauss, 1967) was used as a method to explain the basic social process of the development


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of interpersonal trust. Grounded theory is a qualitative research method used to explain a basic social process. The classical grounded theory method has philosophical underpinnings from symbolic interactionism used in sociology (McCann & Clark, 2003). University and hospital institutional review board approvals were obtained prior to initiating the study.

Sample For participant recruitment, key hospital personnel (e.g., bedside nurses) identified patients who met the inclusion criteria. Inclusion criteria were Englishspeaking Mexican American adults hospitalized at least 2 days and anticipated discharge within 2 days. Exclusion criteria were those cognitively impaired or admitted for psychiatric conditions. In research with Hispanics, it is important to specify the ethnic subgroup because each subgroup has unique cultural characteristics and histories (Smedley, Stith, & Nelson, 2003). The Mexican subgroup was chosen because it is the largest of the Hispanic subgroups in the United States. Because of the young age of Mexican Americans in the United States, the initial participants were female hospitalized for childbirth. Theoretical sampling was used to broaden the scope of participants to those of male gender and medical-surgical hospitalizations. Theoretical sampling refers to comparing groups based on certain characteristics to provide range and is used in classical grounded theory to further develop the emerging theory (Glaser & Strauss, 1967).

Data Collection The researcher obtained written documentation of informed consent from participants before beginning face-to-face interviews. All interviews were conducted in English in a private hospital setting by one researcher and audio recorded; participants were assigned a participant number to protect their identity. Interviews were transcribed verbatim by a transcriptionist. To verify accuracy of transcription, the researcher listened to the audio recordings as she read the transcripts. An interview guide was used and is presented in Table 1. Data collection continued until saturation occurred, indicating no new relevant categories or new properties to existing categories emerged (Glaser, 2001). Data were collected between August and December 2011. Participants received a US$20 gift card as a token of appreciation.

Analysis Using the constant comparison method of grounded theory (Glaser, 2001), the researcher did line-by-line coding of the transcript (open coding)


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Jones Table 1. Interview Guide to Focus Interviews.

1. Tell me about your experiences with the nurses that have been caring for you thus far in the hospital. 2. In the Mexican culture, people use the term confianza to refer to trust or confidence, can you tell me about confianza and any experiences with a particular nurse you had so far in the hospital? 3. What helps you to develop trust in a particular nurse more so than with another nurse? 4. What barriers are there to developing this trust with a particular nurse?

using participant words or phrases for codes. The codes were collapsed into categories and then the categories were linked together into a model based on theoretical memos (axial coding). Theoretical memos are ideas, insights, and theoretical hypotheses about the data and the emerging categories. The theoretical memos provided the basis for the researcher to see relationships between categories that led to the formation of the model. A core category emerged that encompassed all the categories and reflected the core issue for the participants. Data collection and data analysis occurred concurrently. Initially, to ensure accuracy of coding by the researcher, a mentor in grounded theory coded three transcripts and those codes were compared with the researcher’s codes. The comparison of codes indicated a high level of agreement in coding and the researcher proceeded to code the remainder of the transcripts as data collection and analysis proceeded. After several interviews, a pattern and relationships between concepts emerged. At the end of subsequent interviews, participants were asked focused questions related to the emerging hypotheses to elicit feedback. Using focused questions for the purpose of clarifying properties of categories and relationships is another form of theoretical sampling in the classical grounded theory method (Glaser, 1978; Glaser & Strauss, 1967). This study met the criteria to establish trustworthiness through demonstrating credibility, confirmability, dependability, and transferability (Lincoln & Guba, 1985). Credibility indicates the findings represent the participants’ realities (Lincoln & Guba, 1985). Credibility was evidenced by data saturation of the categories. Member checking, bringing concepts back to participants to verify, is inappropriate in grounded theory due to the raised level of abstractness of the concepts (Glaser, 2001). Confirmability relates to researcher bias and indicates the study findings are based on data (Lincoln & Guba, 1985). Confirmability was established through an audit trail and theoretical memos, which connect data to categories to form the model.


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Table 2. Demographic Characteristics of Hospitalized Patients (N = 22).

Gender Female Male Hospital unit Obstetric Medical Country of birth United States Mexico Language preference at home English Spanish No preference

n

%

16 6

73 27

13 9

59 41

12 10

55 45

8 5 9

36 23 41

Dependability relates to the criterion reliability in quantitative designs. Dependability was demonstrated through an audit trail, concluding data collection when saturation occurred, and verifying codes and the developing theory with a mentor in grounded theory considering alternative explanations that arose. Transferability refers to findings being applicable in other situations as judged by the reader of the study (Lincoln & Guba, 1985). Transferability was demonstrated through the categories having range, and the findings may be applied across time and settings.

Results Twenty-two Mexican American adults (ages 19-69 years old), hospitalized in one hospital in an urban area of the Midwestern United States, were interviewed. Demographic characteristics are presented in Table 2. Interviews ranged from 9 minutes to 38 minutes and, at the time of the interview, the number of days participants were hospitalized ranged from 2 days to 2 weeks. Through open coding, 217 unique codes were compiled and collapsed through axial coding into a core category and eight categories with properties. The categories were sequenced in time and linked together in a model of the development of trust that indicates a beginning stage, middle stage, end point (trust), and outcomes of the process. The process of developing trust with the nurse from the patient’s perspective is presented in Figure 1.


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Jones Patient

Having Needs + Relying on Nurse →

Taking Care of Me

Coming Across to Me

Connecting

is ↑

Confiding + Taking Away in Nurse Negative

Feeling Confianza (Trust)

Figure 1. Development of trust in the nurse including outcomes.

Beginning Stage: Having Needs and Relying on the Nurse In the beginning stage, the process of developing trust with the nurse started with the patient Having Needs, which reflected being in a vulnerable position. One participant stated, “I think to me, it was more because of what was important to me was I was in pain, so that was the one thing that I kept focusing on.” The patient relied on the nurse to respond and meet the needs in the Relying on the Nurse category, which included having expectations of nursing care. One participant explained, “Nobody is going to help me but her. I’m kind of relying on her to help me feel better, and that’s a big thing with trust.” When the nurse did not meet the expectation of competently providing care, the participants discussed these negative experiences of relying on the nurse and being disappointed with the results.

Middle Stage: Coming Across to Me, Connecting, Taking Care of Me The middle stage of the process had three categories all indicating an encounter between a nurse and the patient. The categories built on each other with the Coming Across to Me and the Connecting categories as affectively driven responses and the Taking Care of Me category as an action-driven response. Coming Across to Me reflected the nurse making a first impression, responding, and talking. Positive characteristics included having a smile, being friendly, and outgoing; negative characteristics included having a “mad face,” being in a bad mood or rude. One participant stated, “As soon as she came in, with a smile on her face; you know, it’s just her attitude. You can just feel, you know—she just gave you that vibe.” Another participant stated, “I don’t know. Only I see the eyes, their face, and I say these are good.” Perceiving the nurse as being rude or having a negative attitude was the main barrier to developing trust that was echoed by many participants and led to


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the patient feeling uncomfortable and not wanting further contact with the nurse. One participant stated, If they look like they’re mad already, it’s hard, ’cause it’s like a wall up already, so it’s hard to—to tell her I need this, or I need—I need anything, because, I don’t know, I feel like do they get mad?

The participants provided numerous examples of both negative and positive responses from a nurse. When asked what prevents the development of trust with a particular nurse, one participant stated, “I guess the way they answer when you ask them for something. Like the first time you ask them for something, and that way you know.” The way the nurse responded to the patient could lead to trust or hinder the development of trust. Where responding was the gateway to developing trust, talking was the key. When asked how the relationship with the one nurse whom she trusted was different than the nurse she had the previous day, one participant simply stated, “She talks to me [laugh].” Talking was a way for the patient to become familiar with the nurse and for the nurse to demonstrate seeing the patient as a person. One participant explained, You can get closer to her just by her doing something like that . . . you trust again, because she’s talking personally about herself, and about you, and then you trust them again. You trust them and you respect them, because they’re not treating you like a clown; they’re treating you like a person.

The patient and the nurse connected through talking personally. In contrast, not talking to the patient would lead to the patient feeling uncomfortable. For some patients, the nurse speaking Spanish in a social context or to explain care if they had limited English proficiency (LEP) led to a feeling of comfort. Participants acknowledged it was not important that the nurse be Hispanic. Connecting reflected the feeling the patient gets when experiencing positive encounters with the nurse. The participants noted this was a mutual connection with the nurse, “I guess just the way they come—they come at you. Like there’s some that just their attitude isn’t very nice. And there’s some that right away like you can connect with them.” Most participants identified one nurse with whom they established a connection that led to trust. A couple of participants did not have a specific situation arise that led to trust with an individual nurse and noted no “special” connection with any nurse, while others noted they trusted all the nurses on the unit who cared for them. The influence of time on connecting varied. One participant noted no connection


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because of limited time spent with the nurse while another noted connecting during the brief time spent transferring to another room. A few participants experienced negative encounters with the nurse and rather than connecting with the nurse, the participants described feeling like a bother. Taking Care of Me, a more action-oriented response, included being very helpful, coming in and asking, and showing care. The patient appreciated the nurse who did extra, which was sometimes simply a nice gesture toward visiting family. A barrier to trust development was the nurse being perceived as unwilling to help. One participant stated, It’s like with the nurse that’s more helpful, more ask about what you want, or what you need, or how you feel, instead of just saying like, okay, I’m here to do this, this is what’s going to get done, and that’s it.

Not following through on a patient request was perceived as not caring. Participants noted greeting the patient, responding positively to questions, and acting on requests as “simple stuff,” which made the patient feel comfortable and the end point, Feeling Confianza. The nurse who was unwilling to help inhibited communication and would not lead to trust.

End Point: Feeling Confianza (Trust) Feeling Confianza included making the patient feel good and the patient having a feeling like family, in a positive encounter or, if the encounter was negative, feeling like a bother. One participant stated, And these people, for me not to know them, you know, they almost felt like they were like your mother or sister or brother would care for you. In a sense, it’s strange, you know. I guess they’ve been there like that, especially her, more than I could’ve imagined.

In contrast, when the encounter with the nurse was negative, the patient would feel uncomfortable and even feel like a bother. Feeling like a bother has roots in Mexican culture, as one participant noted, But I think that with the one that I really, really liked, that I really felt comfortable asking her for help, ’cause I—I don’t know if it’s like just Mexicans that don’t—but we don’t really like to ask for help or to bother people to help us.

Participants mentioned self-reliance and not imposing on the nurse. When the patient felt like a bother, the patient might be hesitant to ask for help or


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might simply shut down. In addition, a negative encounter with the nurse could affect the patient negatively as one participant shared, You [the nurse] don’t realize that you make the person feel small when you come in here mean. You know, you make them feel not good. Like the one nurse, she made me feel horrible and I was in a lot of pain; not only just because of the pain, but you’re—you’re here to help me, and I’m relying on you, and you’re treating me like this, so it makes me feel worse. Not only my pain, but you’re making me feel worse inside, like I’m nobody.

This powerful statement demonstrated the impact the nurse could have in a single negative encounter not only in developing trust but also on the patient’s well-being in general.

Outcomes: Confiding in the Nurse and Taking Away the Negative When the patient developed trust, outcomes were Confiding in the Nurse and Taking Away the Negative. Confiding in the Nurse reflected the patient’s willingness to share something personal, ask for help, and allow the nurse to help. This participant had a comfort level with the nurse similar to family, indicating no judging: Just by having that trust in them, you might be more willing to maybe have them look at something else that might be ailing you, knowing that they’re going to do their best to help you with it, and confide in them with it, as to where if you felt they were looking at you funny, or didn’t have much to say, you might be more hesitant to tell them something.

When trust was established, the feeling of imposing on the nurse was discarded and the patient allowed the nurse to help. One participant explained, But I trusted her to be like, okay, you can help me to the bathroom, instead of I’m like imposing on her, even if she’s like, that’s my job; I’m here to help you. So she was really nice, that made me feel comfortable around her and be able to trust her and not feel like guilty, or I’m bothering you, or something.

Allowing the nurse to help indicated that accepting assistance while hospitalized was a difficult position to be in for these patients. This same participant explained she would not ask for help from another nurse with whom she had a negative encounter and did not trust:


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I didn’t even want to ask her for anything anymore, ’cause I already seen she was not being helpful, or like I didn’t trust her, . . . So I just didn’t want to, like have any kind of involvement with her.

A negative encounter with the nurse led to the patient not asking for help, which is a major safety concern. Other participants echoed similar sentiments related to not asking for help or having further contact with the nurse if they had a negative encounter with the nurse. Taking Away the Negative, another outcome of trust, reflected the patient putting aside negative feelings about a hospital experience and replacing them with the positive feelings derived from positive encounters with a particular nurse. One participant explained, “If I had any negative stuff happen then, the last 2 days that I was here that she actually took care of me on her shift, made me forget anything that was happening.”

Core Category: Making Me Feel Comfortable The core category of the model was Making Me Feel Comfortable. Making Me Feel Comfortable reflected the patient feeling comfortable with the nurse through positive encounters. This was a state of being, a feeling of ease with the nurse, rather than physical comfort. With feeling comfortable, the patient felt confianza and was willing to confide in the nurse. The term making me reflected the key role the nurse had in the patient reaching this state of being. It was the nurse’s actions that directed whether the encounter would be perceived as positive or negative. One participant explained, And then there’s some that actually come in, “Oh, hi, how’s your day . . . ” and you start, “Oh, hey.” And then, you know, sometimes they start telling you about “Oh, you know, when I was in the emergency”—they try to make you feel like comfortable, and then they start making comments and it makes you feel more comfortable, and then that’s what makes you also be like, oh, I could ask her for anything ’cause she’s being nice and she makes me feel comfortable.

Discussion Comparing this study to findings in previous theoretical literature (Baier, 1986; Sellman, 2007), vulnerability, risk, and power imbalance were clearly evident in the Having Needs and Relying on the Nurse categories. The components of familiarity and goodwill were evident in the middle stage Coming Across to Me, Connecting and Taking Care of Me. In this study, talking led to familiarity with the nurse, which was an important component of trust in


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the theoretical literature (Baier, 1986; Carter, 2009; Sellman, 2007). Throughout the middle stage in encounters with the nurse, the patient perceived the nurse’s intentions as positive or negative. Positive intentions reflected goodwill and led to trust developing, similar to the importance of goodwill noted in theoretical literature (Baier, 1986; De Raeve, 2002; Sellman, 2007). Although empirical studies related to trust did not mention goodwill specifically (Hupcey et al., 2000; Mechanic & Meyer, 2000; Thorne & Robinson, 1988), authors noted the patient testing to see if the provider was “looking out for [the patient’s] best interest” (Hupcey et al., 2000, p. 234), which is synonymous with goodwill. Coming Across to Me was similar to findings in previous empirical studies, noting the first impression and approaching with a social intent rather than task were important with home care nurses and their clients (Trojan & Yonge, 1993) and with Mexican American mothers in an immunization clinic (Keller, 2008). Responding was similar to the testing by patients noted in other studies in which the patient made an initial inquiry to gauge the provider’s response (Hupcey et al., 2000; Mechanic & Meyer, 2000; Thorne & Robinson, 1988). As in this study, not being responsive to patient concerns inhibited trust development in previous studies (Hupcey et al., 2000; Trojan & Yonge, 1993), whereas listening and being nonjudgmental facilitated trust development (Mechanic & Meyer, 2000). Talking personally and seeing the patient as a person were supported in empirical research related to trust in the patient–provider relationship (Hupcey et al., 2000; Mechanic & Meyer, 2000; Skirbekk, Middelthon, Hjortdahl, & Finset, 2011; Thorne & Robinson, 1988), in the nurse–patient relationship (Trojan & Yonge, 1993), and the patient’s perception of nursing care (Schmidt, 2003). The nurse attempting to speak Spanish to become more personal or to establish a connection was noted in research studies related to culturally competent care with Mexican Americans (Jones, 2008; Keller, 2008; Stasiak, 2001; Warda, 2000; Zoucha, 1998) while it was not important that the nurse be Hispanic (Keller, 2008). In the Taking Care of Me category, some findings might be unique to the hospital setting and were similar to previous findings in a hospital setting, which noted taking action and going the extra mile facilitated the establishment of trust (Hupcey et al., 2000; Morse, 1991). However, going the extra mile was not mentioned in the study of trust in the home care setting (Trojan & Yonge, 1993) or the clinic setting with primary care physicians (Thorne & Robinson, 1988). In Connecting, the major influence the nurse had in establishing the perceived mutual connection was similar to findings by Morse (1991). In Morse’s (1991) study with nurses, characteristics of the connected relationship included seeing the patient as a person, going the extra mile, and the


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outcome was trust to confide in the nurse, the process beginning again with the oncoming nurse. Morse (1991) wrote, “The nurse evaluates the patient’s personal needs and support system, assesses the patient as a person, and consciously chooses whether or not to make an emotional investment in the patient, or whether to just do her job” (p. 461, emphasis added). The nurse consciously choosing was similar to theoretical literature noting “reflective scrutiny” (De Raeve, 2002, p. 161). Both Morse and De Raeve alluded to the nurse’s key role in being open to connect with the patient, similar to the essence of the core category in this study, “making me” reflecting the nurse’s key role. This role of the nurse might also explain why length of time spent was not a strong factor in establishing the connection. Likewise, the health care provider’s role in “clicking” was a facilitating behavior to establish trust in the hospital setting (Hupcey et al., 2000, p. 235). Connecting was noted in the home care setting with nurses as a “comfort level” and becoming familiar with each other (Trojan & Yonge, 1993, p. 1906). In Feeling Confianza, the nurse was able to earn trust readily by being open to connect and through “simple stuff.” Perhaps because of the patient’s vulnerable position in the hospital setting, trust is more readily earned compared with earning trust in the community setting (Keller, 2008; Warda, 2000; Zoucha, 1998). In the clinic setting, the relationship between patient and physician started with blind trust at the beginning and then, after a loss of this institutional trust, progressed, for some, to interpersonal trust in one form of guarded alliance (Thorne & Robinson, 1988). With a negative encounter, the patient did not develop trust that was similar to the theoretical literature, which noted the decision to withhold trust or even to mistrust (Carter, 2009). In previous empirical literature, findings indicated distrust when a negative encounter occurred and the patient becoming angry and vigilant while receiving care (Hupcey et al., 2000), or the patient exhibiting nagging and manipulative behavior (Morse, 1991). A unique finding in this study was participants referred simply to trust not developing or the patient shutting down, feeling like a bother, and waiting until the next shift. This may reflect the Hispanic value of positive relations (personalismo, simpatia) and avoiding negative encounters (Warda, 2000; Zoucha, 1998). Feeling like a bother may reflect the Mexican value of doing for themselves and not imposing on others. Future research is needed to determine if feeling like a bother is indeed a unique cultural value of Mexican Americans or a common value shared by hospitalized adults. Feeling like family was another finding that might be unique to Hispanic patients because of the cultural value of familism. This finding was not seen in previous research studies related to trust with hospitalized patients (Hupcey et al., 2000; Morse, 1991) or in the outpatient setting (Thorne & Robinson,


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1988; Trojan & Yonge, 1993). A sense of family was a factor in establishing trust for school nurses in a high school setting (Summach, 2011); however, this could be attributed to the extended contact and the adult–child relationship. In this study, feeling like family more likely reflected familism (Sabogal, Marin, Otero-Sabogal, Marin, & Perez-Stable, 1987) and confianza as based on trust with family and close friends (Purnell & Paulanka, 2003). The importance of family in care of Mexican Americans was noted in other studies of cultural competence (Stasiak, 2001; Warda, 2000) and literature related to compadrazgo (kinship) and social support in the Hispanic culture (GillHopple & Brage-Hudson, 2012; Martinez-Schallmoser, MacMullen, & Telleen, 2005). Given their value for privacy (Purnell & Paulanka, 2003), this feeling of comfort with family providing care may not be shared by AngloAmericans and is an area for future research. The finding sharing personal concerns or asking questions of a personal nature in the Confiding in the Nurse category was not mentioned in key previous studies related to trust (Hupcey et al., 2000; Thorne & Robinson, 1988; Trojan & Yonge, 1993). However, patients in Norway were more open to share with the physician when trust was established (Skirbekk et al., 2011) and Zoucha (1998) noted that the Mexican American patient might ask questions if confianza was established and a lack of confianza could have negative health outcomes although no elaboration was provided. The findings in this study provide a more in-depth explanation with supporting evidence of the importance of confianza and the outcome, confiding in the nurse. Unlike in previous research studies of culturally competent care (Stasiak, 2001; Warda, 2000; Zoucha, 1998), participants in this study did not mention respect specifically, a key Hispanic cultural factor. One participant who used the word respect attributed it to growing up in an Italian neighborhood rather than his Mexican culture. However, being seen as an individual does denote respect for the person. Finally, the development of trust was a cyclical process with the patient starting again with the next shift (oncoming nurse). This cyclical process is further evidence that the trust examined in this study was interpersonal trust rather than institutional trust and that the nurse drove whether trust was established. A limitation of this study was the recruitment of English-speaking participants. Because of the importance of language nuances in qualitative research (Ojeda, Flores, Meza, & Morales, 2011), data collection was done in English to avoid added layers of complexity that occurs with translation. It is possible that the development of trust may be different for non-English-speaking Mexican Americans. However, Mexican Americans tend to retain some of their cultural values even as they acquire English language skills (Sabogal et al., 1987; Warda, 2000). Interviewing patients while hospitalized may be


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seen as a limitation of the data collection method (Robinson, 2000). The participants were interviewed in a private setting and readily discussed both negative and positive experiences with particular nurses, which led to categories with range and indicates this was not a limitation. The lack of triangulation of data from other sources (e.g., observation, nurse interviews) is a limitation of the study. Future research related to the development of trust with the Mexican American patient is warranted using a wider range of data sources, such as nurse’s perceptions and observation. The importance of establishing interpersonal trust with Mexican American patients cannot be overstated as it pertains to patient safety and quality care. The patient who has a positive encounter and develops trust is more willing to confide in the nurse and ask for help. More importantly, the patient who has a negative encounter does not establish trust, shuts down, and will not ask for assistance. For example, the patient may not request help to the bathroom or mention the onset of a new pain, which affects patient safety and quality of care. In educating nurses, interpersonal communication skills should continue to be emphasized. Future research is needed with LEP and monolingual Spanish-speaking Mexican Americans to confirm or modify the model. Research with non-Hispanics is needed to identify any similarities and differences with the current findings. In this grounded theory study, the model that emerged conceptualizes how trust develops between nurse and patient from the patient’s perspective. This is the first time trust has been examined from the perspective of hospitalized Mexican American patients. As important as it is to develop trust, not developing trust can lead to the patient not wanting further contact with the nurse. To develop trust, first, the nurse needs to be emotionally available to connect. Second, the nurse needs to walk in the room with a smile, chat with the patient and family present, and then ask the patient and family, “What do you need?” Acknowledgments I thank my dissertation committee at Loyola University Chicago chair Lee Schmidt, PhD, RN and members Nancy Hogan, PhD, RN, FAAN and Lucy Martinez– Schallmoser, PhD, RN. I am grateful to Elizabeth Rodriguez-Negrete, RN for her efforts in identifying patients and to the patients who shared their stories for this research study.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.


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Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by a research grant from Alpha Chapter of Sigma Theta Tau International.

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Trust me, I'm a nurse.

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Trust me, I'm a vet.

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Lactose intolerance among Mexican Americans.

Religion and health in Mexican Americans.

Vitamin D metabolism in Mexican-Americans.

Making patients feel safe and valued.

Trust me, this is the worst "acne" of your life!

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Public trust in the healthcare system in a developing country.

Evaluation of the spoken knowledge in low literacy in diabetes scale for use with Mexican Americans.

Liver and Other Gastrointestinal Cancers Are Frequent in Mexican Americans.

NEIGHBORHOOD PERCEPTION AND OBESITY IN AGED MEXICAN AMERICANS.

Trajectories of Depressive Symptoms in Elderly Mexican Americans.

Neurological, functional, and cognitive stroke outcomes in Mexican Americans.

Alteration of vitamin D metabolism in Mexican-Americans.

Ancestral origin of insulin-dependent diabetes in Mexican-Americans.