AN INDEPENDENT VOICE FOR NURSING
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Trust in African Americans’ Healthcare Experiences Traci M. Murray, RN Traci M. Murray, RN, is a Doctoral Candidate, College of Nursing, University of Texas at Tyler, Tyler, TX. Keywords African American, concept analysis, health care, nursing, trust Correspondence Traci M. Murray, RN, College of Nursing, University of Texas at Tyler, Tyler, TX E-mail: [email protected] .edu
Murray
PURPOSE. The purpose of the study is to clarify the concept of trust, identify its defining attributes, antecedents, and consequences, and apply to the healthcare experiences of African Americans. BACKGROUND. For African Americans, mistrust in the healthcare system is the result of unequal treatment that began in slavery. Fear and negative experiences engender a reluctance to trust healthcare providers, which contributes to health disparities. DESIGN. Walker and Avant’s method of concept analysis was used to clarify the concept of trust. The concept was applied to African Americans’ healthcare experiences with discussion of opportunities for trust building. DATA SOURCE. Data support for concept development was done using Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, and online reference sources. REVIEW METHODS. Literature review was guided by using the keyword trust. Further contextual explication was done by adding a review of literature from sociology and history regarding the evolution of African American mistrust of the U.S. healthcare system. RESULTS. The defining attributes of trust are dependence, willingness, and met expectations. Antecedents to trust include a need requiring the help of another and prior knowledge or experience. The consequence of trust is an evaluation of the congruence between expected and actual behaviors of the trusted person or thing. Literature review of the African American culture adds a dynamic aspect for nurses to consider when developing relationships in minority communities. CONCLUSION. Trust is the willingness to enter a dependent relationship to have the needs addressed, and is maintained by met expectations. Rebuilding trusting relationships between providers and African American patients is a vital step toward reducing health disparities.
Introduction When individuals seeking health care experience unmet needs or poor treatment, it generally affects their ability and willingness to trust. Yet what is the result when sizeable populations perceive these experiences over several generations? For African Americans, mistrust in the healthcare system is the result of unequal treatment that began in slavery when their ancestors were codified by law as inferior to Caucasians. This mistrust of the healthcare system still per-
meates throughout African American culture today as they perceive that the care delivery system remains under the control of the white majority. Fear and negative experiences cause many African Americans to be reluctant to trust healthcare providers, which often results in poor health outcomes contributing to health disparities. The purpose of this article is to explore the concept of trust using Walker and Avant’s (2011) concept analysis methods. The concept is applied to African Americans’ healthcare experiences with discussion of opportunities for trust building. 285
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Trust in Healthcare Experiences Methods Data support for the concept development was done using the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, and online reference sources, such as the Merriam-Webster Dictionary. To ensure that results focused on the concept of trust, search parameters included “trust” alone and with “African American” as subject terms. Searches were not limited by publication date to capture classic works that have contributed to concept development over time. However, searches were limited to scholarly, peer-reviewed journals only. Additional literature reviews were conducted to develop support for the role of trust in African Americans’ healthcare experiences. Medline and CINAHL were searched using keywords such as “African American,” “trust,” “mistrust,” and “healthcare.” Specific support was sought regarding the impact of the Tuskegee Syphilis study and its impact on African Americans’ view of the healthcare system. Background The history of African Americans’ mistrust in the healthcare system is rooted in the deplorable health conditions of slavery and medical experimentation of the Tuskegee Syphilis study (Braunstein, Sherber, Schulman, Ding, & Powe, 2008; Bronson & Nuriddin, 2014; George, Duran, & Norris, 2014; McDonald, Powell, Perryman, Thompson, & Jacob Arriola, 2013; Sabir & Pillemer, 2014). Bronson and Nuriddin (2014) reviewed narratives from former slaves following their emancipation to learn about medical practices and perceptions of care during and after the slavery period in the United States. Findings from the narratives revealed a preference for medical treatment using native African herbs and folk remedies administered by trusted enslaved individuals, often called “granny doctors” (Bronson & Nuriddin, 2014). An inherent mistrust of care and medication given by Caucasian physicians was clear. African Americans became victims of racial stereotypes, reinforcing the belief that they were inferior to Caucasians and subject to legalized, systematic discrimination, even after emancipation. In general, the issue of mistrust in health care has been discussed for many years. Perhaps the most wellknown use of the word trust comes from Erikson’s stages of psychological development, where resolution of trust versus mistrust is the first stage of infant development occurring between birth and at the age of two 286 © 2015 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 4, October-December 2015
T. M. Murray (McLeod, 2013). During this time, an infant seeks consistent, reliable care from the caregiver or parent as a foundation for building trusting relationships with others. This idea of consistency and reliability appears to be at the heart of many trust/mistrust situations. In health care, nurses have been the key to public health initiatives aimed at preventing the spread of disease. However, the mistrust issues of the homosexual population, another vulnerable group, in the 1980s led to unique challenges in addressing the HIV/AIDS epidemic. During that time, AIDS was incorrectly categorized as a “gay syndrome” preventing homosexual males from seeking care (Schmidt, 2011). Today, the issue of mistrust in healthcare research is an obstacle, which nurse scientists must address by identifying potential conflicts of interest that may harm the patient–provider relationship (Milton, 2012). Thus, general mistrust in health care combined with the historical abuses suffered by the African American community has created an environment where developing trust in healthcare providers is difficult. In a cross-sectional study, Shavers, Lynch, and Burmeister (2002) surveyed 179 adults (African American n = 91, Caucasian n = 88, other race/ ethnicity n = 19) in Detroit to determine whether there were racial differences in barriers to medical research participation. Results revealed that African Americans were more likely to believe that minorities and the poor were unequally subject to more risks in research when compared with the beliefs of Caucasians. Additionally, 81% of African Americans were aware of the Tuskegee study compared with only 28% of Caucasians. As a result of their awareness of the Tuskegee study, 51% of African Americans reported decreased trust in medical researchers compared with only 17% of Caucasians (Shavers et al., 2002). Washington (2006) suggests that the devaluing of free and enslaved African Americans contributed to the medical experimentation and unequal medical treatment, which led to chronic mistrust of the healthcare system. Consequences of Mistrust The chronic mistrust of the healthcare system by African Americans may contribute to the health disparities experienced by many within this population (McDonald et al., 2013; Saha, Jacobs, Moore, & Beach, 2010). McDonald et al. (2013) investigated the relationship between trust in health care and attitudes toward living donor transplant (LDT) in African
T. M. Murray Americans with end-stage renal disease. Researchers hypothesized that decreased levels of trust in health care, including one’s physician and hospital, and in racial equity of care would be significantly associated with negative attitudes toward LDT. The findings supported this hypothesis as positive attitudes toward LDT were significantly correlated with higher trust in one’s physician (r = 0.265, p < .001), hospital (r = 0.131, p = .04), and in perception of racial equity in care (r = 0.202, p = .001) (McDonald et al., 2013). These results suggest that mistrust in healthcare providers and facilities presents a serious issue related to African Americans’ perception of organ donation and transplant. As a result, African Americans are less likely to become organ donors, and likewise less likely to receive an organ transplant, contributing to the health disparity. Saha et al. (2010) analyzed data from a cohort study conducted at an HIV clinic from 2005 to 2008 including 1,104 African American and 201 Caucasian patients to determine the relationship between trust in a healthcare provider and racial disparities in HIV care. African American patients reported less trust in their healthcare providers than their Caucasian counterparts (8.9 vs. 9.4 on a 0–10 scale; p < .001). However, trust in healthcare providers was only significantly associated with adherence to prescribed antiretroviral treatment in all participants (Saha et al., 2010). Improving the patient–provider relationship by building trust can potentially reduce health disparities in HIV care by increasing adherence and associated positive health outcomes. Trust has gained considerable attention in health care as a global attribute of treatment relationships (Hall, Dogan, Zheng, & Mishra, 2001). The Healthy People 2020 initiative indicates trust as an important factor when locating a healthcare provider (U.S. Department of Health and Human Services, 2012). Similarly, it has been described as giving the physician–patient relationship meaning and substance, and is essential for therapeutic interactions. According to Gallup (2014), for the past decade, nurses have been the most trusted profession. As new healthcare reform initiatives are implemented, nurses will need to maintain their trustworthiness as the population of African Americans seeking health care increases. However, while there is consensus about the importance of trust, its conceptual definition remains elusive. Defining the concept of trust and applying it to the experience of African Americans in the healthcare system will shed light on the
Trust in Healthcare Experiences nursing implications of this increasingly important issue. Concept Analysis The term trust has been ill-defined since its origination in a variety of thirteenth-century languages. The Old Norse, or Norwegian, term traust means help or confidence, while the Dutch term troost means comfort or consolation (Harper, 2012). Although the modern German term trost also means comfort or consolation, its original Old High German translation meant fidelity, which is similar to the Old English term treowe meaning faithful. In contrast, the Gothic term trausti means agreement or alliance (Harper, 2012). A more industrial use of trust was first recorded in 1877 meaning businesses organized to minimize competition (Harper, 2012). More recent definitions of trust utilize a combination of its original meanings. The Merriam-Webster Dictionary (Trust, 2014a) provides a multitude of definitions for trust, but all contain a relational aspect. Definitions of trust as a noun include an assured reliance on the character, ability, or strength of someone or something, reliance on future payment for property, or delivered goods, and a combination of corporations formed by legal agreement that reduces competition (Trust, 2014a). As a noun, trust can also mean something committed to one to be cared for in the interest of another, responsible charge or office, and custody (Trust, 2014b). Similarly, in law, trust is defined as a relationship between two parties in which the fiduciary, or trustee, is given power to manage property while the beneficiary is given the privilege to receive benefits from that property (Trust, 2014b). Associated expressions, or synonyms, of trust as a noun include assurance, confidence, faith, hope, and reliance (Trust, 2014c). In comparison, as a verb, trust means to do something without fear, to rely on the accuracy of someone or something, and to give a task or responsibility to (Trust, 2014b). Its associated expressions include authorize, confide, and empower (Trust, 2014d). Defining Attributes Defining attributes represent the core of concept analysis by identifying specific phenomena to differentiate a concept from a similar or related concept (Walker & Avant, 2011). Various fields, such as health 287
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Trust in Healthcare Experiences care, nursing, and psychology, were examined to determine the defining attributes of trust. The most evident characteristic of trust is the dependent relationship between the truster and the trusted individual. This relationship requires a degree of vulnerability to depend on another individual to meet one’s need (Horn, Mitchell, Wang, Joseph, & Wissow, 2012; Hupcey, Penrod, Morse, & Mitcham, 2001; Johns, 1996). According to Meize-Grochowski (1984), dependence may also be described as reliability, or counting on someone or something to meet a specified need. Another defining attribute of trust is the willingness or choice to take a risk of relying on another (Hupcey et al., 2001; Johns, 1996). This willingness is greatly affected by the attitude of an individual in relation to someone or something (McCabe & Sambrook, 2014). Lastly, trust involves expectation that the trusted individual will behave in a certain way (Horn et al., 2012; Hupcey et al., 2001). According to McCabe and Sambrook (2014), expectation requires confidence, or freedom from uncertainty or doubt, that the trusted individual will behave as expected. Based on the literature, trust may be viewed as an evolving process or a static outcome. Depending on the perspective, there are additional defining attributes of trust. Trust is bound by time and space (McCabe & Sambrook, 2014). As an outcome, trust must be focused on the current behaviors of the individual meeting the need. In contrast, the process of trust involves positive past experiences that led to the development of current trust, which in turn affects the future of the trust. African American parents who reported a previous relationship with their child’s healthcare provider also reported more trust in the provider (p = .03) than parents who did not have a previous relationship (Horn et al., 2012). Those past positive experiences created an environment for developing a trusting relationship between African American parents and providers. There is an element of risk associated with the process of trust because one must act as though the future is certain, or that the trust will be maintained (Meize-Grochowski, 1984). According to Meize-Grochowski (1984), although trust occurs in the present, elements of the past and future occur in tandem with the act of trust. The attribute of fragility defines the outcome of trust, but may be implied in the process of trust (Johns, 1996; McCabe & Sambrook, 2014). If there is a negative outcome with someone or something previously trusted, the trust is broken or destroyed (McCabe 288 © 2015 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 4, October-December 2015
T. M. Murray & Sambrook, 2014). The process of regaining trust is long and tenuous, and requires sensitivity and care. In summary, the following are the three defining attributes of trust: • Dependence—a vulnerable relationship relying on another to meet needs • Willingness—a choice to take the risk of depending on another • Met expectations—confirmations of a belief that another will behave in a certain way
Antecedents and Consequences Walker and Avant (2011) define antecedents as events or incidents that must occur or be in place before a concept occurs. Likewise, a consequence is defined as the outcome of a concept or the events or incidents that occur as a result of the concept. The antecedents of trust include a need requiring the help of another in order to be met, prior knowledge or experience with the other, and a risk assessment of what is at stake by depending on another (Hupcey et al., 2001). Antecedents of trust in the healthcare system may take on a variety of forms. A patient may be in need of specific treatment to address an illness that is only available by seeing a nurse or other healthcare professional. Individuals may draw from their own experiences or the experiences of those around them to determine the trustworthiness of a provider or facility. Similarly, one may evaluate those experiences to consider the risks associated with trusting another individual to meet their needs. The consequence, or outcome, of trust is an evaluation of the congruence between expected and actual behaviors of the trusted person or thing. Evaluation of trust occurs on occasion when defining trust as an outcome, or may be ongoing in the process of trust (Hupcey et al., 2001; Johns, 1996). In health care, the consequences of trust significantly impact the patient–provider relationship and can have serious implications for health outcomes. African American men who reported higher trust in the medical system also reported higher adherence to treatment regimens (Cuffee et al., 2013; Elder et al., 2012). Therefore, interventions aimed at promoting trust in healthcare providers and health systems may positively impact health outcomes for African Americans.
Trust in Healthcare Experiences
T. M. Murray Empirical Referents The final step in a concept analysis is determining the empirical referents or classes or categories of actual phenomena that demonstrate the occurrence of the concept (Walker & Avant, 2011). Instruments designed to measure trust include the Interpersonal Physician Trust Scale, or the Wake Forest Physician Trust Scale, a 10-item instrument developed by Hall, Camacho, Dugan, and Balkrishnan (2002). The Wake Forest Physician Trust Scale measures trust as categorized by five conceptual domains: fidelity, competence, honesty, confidentiality, and global trust (Hall et al., 2002). This instrument has been used in African American populations to assess associations between patient trust in physicians and adherence to treatment plans (Cuffee et al., 2013; Elder et al., 2012; Horn et al., 2012). Anderson and Dedrick (1990) created the 11-item Trust in Physician Scale to measure trust using three major domains: dependability, confidence, and confidentiality. Peters, Benkert, Templin, and Cassidy-Bushrow (2014) used the Trust in Physician Scale in a population of 189 African American pregnant women to identify the key characteristics associated with trust in obstetric providers. Behaviors by an individual that demonstrate the concept of trust include sharing confidential information with another, the existence of a long-term positive relationship, and willingness of an individual to maintain dependence or vulnerability with respect to the trusted individual (Johns, 1996). These are all important behaviors in health care as patients must feel free to provide sensitive, personal information to nurses and other healthcare providers, and feel assured that information will remain confidential. Likewise, patients must be willing to depend on providers for appropriate, effective treatment to meet their healthcare needs. New healthcare reform options encourage consumers to have a medical home for their health needs. This will require the development of trusting, long-term relationships between patients and their healthcare providers. Application of the Trust to the African American Healthcare Experience Planning for healthcare needs and management of African American consumers can benefit from a clear understanding of the concept of trust within this community. Understanding the integral part played by trust and confidence will allow healthcare providers to
create more positive patient–provider relationships and improve health outcomes in this vulnerable population. The three defining attributes, dependence, willingness, and met expectations, are essential to experiencing the phenomenon of trust. However, for African Americans accessing the healthcare system, one or more attributes may be missing, resulting in mistrust and poor perceptions of healthcare providers and systems.
Dependence Research has shown that African Americans are less willing to take the risk of depending on healthcare providers for care. Many African American adults would rather risk the unpredictability of possible illness in the future than be placed in the dependent role of seeking preventive medical treatment from a healthcare provider. Dependence is represented by a relationship in which one relies on another to meet a specific need, and may be passive or active. Passive dependence occurs in more traditional patient– provider relationships where healthcare providers are perceived as better educated and given sole authority to make decisions on behalf of the patient. However, individuals who perceive themselves as having an important role in their healthcare decisions assume a more active dependence, or patient activism, in the patient–provider relationship. Alexander, Hearld, Mittler, and Harvey (2012) investigated the relationship between the perception of one’s role in the patient–provider relationship and levels of patient activism in 8,140 chronically ill patients (Caucasian— 65%, African American—26%, Hispanic—7%, other race/ethnicities—2%) using a cross-sectional random digit dial survey design. The findings showed that higher perceived quality of interpersonal exchange, greater fairness in the treatment process, and more out-of-office contact with healthcare providers were associated with higher levels of activism (Alexander et al., 2012). Patients assume a more active role in their health care when they perceive they are treated fairly and have valuable input related to their treatment plan. As healthcare providers begin to foster an active dependent relationship with African American patients, they must consider the quality of their interactions, equity of care, and opportunities for outof-office contact such as community or outreach activities. Such out-of-office contacts between providers and African Americans begin to diminish 289
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Trust in Healthcare Experiences paternalistic views of providers and create an environment for African Americans to see providers in different capacities. Willingness The defining attribute, willingness, appears to be a key aspect of African American utilization of healthcare services. Sabir and Pillemer (2014) explored strategies for increasing the willingness of African Americans to participate in medical research using meaningful experiential similarities. Experiential similarities between healthcare providers and African American patients are significantly different and more effective from structural similarities, such as gender or race/ethnicity (Sabir & Pillemer, 2014). Instead, experiential similarities build on the common threads of human existence that tie all of us together. For example, an African American patient may be experiencing a period of financial distress being unsure of the ability to afford a prescription. While the healthcare provider may not have had the exact experience, most adults can recall a time when they did not have necessary resources to meet an essential need. Drawing from those experiences creates a relational link between providers and patients through meaningful experiential similarities, and fosters an environment for increased willingness to trust one another. Met Expectations African Americans may have experiences of met expectations with healthcare providers. However, it may be difficult or impossible to shed the memories or expectations of poor treatment with many African Americans aware of the medical experimentation that occurred throughout history. Earl, Alegría, Mendieta, and Linhart (2011) used semi-structured interviews in an exploratory study to explore the interactions between 14 African American patients and 11 of their non-African American mental health providers to better understand how African American patients determine their initial provider experience as good (favorable) or poor (unfavorable). The study results suggested that patients frequently referred to past negative experiences to set expectations for provider experiences and determine the trustworthiness of a provider (Earl et al., 2011). In one interview, a patient describes how expectations of the current provider encounter were developed from previous negative experiences with unmet expectations. 290 © 2015 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 4, October-December 2015
T. M. Murray Just be straight, you know, speak (to) and treat me just like you’re talking to any other man. You don’t have to be careful with me. Don’t treat me like, “I got to be careful with him, he’s Black.” Just talk to me, just like any other man, because if you be careful with me, I’m going to feel it, I’m going to know you’re doing it. Don’t give me that, “hey buddy.” I don’t need that, let’s just be straight. That’s what he (the provider) was doing with me . . . I feel good about him, I trust and respect him and I think he respects me . . . (Patient 411; Earl et al., 2011, p. 522) Therefore, it is imperative for providers to understand the impact of prior negative experiences and the influence on setting expectations and developing trust in patient–provider relationships. Trust Building Nurses and other healthcare professionals will need to utilize evidence-based strategies to build trust with African American patients. It is important to realize that trust develops over time. While one interaction impacts whether trust is lost or maintained, trustworthiness is developed over time, that is, with recurring interactions where an individual remains willing to depend on another to meet a need because expectations have continuously been met (Dilworth-Anderson, 2011). Patient–provider interactions that focus on honesty, confidentiality, and fidelity are the foundation of trust building (Hall et al., 2001). A willingness to discuss trust issues in an open and nonjudgmental way is an indication that the provider has nothing to hide and acknowledges the patient’s legitimate right to have these reservations. Nurses and other healthcare providers must thoughtfully discuss medications, treatments, and other aspects of care by offering honesty about side effects, recovery times, and the potential impact on activities of daily living. Honesty allows the patient to create realistic expectations of the provider and plan of care that are more likely to be met than expectations built on misinformation. Fidelity, defined as the quality of being faithful or loyal (Fidelity, 2014), influences trust in several ways. When nurses and other healthcare providers consistently remain faithful to what they have told a patient they plan to do, they prove themselves to be dependable or reliable. This creates an environment where patients may be more willing to depend on providers to meet their healthcare needs. Additionally, fidelity
Trust in Healthcare Experiences
T. M. Murray fosters an environment for continued met expectations and trust building when providers honor agreements or plans made with patients, such as scheduled appointments or changes in plan of care. Summary This brief concept analysis provided better understanding of the meaning of trust and its application in the African American patient’s healthcare experience. Trust is the willingness to enter a dependent relationship in order to have the needs addressed, and is maintained by experiencing the positive outcome of met expectations. For African Americans, trust in the healthcare system has been shaped by years of unequal treatment. Yet rebuilding trusting relationships between providers and African American patients is a vital step toward reducing the health disparities experienced by this population. Evidence has shown that African Americans who trust their healthcare providers are more likely to adhere to prescribed plans of care, which results in improved health outcomes. Nurses, often the frontline of care, play a critical role in developing trust with African American patients by incorporating honesty, confidentiality, and fidelity into their numerous patient interactions. However, more research is needed to determine how trust is initiated with African American patients. Answering this question will assist healthcare providers in establishing and maintaining trust with new consumers who will need a medical home following the implementation of healthcare reform. Determining how trust is initiated will also shed light on the accountability of the truster and the trusted in the relationship. Further research into accountability and effectiveness in the trust relationship will guide interventions necessary for improving the health outcomes for a vulnerable part of the U.S. population. References Alexander, J. A., Hearld, L. R., Mittler, J. N., & Harvey, J. (2012). Patient-physician role relationships and patient activation among individuals with chronic illness. Health Services Research, 47(3, Pt. 1), 1201–1223. doi:10.1111/ j.1475-6773.2011.01354.x Anderson, L. A., & Dedrick, R. F. (1990). Development of the Trust in Physician Scale: A measure to assess interpersonal trust in patient-physician relationships. Psychological Reports, 67, 1091–1100. doi:10.2466/pr0.1990.67.3f.1091 Braunstein, J., Sherber, N., Schulman, S., Ding, E., & Powe, N. (2008). Race, medical researcher distrust, perceived
harm, and willingness to participate in cardiovascular prevention trials. Medicine, 87(1), 1–9. doi:10.1097/MD .0b013e3181625d78 Bronson, J., & Nuriddin, T. (2014). “I don’t believe in doctors much”: The social control of health care, mistrust, and folk remedies in the African American slave narrative. Journal of Alternative Perspectives in the Social Sciences, 5(4), 706–732. Cuffee, Y. L., Hargraves, J., Rosal, M., Briesacher, B. A., Schoenthaler, A., Person, S., & Allison, J. (2013). Reported racial discrimination, trust in physicians, and medication adherence among inner-city African Americans with hypertension. American Journal of Public Health, 103(11), e55–e62. doi:10.2105/AJPH.2013.301554 Dilworth-Anderson, P. (2011). Introduction to the science of recruitment and retention among ethnically diverse populations. Gerontologist, 51(Suppl. 1), S1–S4. doi:10 .1093/geront/gnr043 Earl, T. R., Alegría, M., Mendieta, F., & Linhart, Y. (2011). “Just be straight with me:” An exploration of Black patient experiences in initial mental health encounters. American Journal of Orthopsychiatry, 81(4), 519–525. doi:10.1111/j.1939-0025.2011.01123.x Elder, K., Ramamonjiarivelo, Z., Wiltshire, J., Piper, C., Horn, W. S., Gilbert, K. L., & Allison, J. (2012). Trust, medication adherence, and hypertension control in Southern African American men. American Journal of Public Health, 102(12), 2242–2245. doi:10.2105/ AJPH.2012.300777 Fidelity. (2014). In Merriam-Webster Dictionary Online. Retrieved from http://www.merriam-webster.com/ dictionary/fidelity Gallup. (2014). Honesty/ethics in professions. Retrieved from http://www.gallup.com/poll/1654/honesty-ethicsprofessions.aspx George, S., Duran, N., & Norris, K. (2014). A systematic review of barriers and facilitators to minority research participation among African Americans, Latinos, Asian Americans, and Pacific Islanders. American Journal of Public Health, 104(2), e16–e31. doi:10.2105/ AJPH.2013.301706 Hall, M., Dogan, E., Zheng, B., & Mishra, A. (2001). Trust in physicians and medical institutions: What is it, can it be measured, and does it matter? Milbank Quarterly, 79(4), 613–639. Hall, M. A., Camacho, F. F., Dugan, E. E., & Balkrishnan, R. R. (2002). Trust in the medical profession: Conceptual and measurement issues. Health Services Research, 37(5), 1419–1439. doi:10.1111/1475-6773.01070 Harper, D. (2012). Trust. In Online etymology dictionary. Retrieved from http://www.etymonline.com/index .php?allowed_in_frame=0&search=trust&searchmode= none Horn, I., Mitchell, S., Wang, J., Joseph, J., & Wissow, L. (2012). African-American parents’ trust in their child’s primary care provider. Academic Pediatrics, 12(5), 399– 404. Hupcey, J., Penrod, J., Morse, J., & Mitcham, C. (2001). An exploration and advancement of the concept of trust. Journal of Advanced Nursing, 36(2), 282–293. doi:10.1046/ j.1365-2648.2001.01970.x 291
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Trust in Healthcare Experiences Johns, J. (1996). A concept analysis of trust. Journal of Advanced Nursing, 24(1), 76–83. doi:10.1046/j.13652648.1996.16310.x McCabe, T. J., & Sambrook, S. (2014). The antecedents, attributes and consequences of trust among nurses and nurse managers: A concept analysis. International Journal of Nursing Studies, 51(5), 815–827. doi:10.1016/ j.ijnurstu.2013.10.003 McDonald, E. L., Powell, C., Perryman, J. P., Thompson, N. J., & Jacob Arriola, K. R. (2013). Understanding the relationship between trust in health care and attitudes toward living donor transplant among African Americans with end-stage renal disease. Clinical Transplantation, 27(4), 619–626. doi:10.1111/ctr.12176 McLeod, S. (2013). Erik Erikson. Retrieved from http:// www.simplypsychology.org/Erik-Erikson.html Meize-Grochowski, R. (1984). An analysis of the concept of trust . . . in the nursing literature. Journal of Advanced Nursing, 9(6), 563–572. doi:10.1111/j.1365-2648.1984 .tb00412.x Milton, C. L. (2012). Trust-mistrust: Conflicts of interest and nurse research. Nursing Science Quarterly, 25(2), 133–136. doi:10.1177/0894318412437961 Peters, R., Benkert, R., Templin, T., & Cassidy-Bushrow, A. (2014). Measuring African American women’s trust in provider during pregnancy. Research in Nursing & Health, 37(2), 144–154. doi:10.1002/nur.21581 Sabir, M. G., & Pillemer, K. A. (2014). An intensely sympathetic awareness: Experiential similarity and cultural norms as means for gaining older African Americans’ trust of scientific research. Journal of Aging Studies, 29, 142–149. doi:10.1016/j.jaging.2013 .11.005
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T. M. Murray Saha, S., Jacobs, E., Moore, R., & Beach, M. (2010). Trust in physicians and racial disparities in HIV care. AIDS Patient Care and STDs, 24(7), 415–420. doi:10.1089/apc .2009.0288 Schmidt, P. J. (2011). Blood, AIDS, and bureaucracy. The crisis and the tragedy. Transfusion Medicine Reviews, 25(4), 335–343. doi:10.1016/j.tmrv.2011.04.007 Shavers, V., Lynch, C., & Burmeister, L. (2002). Original report: Racial differences in factors that influence the willingness to participate in medical research studies. Annals of Epidemiology, 122, 48–256. doi:10.1016/S10472797(01)00265-4 Trust. (2014a). In Merriam-Webster Encyclopedia online. Retrieved from http://www.merriam-webster.com/concise/ trust Trust. (2014b). In Merriam-Webster Dictionary online. Retrieved from http://www.merriam-webster.com/ dictionary/trust Trust. (2014c). In Merriam-Webster Thesaurus online (noun). Retrieved from http://www.merriam-webster.com/ thesaurus/trust Trust. (2014d). In Merriam-Webster Thesaurus online (verb). Retrieved from http://www.merriam-webster.com/ thesaurus/trust U.S. Department of Health and Human Services. (2012). Healthy People 2020 topics & objectives: Access to health services. Retrieved from http://www.healthypeople.gov/2020/ topicsobjectives2020/overview.aspx?topicid=1 Walker, L., & Avant, K. (2011). Strategies for theory construction in nursing (5th ed.). Boston: Prentice Hall. Washington, H. A. (2006). Medical apartheid: The dark history of medical experimentation on Black Americans from colonial times to the present. New York: Doubleday.
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Trust in African Americans’ Healthcare Experiences Traci M. Murray, RN Traci M. Murray, RN, is a Doctoral Candidate, College of Nursing, University of Texas at Tyler, Tyler, TX. Keywords African American, concept analysis, health care, nursing, trust Correspondence Traci M. Murray, RN, College of Nursing, University of Texas at Tyler, Tyler, TX E-mail: [email protected] .edu
Murray
PURPOSE. The purpose of the study is to clarify the concept of trust, identify its defining attributes, antecedents, and consequences, and apply to the healthcare experiences of African Americans. BACKGROUND. For African Americans, mistrust in the healthcare system is the result of unequal treatment that began in slavery. Fear and negative experiences engender a reluctance to trust healthcare providers, which contributes to health disparities. DESIGN. Walker and Avant’s method of concept analysis was used to clarify the concept of trust. The concept was applied to African Americans’ healthcare experiences with discussion of opportunities for trust building. DATA SOURCE. Data support for concept development was done using Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, and online reference sources. REVIEW METHODS. Literature review was guided by using the keyword trust. Further contextual explication was done by adding a review of literature from sociology and history regarding the evolution of African American mistrust of the U.S. healthcare system. RESULTS. The defining attributes of trust are dependence, willingness, and met expectations. Antecedents to trust include a need requiring the help of another and prior knowledge or experience. The consequence of trust is an evaluation of the congruence between expected and actual behaviors of the trusted person or thing. Literature review of the African American culture adds a dynamic aspect for nurses to consider when developing relationships in minority communities. CONCLUSION. Trust is the willingness to enter a dependent relationship to have the needs addressed, and is maintained by met expectations. Rebuilding trusting relationships between providers and African American patients is a vital step toward reducing health disparities.
Introduction When individuals seeking health care experience unmet needs or poor treatment, it generally affects their ability and willingness to trust. Yet what is the result when sizeable populations perceive these experiences over several generations? For African Americans, mistrust in the healthcare system is the result of unequal treatment that began in slavery when their ancestors were codified by law as inferior to Caucasians. This mistrust of the healthcare system still per-
meates throughout African American culture today as they perceive that the care delivery system remains under the control of the white majority. Fear and negative experiences cause many African Americans to be reluctant to trust healthcare providers, which often results in poor health outcomes contributing to health disparities. The purpose of this article is to explore the concept of trust using Walker and Avant’s (2011) concept analysis methods. The concept is applied to African Americans’ healthcare experiences with discussion of opportunities for trust building. 285
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Trust in Healthcare Experiences Methods Data support for the concept development was done using the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, and online reference sources, such as the Merriam-Webster Dictionary. To ensure that results focused on the concept of trust, search parameters included “trust” alone and with “African American” as subject terms. Searches were not limited by publication date to capture classic works that have contributed to concept development over time. However, searches were limited to scholarly, peer-reviewed journals only. Additional literature reviews were conducted to develop support for the role of trust in African Americans’ healthcare experiences. Medline and CINAHL were searched using keywords such as “African American,” “trust,” “mistrust,” and “healthcare.” Specific support was sought regarding the impact of the Tuskegee Syphilis study and its impact on African Americans’ view of the healthcare system. Background The history of African Americans’ mistrust in the healthcare system is rooted in the deplorable health conditions of slavery and medical experimentation of the Tuskegee Syphilis study (Braunstein, Sherber, Schulman, Ding, & Powe, 2008; Bronson & Nuriddin, 2014; George, Duran, & Norris, 2014; McDonald, Powell, Perryman, Thompson, & Jacob Arriola, 2013; Sabir & Pillemer, 2014). Bronson and Nuriddin (2014) reviewed narratives from former slaves following their emancipation to learn about medical practices and perceptions of care during and after the slavery period in the United States. Findings from the narratives revealed a preference for medical treatment using native African herbs and folk remedies administered by trusted enslaved individuals, often called “granny doctors” (Bronson & Nuriddin, 2014). An inherent mistrust of care and medication given by Caucasian physicians was clear. African Americans became victims of racial stereotypes, reinforcing the belief that they were inferior to Caucasians and subject to legalized, systematic discrimination, even after emancipation. In general, the issue of mistrust in health care has been discussed for many years. Perhaps the most wellknown use of the word trust comes from Erikson’s stages of psychological development, where resolution of trust versus mistrust is the first stage of infant development occurring between birth and at the age of two 286 © 2015 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 4, October-December 2015
T. M. Murray (McLeod, 2013). During this time, an infant seeks consistent, reliable care from the caregiver or parent as a foundation for building trusting relationships with others. This idea of consistency and reliability appears to be at the heart of many trust/mistrust situations. In health care, nurses have been the key to public health initiatives aimed at preventing the spread of disease. However, the mistrust issues of the homosexual population, another vulnerable group, in the 1980s led to unique challenges in addressing the HIV/AIDS epidemic. During that time, AIDS was incorrectly categorized as a “gay syndrome” preventing homosexual males from seeking care (Schmidt, 2011). Today, the issue of mistrust in healthcare research is an obstacle, which nurse scientists must address by identifying potential conflicts of interest that may harm the patient–provider relationship (Milton, 2012). Thus, general mistrust in health care combined with the historical abuses suffered by the African American community has created an environment where developing trust in healthcare providers is difficult. In a cross-sectional study, Shavers, Lynch, and Burmeister (2002) surveyed 179 adults (African American n = 91, Caucasian n = 88, other race/ ethnicity n = 19) in Detroit to determine whether there were racial differences in barriers to medical research participation. Results revealed that African Americans were more likely to believe that minorities and the poor were unequally subject to more risks in research when compared with the beliefs of Caucasians. Additionally, 81% of African Americans were aware of the Tuskegee study compared with only 28% of Caucasians. As a result of their awareness of the Tuskegee study, 51% of African Americans reported decreased trust in medical researchers compared with only 17% of Caucasians (Shavers et al., 2002). Washington (2006) suggests that the devaluing of free and enslaved African Americans contributed to the medical experimentation and unequal medical treatment, which led to chronic mistrust of the healthcare system. Consequences of Mistrust The chronic mistrust of the healthcare system by African Americans may contribute to the health disparities experienced by many within this population (McDonald et al., 2013; Saha, Jacobs, Moore, & Beach, 2010). McDonald et al. (2013) investigated the relationship between trust in health care and attitudes toward living donor transplant (LDT) in African
T. M. Murray Americans with end-stage renal disease. Researchers hypothesized that decreased levels of trust in health care, including one’s physician and hospital, and in racial equity of care would be significantly associated with negative attitudes toward LDT. The findings supported this hypothesis as positive attitudes toward LDT were significantly correlated with higher trust in one’s physician (r = 0.265, p < .001), hospital (r = 0.131, p = .04), and in perception of racial equity in care (r = 0.202, p = .001) (McDonald et al., 2013). These results suggest that mistrust in healthcare providers and facilities presents a serious issue related to African Americans’ perception of organ donation and transplant. As a result, African Americans are less likely to become organ donors, and likewise less likely to receive an organ transplant, contributing to the health disparity. Saha et al. (2010) analyzed data from a cohort study conducted at an HIV clinic from 2005 to 2008 including 1,104 African American and 201 Caucasian patients to determine the relationship between trust in a healthcare provider and racial disparities in HIV care. African American patients reported less trust in their healthcare providers than their Caucasian counterparts (8.9 vs. 9.4 on a 0–10 scale; p < .001). However, trust in healthcare providers was only significantly associated with adherence to prescribed antiretroviral treatment in all participants (Saha et al., 2010). Improving the patient–provider relationship by building trust can potentially reduce health disparities in HIV care by increasing adherence and associated positive health outcomes. Trust has gained considerable attention in health care as a global attribute of treatment relationships (Hall, Dogan, Zheng, & Mishra, 2001). The Healthy People 2020 initiative indicates trust as an important factor when locating a healthcare provider (U.S. Department of Health and Human Services, 2012). Similarly, it has been described as giving the physician–patient relationship meaning and substance, and is essential for therapeutic interactions. According to Gallup (2014), for the past decade, nurses have been the most trusted profession. As new healthcare reform initiatives are implemented, nurses will need to maintain their trustworthiness as the population of African Americans seeking health care increases. However, while there is consensus about the importance of trust, its conceptual definition remains elusive. Defining the concept of trust and applying it to the experience of African Americans in the healthcare system will shed light on the
Trust in Healthcare Experiences nursing implications of this increasingly important issue. Concept Analysis The term trust has been ill-defined since its origination in a variety of thirteenth-century languages. The Old Norse, or Norwegian, term traust means help or confidence, while the Dutch term troost means comfort or consolation (Harper, 2012). Although the modern German term trost also means comfort or consolation, its original Old High German translation meant fidelity, which is similar to the Old English term treowe meaning faithful. In contrast, the Gothic term trausti means agreement or alliance (Harper, 2012). A more industrial use of trust was first recorded in 1877 meaning businesses organized to minimize competition (Harper, 2012). More recent definitions of trust utilize a combination of its original meanings. The Merriam-Webster Dictionary (Trust, 2014a) provides a multitude of definitions for trust, but all contain a relational aspect. Definitions of trust as a noun include an assured reliance on the character, ability, or strength of someone or something, reliance on future payment for property, or delivered goods, and a combination of corporations formed by legal agreement that reduces competition (Trust, 2014a). As a noun, trust can also mean something committed to one to be cared for in the interest of another, responsible charge or office, and custody (Trust, 2014b). Similarly, in law, trust is defined as a relationship between two parties in which the fiduciary, or trustee, is given power to manage property while the beneficiary is given the privilege to receive benefits from that property (Trust, 2014b). Associated expressions, or synonyms, of trust as a noun include assurance, confidence, faith, hope, and reliance (Trust, 2014c). In comparison, as a verb, trust means to do something without fear, to rely on the accuracy of someone or something, and to give a task or responsibility to (Trust, 2014b). Its associated expressions include authorize, confide, and empower (Trust, 2014d). Defining Attributes Defining attributes represent the core of concept analysis by identifying specific phenomena to differentiate a concept from a similar or related concept (Walker & Avant, 2011). Various fields, such as health 287
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Trust in Healthcare Experiences care, nursing, and psychology, were examined to determine the defining attributes of trust. The most evident characteristic of trust is the dependent relationship between the truster and the trusted individual. This relationship requires a degree of vulnerability to depend on another individual to meet one’s need (Horn, Mitchell, Wang, Joseph, & Wissow, 2012; Hupcey, Penrod, Morse, & Mitcham, 2001; Johns, 1996). According to Meize-Grochowski (1984), dependence may also be described as reliability, or counting on someone or something to meet a specified need. Another defining attribute of trust is the willingness or choice to take a risk of relying on another (Hupcey et al., 2001; Johns, 1996). This willingness is greatly affected by the attitude of an individual in relation to someone or something (McCabe & Sambrook, 2014). Lastly, trust involves expectation that the trusted individual will behave in a certain way (Horn et al., 2012; Hupcey et al., 2001). According to McCabe and Sambrook (2014), expectation requires confidence, or freedom from uncertainty or doubt, that the trusted individual will behave as expected. Based on the literature, trust may be viewed as an evolving process or a static outcome. Depending on the perspective, there are additional defining attributes of trust. Trust is bound by time and space (McCabe & Sambrook, 2014). As an outcome, trust must be focused on the current behaviors of the individual meeting the need. In contrast, the process of trust involves positive past experiences that led to the development of current trust, which in turn affects the future of the trust. African American parents who reported a previous relationship with their child’s healthcare provider also reported more trust in the provider (p = .03) than parents who did not have a previous relationship (Horn et al., 2012). Those past positive experiences created an environment for developing a trusting relationship between African American parents and providers. There is an element of risk associated with the process of trust because one must act as though the future is certain, or that the trust will be maintained (Meize-Grochowski, 1984). According to Meize-Grochowski (1984), although trust occurs in the present, elements of the past and future occur in tandem with the act of trust. The attribute of fragility defines the outcome of trust, but may be implied in the process of trust (Johns, 1996; McCabe & Sambrook, 2014). If there is a negative outcome with someone or something previously trusted, the trust is broken or destroyed (McCabe 288 © 2015 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 4, October-December 2015
T. M. Murray & Sambrook, 2014). The process of regaining trust is long and tenuous, and requires sensitivity and care. In summary, the following are the three defining attributes of trust: • Dependence—a vulnerable relationship relying on another to meet needs • Willingness—a choice to take the risk of depending on another • Met expectations—confirmations of a belief that another will behave in a certain way
Antecedents and Consequences Walker and Avant (2011) define antecedents as events or incidents that must occur or be in place before a concept occurs. Likewise, a consequence is defined as the outcome of a concept or the events or incidents that occur as a result of the concept. The antecedents of trust include a need requiring the help of another in order to be met, prior knowledge or experience with the other, and a risk assessment of what is at stake by depending on another (Hupcey et al., 2001). Antecedents of trust in the healthcare system may take on a variety of forms. A patient may be in need of specific treatment to address an illness that is only available by seeing a nurse or other healthcare professional. Individuals may draw from their own experiences or the experiences of those around them to determine the trustworthiness of a provider or facility. Similarly, one may evaluate those experiences to consider the risks associated with trusting another individual to meet their needs. The consequence, or outcome, of trust is an evaluation of the congruence between expected and actual behaviors of the trusted person or thing. Evaluation of trust occurs on occasion when defining trust as an outcome, or may be ongoing in the process of trust (Hupcey et al., 2001; Johns, 1996). In health care, the consequences of trust significantly impact the patient–provider relationship and can have serious implications for health outcomes. African American men who reported higher trust in the medical system also reported higher adherence to treatment regimens (Cuffee et al., 2013; Elder et al., 2012). Therefore, interventions aimed at promoting trust in healthcare providers and health systems may positively impact health outcomes for African Americans.
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T. M. Murray Empirical Referents The final step in a concept analysis is determining the empirical referents or classes or categories of actual phenomena that demonstrate the occurrence of the concept (Walker & Avant, 2011). Instruments designed to measure trust include the Interpersonal Physician Trust Scale, or the Wake Forest Physician Trust Scale, a 10-item instrument developed by Hall, Camacho, Dugan, and Balkrishnan (2002). The Wake Forest Physician Trust Scale measures trust as categorized by five conceptual domains: fidelity, competence, honesty, confidentiality, and global trust (Hall et al., 2002). This instrument has been used in African American populations to assess associations between patient trust in physicians and adherence to treatment plans (Cuffee et al., 2013; Elder et al., 2012; Horn et al., 2012). Anderson and Dedrick (1990) created the 11-item Trust in Physician Scale to measure trust using three major domains: dependability, confidence, and confidentiality. Peters, Benkert, Templin, and Cassidy-Bushrow (2014) used the Trust in Physician Scale in a population of 189 African American pregnant women to identify the key characteristics associated with trust in obstetric providers. Behaviors by an individual that demonstrate the concept of trust include sharing confidential information with another, the existence of a long-term positive relationship, and willingness of an individual to maintain dependence or vulnerability with respect to the trusted individual (Johns, 1996). These are all important behaviors in health care as patients must feel free to provide sensitive, personal information to nurses and other healthcare providers, and feel assured that information will remain confidential. Likewise, patients must be willing to depend on providers for appropriate, effective treatment to meet their healthcare needs. New healthcare reform options encourage consumers to have a medical home for their health needs. This will require the development of trusting, long-term relationships between patients and their healthcare providers. Application of the Trust to the African American Healthcare Experience Planning for healthcare needs and management of African American consumers can benefit from a clear understanding of the concept of trust within this community. Understanding the integral part played by trust and confidence will allow healthcare providers to
create more positive patient–provider relationships and improve health outcomes in this vulnerable population. The three defining attributes, dependence, willingness, and met expectations, are essential to experiencing the phenomenon of trust. However, for African Americans accessing the healthcare system, one or more attributes may be missing, resulting in mistrust and poor perceptions of healthcare providers and systems.
Dependence Research has shown that African Americans are less willing to take the risk of depending on healthcare providers for care. Many African American adults would rather risk the unpredictability of possible illness in the future than be placed in the dependent role of seeking preventive medical treatment from a healthcare provider. Dependence is represented by a relationship in which one relies on another to meet a specific need, and may be passive or active. Passive dependence occurs in more traditional patient– provider relationships where healthcare providers are perceived as better educated and given sole authority to make decisions on behalf of the patient. However, individuals who perceive themselves as having an important role in their healthcare decisions assume a more active dependence, or patient activism, in the patient–provider relationship. Alexander, Hearld, Mittler, and Harvey (2012) investigated the relationship between the perception of one’s role in the patient–provider relationship and levels of patient activism in 8,140 chronically ill patients (Caucasian— 65%, African American—26%, Hispanic—7%, other race/ethnicities—2%) using a cross-sectional random digit dial survey design. The findings showed that higher perceived quality of interpersonal exchange, greater fairness in the treatment process, and more out-of-office contact with healthcare providers were associated with higher levels of activism (Alexander et al., 2012). Patients assume a more active role in their health care when they perceive they are treated fairly and have valuable input related to their treatment plan. As healthcare providers begin to foster an active dependent relationship with African American patients, they must consider the quality of their interactions, equity of care, and opportunities for outof-office contact such as community or outreach activities. Such out-of-office contacts between providers and African Americans begin to diminish 289
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Trust in Healthcare Experiences paternalistic views of providers and create an environment for African Americans to see providers in different capacities. Willingness The defining attribute, willingness, appears to be a key aspect of African American utilization of healthcare services. Sabir and Pillemer (2014) explored strategies for increasing the willingness of African Americans to participate in medical research using meaningful experiential similarities. Experiential similarities between healthcare providers and African American patients are significantly different and more effective from structural similarities, such as gender or race/ethnicity (Sabir & Pillemer, 2014). Instead, experiential similarities build on the common threads of human existence that tie all of us together. For example, an African American patient may be experiencing a period of financial distress being unsure of the ability to afford a prescription. While the healthcare provider may not have had the exact experience, most adults can recall a time when they did not have necessary resources to meet an essential need. Drawing from those experiences creates a relational link between providers and patients through meaningful experiential similarities, and fosters an environment for increased willingness to trust one another. Met Expectations African Americans may have experiences of met expectations with healthcare providers. However, it may be difficult or impossible to shed the memories or expectations of poor treatment with many African Americans aware of the medical experimentation that occurred throughout history. Earl, Alegría, Mendieta, and Linhart (2011) used semi-structured interviews in an exploratory study to explore the interactions between 14 African American patients and 11 of their non-African American mental health providers to better understand how African American patients determine their initial provider experience as good (favorable) or poor (unfavorable). The study results suggested that patients frequently referred to past negative experiences to set expectations for provider experiences and determine the trustworthiness of a provider (Earl et al., 2011). In one interview, a patient describes how expectations of the current provider encounter were developed from previous negative experiences with unmet expectations. 290 © 2015 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 4, October-December 2015
T. M. Murray Just be straight, you know, speak (to) and treat me just like you’re talking to any other man. You don’t have to be careful with me. Don’t treat me like, “I got to be careful with him, he’s Black.” Just talk to me, just like any other man, because if you be careful with me, I’m going to feel it, I’m going to know you’re doing it. Don’t give me that, “hey buddy.” I don’t need that, let’s just be straight. That’s what he (the provider) was doing with me . . . I feel good about him, I trust and respect him and I think he respects me . . . (Patient 411; Earl et al., 2011, p. 522) Therefore, it is imperative for providers to understand the impact of prior negative experiences and the influence on setting expectations and developing trust in patient–provider relationships. Trust Building Nurses and other healthcare professionals will need to utilize evidence-based strategies to build trust with African American patients. It is important to realize that trust develops over time. While one interaction impacts whether trust is lost or maintained, trustworthiness is developed over time, that is, with recurring interactions where an individual remains willing to depend on another to meet a need because expectations have continuously been met (Dilworth-Anderson, 2011). Patient–provider interactions that focus on honesty, confidentiality, and fidelity are the foundation of trust building (Hall et al., 2001). A willingness to discuss trust issues in an open and nonjudgmental way is an indication that the provider has nothing to hide and acknowledges the patient’s legitimate right to have these reservations. Nurses and other healthcare providers must thoughtfully discuss medications, treatments, and other aspects of care by offering honesty about side effects, recovery times, and the potential impact on activities of daily living. Honesty allows the patient to create realistic expectations of the provider and plan of care that are more likely to be met than expectations built on misinformation. Fidelity, defined as the quality of being faithful or loyal (Fidelity, 2014), influences trust in several ways. When nurses and other healthcare providers consistently remain faithful to what they have told a patient they plan to do, they prove themselves to be dependable or reliable. This creates an environment where patients may be more willing to depend on providers to meet their healthcare needs. Additionally, fidelity
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T. M. Murray fosters an environment for continued met expectations and trust building when providers honor agreements or plans made with patients, such as scheduled appointments or changes in plan of care. Summary This brief concept analysis provided better understanding of the meaning of trust and its application in the African American patient’s healthcare experience. Trust is the willingness to enter a dependent relationship in order to have the needs addressed, and is maintained by experiencing the positive outcome of met expectations. For African Americans, trust in the healthcare system has been shaped by years of unequal treatment. Yet rebuilding trusting relationships between providers and African American patients is a vital step toward reducing the health disparities experienced by this population. Evidence has shown that African Americans who trust their healthcare providers are more likely to adhere to prescribed plans of care, which results in improved health outcomes. Nurses, often the frontline of care, play a critical role in developing trust with African American patients by incorporating honesty, confidentiality, and fidelity into their numerous patient interactions. However, more research is needed to determine how trust is initiated with African American patients. Answering this question will assist healthcare providers in establishing and maintaining trust with new consumers who will need a medical home following the implementation of healthcare reform. Determining how trust is initiated will also shed light on the accountability of the truster and the trusted in the relationship. Further research into accountability and effectiveness in the trust relationship will guide interventions necessary for improving the health outcomes for a vulnerable part of the U.S. population. References Alexander, J. A., Hearld, L. R., Mittler, J. N., & Harvey, J. (2012). Patient-physician role relationships and patient activation among individuals with chronic illness. Health Services Research, 47(3, Pt. 1), 1201–1223. doi:10.1111/ j.1475-6773.2011.01354.x Anderson, L. A., & Dedrick, R. F. (1990). Development of the Trust in Physician Scale: A measure to assess interpersonal trust in patient-physician relationships. Psychological Reports, 67, 1091–1100. doi:10.2466/pr0.1990.67.3f.1091 Braunstein, J., Sherber, N., Schulman, S., Ding, E., & Powe, N. (2008). Race, medical researcher distrust, perceived
harm, and willingness to participate in cardiovascular prevention trials. Medicine, 87(1), 1–9. doi:10.1097/MD .0b013e3181625d78 Bronson, J., & Nuriddin, T. (2014). “I don’t believe in doctors much”: The social control of health care, mistrust, and folk remedies in the African American slave narrative. Journal of Alternative Perspectives in the Social Sciences, 5(4), 706–732. Cuffee, Y. L., Hargraves, J., Rosal, M., Briesacher, B. A., Schoenthaler, A., Person, S., & Allison, J. (2013). Reported racial discrimination, trust in physicians, and medication adherence among inner-city African Americans with hypertension. American Journal of Public Health, 103(11), e55–e62. doi:10.2105/AJPH.2013.301554 Dilworth-Anderson, P. (2011). Introduction to the science of recruitment and retention among ethnically diverse populations. Gerontologist, 51(Suppl. 1), S1–S4. doi:10 .1093/geront/gnr043 Earl, T. R., Alegría, M., Mendieta, F., & Linhart, Y. (2011). “Just be straight with me:” An exploration of Black patient experiences in initial mental health encounters. American Journal of Orthopsychiatry, 81(4), 519–525. doi:10.1111/j.1939-0025.2011.01123.x Elder, K., Ramamonjiarivelo, Z., Wiltshire, J., Piper, C., Horn, W. S., Gilbert, K. L., & Allison, J. (2012). Trust, medication adherence, and hypertension control in Southern African American men. American Journal of Public Health, 102(12), 2242–2245. doi:10.2105/ AJPH.2012.300777 Fidelity. (2014). In Merriam-Webster Dictionary Online. Retrieved from http://www.merriam-webster.com/ dictionary/fidelity Gallup. (2014). Honesty/ethics in professions. Retrieved from http://www.gallup.com/poll/1654/honesty-ethicsprofessions.aspx George, S., Duran, N., & Norris, K. (2014). A systematic review of barriers and facilitators to minority research participation among African Americans, Latinos, Asian Americans, and Pacific Islanders. American Journal of Public Health, 104(2), e16–e31. doi:10.2105/ AJPH.2013.301706 Hall, M., Dogan, E., Zheng, B., & Mishra, A. (2001). Trust in physicians and medical institutions: What is it, can it be measured, and does it matter? Milbank Quarterly, 79(4), 613–639. Hall, M. A., Camacho, F. F., Dugan, E. E., & Balkrishnan, R. R. (2002). Trust in the medical profession: Conceptual and measurement issues. Health Services Research, 37(5), 1419–1439. doi:10.1111/1475-6773.01070 Harper, D. (2012). Trust. In Online etymology dictionary. Retrieved from http://www.etymonline.com/index .php?allowed_in_frame=0&search=trust&searchmode= none Horn, I., Mitchell, S., Wang, J., Joseph, J., & Wissow, L. (2012). African-American parents’ trust in their child’s primary care provider. Academic Pediatrics, 12(5), 399– 404. Hupcey, J., Penrod, J., Morse, J., & Mitcham, C. (2001). An exploration and advancement of the concept of trust. Journal of Advanced Nursing, 36(2), 282–293. doi:10.1046/ j.1365-2648.2001.01970.x 291
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Trust in Healthcare Experiences Johns, J. (1996). A concept analysis of trust. Journal of Advanced Nursing, 24(1), 76–83. doi:10.1046/j.13652648.1996.16310.x McCabe, T. J., & Sambrook, S. (2014). The antecedents, attributes and consequences of trust among nurses and nurse managers: A concept analysis. International Journal of Nursing Studies, 51(5), 815–827. doi:10.1016/ j.ijnurstu.2013.10.003 McDonald, E. L., Powell, C., Perryman, J. P., Thompson, N. J., & Jacob Arriola, K. R. (2013). Understanding the relationship between trust in health care and attitudes toward living donor transplant among African Americans with end-stage renal disease. Clinical Transplantation, 27(4), 619–626. doi:10.1111/ctr.12176 McLeod, S. (2013). Erik Erikson. Retrieved from http:// www.simplypsychology.org/Erik-Erikson.html Meize-Grochowski, R. (1984). An analysis of the concept of trust . . . in the nursing literature. Journal of Advanced Nursing, 9(6), 563–572. doi:10.1111/j.1365-2648.1984 .tb00412.x Milton, C. L. (2012). Trust-mistrust: Conflicts of interest and nurse research. Nursing Science Quarterly, 25(2), 133–136. doi:10.1177/0894318412437961 Peters, R., Benkert, R., Templin, T., & Cassidy-Bushrow, A. (2014). Measuring African American women’s trust in provider during pregnancy. Research in Nursing & Health, 37(2), 144–154. doi:10.1002/nur.21581 Sabir, M. G., & Pillemer, K. A. (2014). An intensely sympathetic awareness: Experiential similarity and cultural norms as means for gaining older African Americans’ trust of scientific research. Journal of Aging Studies, 29, 142–149. doi:10.1016/j.jaging.2013 .11.005
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T. M. Murray Saha, S., Jacobs, E., Moore, R., & Beach, M. (2010). Trust in physicians and racial disparities in HIV care. AIDS Patient Care and STDs, 24(7), 415–420. doi:10.1089/apc .2009.0288 Schmidt, P. J. (2011). Blood, AIDS, and bureaucracy. The crisis and the tragedy. Transfusion Medicine Reviews, 25(4), 335–343. doi:10.1016/j.tmrv.2011.04.007 Shavers, V., Lynch, C., & Burmeister, L. (2002). Original report: Racial differences in factors that influence the willingness to participate in medical research studies. Annals of Epidemiology, 122, 48–256. doi:10.1016/S10472797(01)00265-4 Trust. (2014a). In Merriam-Webster Encyclopedia online. Retrieved from http://www.merriam-webster.com/concise/ trust Trust. (2014b). In Merriam-Webster Dictionary online. Retrieved from http://www.merriam-webster.com/ dictionary/trust Trust. (2014c). In Merriam-Webster Thesaurus online (noun). Retrieved from http://www.merriam-webster.com/ thesaurus/trust Trust. (2014d). In Merriam-Webster Thesaurus online (verb). Retrieved from http://www.merriam-webster.com/ thesaurus/trust U.S. Department of Health and Human Services. (2012). Healthy People 2020 topics & objectives: Access to health services. Retrieved from http://www.healthypeople.gov/2020/ topicsobjectives2020/overview.aspx?topicid=1 Walker, L., & Avant, K. (2011). Strategies for theory construction in nursing (5th ed.). Boston: Prentice Hall. Washington, H. A. (2006). Medical apartheid: The dark history of medical experimentation on Black Americans from colonial times to the present. New York: Doubleday.
