Application of the Reina Trust and Betrayal Model to the Experience of Pediatric Critical Care Clinicians

Trust is a complicated and multidimensional concept with diverse interpretations.^3,4 Psychologically, trust can be interpreted as involving attachment⁵ or as a causal factor in the development of the self.⁶ Behaviorally, trust and its counterpart, betrayal, are understood as 2 dichotomous forces that affect the quality of relationships at the organizational, team, interpersonal, and intrapersonal levels.⁷ In human interactions, the dynamics of trust and betrayal are instrumental in developing and maintaining relationships, achieving outcomes and goals, and ensuring the integrity of individuals, processes, and structures.³ 

Trust is built incrementally and behaviorally.^7,–9 Perceptions of trust or betrayal are influenced by a person’s capacities and expectations of self and others.^6,7,10 The capacity for trust expands or contracts, depending on positive or negative experiences, beliefs about how the world works, and perceptions of reality at a particular moment.^6,7 This concept and its role in developing and maintaining relationships with patients¹¹ or between nurses¹² has been addressed. The Reina Trust and Betrayal Model, the focus of our research, has been used in other investigations.^13,14 

Valid measures of trust within health care settings are limited.³ No general measurement exists to determine trust between physicians and patients^15,–20; patients, physicians, and insurers; nurses and patients^21,–23; parents and nurses²⁴; nurses¹²; and nurses and the children they care for.²⁵ Although extensive research has been done on measurement of patients’ satisfaction, little empirical research has been done on the correlates of patient-physician or nurse trust.³ Attempts to measure interpersonal trust between health care professionals and patients are just beginning, and few measures exist of team, organizational, and leadership trust in health care organizations. Use of a behaviorally based construct to measure trust across different contexts (eg, individual, group, and organizational levels) has not been reported.

Studies on the organizational level have targeted the relationship of managed care and economic models and patient-client perceptions of trustworthiness,^26,–30 patients’ trust in their insurers,²⁰ and health care system distrust.³¹ The Reina trust scales, used in corporate environments since 1993, have also been used in several studies.^32,–36 Mendoza³² used the Team Trust Scale (TTS) and found statistically significant results: the contractual, communication, and competence trust mean group scores increased over time (posttest and post-posttest) when the pretest score was used as a covariate. To date, no systematic studies of trust among pediatric critical care professionals have been done.

The conceptual model for this study was the Reina Trust and Betrayal Model (see FigureF1), which is used to identify 3 components of transactional trust and the specific behaviors that foster those components of trust⁷:

1. Contractual trust (trust of character): Confidence in the intentions, consistency, and reliability of individuals to honor commitments makes or breaks contractual trust, especially in the workplace.

2. Communication trust (trust of disclosure): Communication trust contributes to the development of safe and productive work environments where a person’s capacity to trust in self and others increases and the organization’s capacity to perform expands.

3. Competence trust (trust of capability): Acknowledging and respecting a person’s competence to do what is needed in a particular situation, whether the situation involves an interpersonal interaction, role, or specific skills, builds trust. A person’s sense of competence is related to his or her sense of self-worth and job-related performance.

The purpose of this study was to determine the feasibility of measuring levels of trust between pediatric critical care nurses and physicians in relation to their organization and work group and levels of perceived trust in health care professionals by patients and patients’ families. In addition, data were analyzed to identify themes about the behaviors that build or break trust in the pediatric critical care unit (PICU).

The study was reviewed by the appropriate institutional review board. The investigation consisted of 2 phases. In phase 1, baseline quantitative data were collected on 3 dimensions of trust by using 3 Reina trust scales. In Phase 2, responses to 3 open-ended questions were analyzed qualitatively, coded, and compared with the results from phase 1.

The Reina trust scales consist of open-ended questions and a self-report 5-point Likert scale used to measure behaviors that contribute to the 3 types of transactional trust. The Reina Organizational Trust Scale (OTS) consists of 54 items used to measure the level of trust between employees and management across the organization, department, or division. The Reina Team Trust Scale (TTS) consists of 48 items used to measure the level of trust within a team. The Reina Patient Trust Scale–Health Care Professional (PTS-HCP) consists of 46 items used to measure the level of trust health care professionals think patients and patients’ families have for the health care team. Details on each of the 3 scales, with representative items in each category, are provided in Table 1.

Before their formal administration, the Reina trust scales were subjected to rigorous development. This work included linking the theory of transactional trust⁷ to the specific behaviors⁷ (see FigureF1) within each trust dimension (type of trust) and establishing the face validity of these items through extensive research within organizations and consultation with organizational development professionals in academic and practice settings. During the initial development, internal consistency and reliability of the dimensions were assessed, and each item was examined for its integrity as a component of its respective scale. These analyses resulted in modifications in the wording of some items, which improved scale reliability on subsequent administrations. (For more details, see http://www.reinatrustbuilding.com/index.php?contentId=125.)

The internal consistency reliability of the OTS during the 3 most recent administrations was assessed by using Cronbach α to overcome the limitations of other measures of reliability, such as split-half and test-retest.^37,38 The reliability coefficients for the OTS, TTS, and PTS-HCP are provided in Table 2. Additionally, results from 3 different organizations and 132 respondents yielded reliability coefficients for the OTS ranging from 0.90 to 0.93, values exceeding the α value of 0.80 or higher considered suitable for widely administered rating scales. The predictive validity of the OTS has yet to be assessed; its concurrent validity has been assessed by comparing the mean ratings within one’s group, which in general are higher than those outside of one’s group. The results of the TTS closely reflect those of the OTS (Table 2.)

A bidirectional measure of trust between workers and customers in business settings, the Customer Trust Scale, is undergoing beta testing. The PTS-HCP used in this study is an adaptation of the Customer Trust Scale in which the survey was customized by using language specific to health care; therefore, the psychometric data on both instruments are not yet available.

The sample was drawn from registered nurses and physicians in a PICU in a mid-Atlantic medical center. Although the nurses were the primary focus, comparison of their responses with those of their physician colleagues helped in understanding the applicability of the scales and the narrative responses to the open-ended questions. Groups with small numbers of clinicians (eg, social work, child life) were not included to avoid concerns about anonymity. A total of 85 pediatric critical care professionals (70 nurses, 15 physicians) were eligible to participate in the study. Results of similar studies³⁹ suggested that the response rate would be at least 50%. On the basis of incentives and interest in the topic, 65% participation was projected.

Participation was voluntary. All full-time and part-time PICU nurses, fellows, and attending physicians received an e-mail and a written invitation explaining the project; nonrespondents were sent a second invitation 2 weeks after the initial mailing. Presentations at regularly scheduled staff meetings provided an outline of the project and an overview of the Reina Trust and Betrayal Model. Volunteers completed the informed consent process. A gift certificate for the unit was offered as an incentive.

Instructions for supplying baseline demographic data and completing the Reina trust scales were provided online and on paper. All participants used the secure online method for data collection. Each instrument required 15 to 20 minutes of a respondent’s time; each instrument was completed within 14 days, with a 4-week interval between each subsequent instrument. All participants gave their consent to participate in the study.

Data from participants who completed the online survey and provided narrative responses to the 3 open-ended questions that accompanied each instrument, asking what builds, breaks, and rebuilds trust, were analyzed.

The qualitative responses to the open-ended questions were analyzed by using a standard iterative process of open coding of the transcribed responses.^40,–44 The data consisted of 26 pages of narrative responses coded to 1 or more of the 16 behaviors identified in the model as contributing to building or breaking trust⁷ (see FigureF1). Results of the qualitative analysis were compared with a summary of means from the 3 Reina trust scales. The key objectives were to identify, describe, and compare themes in the data.⁴² The raw narratives were imported into NVivo 8 (computer program, QRS International, Cambridge, Massachusetts) and sorted by instrument and by question. Codes reflecting the 16 behaviors were used to organize the data into categories that could be retrieved and linked to each other.⁴² The behaviors were grouped under contractual trust (6), communication trust (6), or competence trust (4). Each statement was coded to 1 or more behaviors; frequency counts were made of the coded data. Second-level pattern coding was used to organize the data into relationships among emerging themes.⁴³ Results were compared with a summary of means from the Reina trust scales. Interrater reliability was 0.60 to 0.85 on sample narratives; as a further reliability check, a structured feedback session with PICU clinicians was used to validate findings and themes.

Participants completed 3 online surveys to measure levels of trust between team members (TTS; n = 39), in relation to their organization (OTS; n = 56), and, from the staff’s perspective, with patients and patients’ families (PTS-HCP; n = 28). A total of 47 nurses (67% of PICU nurses) and 9 physicians (60% of the PICU physicians) completed the OTS. Participants were categorized by experience level of less than 3 years (13 participants), 3 to 5 years (9 participants), and more than 5 years (34 participants). Among the nurses, 2 had diplomas, 2 had an associate degree, 41 had a bachelor’s degree, and 2 had a master’s degree. Among the physicians, 4 were fellows and 5 were attending physicians. Of the 56 participants who completed the OTS, 28 (50%) completed the PTS-HCP, and 40 (71%) completed the TTS.

Congruence among the results of all 3 instruments was significant (Table 3). Overall scores on all 3 indicated moderate to high levels of trust among team members, with management, and (from the clinicians’ perspective) with patients and patients’ families. Higher scores in the competence and contractual trust areas indicated that respondents generally respected each other’s capabilities, acted with mutually serving intentions, and strove to keep their agreements with one another and with their patients and the patients’ families. Lower scores in the communication area (although still a generally healthy level) suggested a tendency of health care providers to participate in gossip or unfair criticism.

Scores on the TTS indicated agreement on behaviors that build trust. Respondents rated pointing out risky situations or areas of caution to each other and receiving constructive feedback without getting defensive as frequently occurring behaviors. They also rated actively striving to build supportive and productive relationships, being truthful with each other, and being able to speak their mind even when others disagree as occurring frequently within the team.

Communication trust scores on the TTS provided rates for behaviors that contribute to breaking trust. The items that scored the highest as breaking trust were gossip or participating in unfair criticism about other people (mean = 2.74) and shooting the messenger who brings bad news (mean = 2.18).

On the OTS also, gossip was the gravest threat to communication trust, particularly in the 2 groups with more years of experience in critical care (Table 4). On the positive side, those with more years of experience thought that professionals with more experience took on more responsibility, making the “management” of errors and mistakes more predictable.

Across all 3 instruments, ratings of communication trust had a pattern of disaffection that was evident through all demographic groups and converged on a few specific behaviors. Analysis revealed that the in the OTS and PTS-HCP scales, years of experience accounted for the greatest variation in the communication trust scores overall.

In phase 2, responses to the open-ended questions were coded to the 16 behaviors identified in the Reina Trust Model (Table 5). Analysis focused on patterns across the 3 survey instruments (Table 6). The 16 behaviors identified are expressed in their positive sense (eg, speaking with good purpose is described as speaking constructively and affirmatively), but each behavior also has a shadow side. Responses to question 2 (see following) were typically coded in this negative sense. The shadow side of speaking with good purpose, for example, is roughly understood as gossip or speech that is in some way harmful or corrosive to trust. Gossip may play a much larger role in certain communities and may not necessarily reflect trust-breaking speech.

The strongest contractual trust factor was a sense of “we” and a shared mission; mutually serving intentions was stressed on all 3 surveys. Managing expectations was highlighted on the PTS-HCP. The strongest factor in communication trust across all 3 surveys was information sharing, to which telling the truth and giving and receiving constructive feedback were added on the TTS. The strongest factor in competence trust involved acknowledging people’s skills and abilities. The standout in terms of building competence trust was involving others and seeking their input; analysis of the PTS-HCP indicated that this response was prominent in the answers to all 3 questions.

The most prominent breaches of contractual trust involved lack of team work, boundaries, and managing expectations. Numerous comments, collected under the code of speaking with good purpose, addressed gossip as defensive or negative communication spoken with negative intent. Communication issues were related to sharing information and perceived openness of communication. In competence trust, a significant number of responses focused on how staff and patients were consulted and involved in decision making. The next most prevalent class of comments was criticizing people’s skills and abilities.

Responses indicated that giving feedback, greater accountability for attitudes and behaviors of all levels of staff and management, improved communication, and addressing gossip were important in rebuilding trust. Other categories mentioned included managing expectations as a strategy to strengthen contractual trust. For communication trust, speaking with good purpose was mentioned as an antidote to gossip and negative language. For competence trust, a blend of sharing information and involving others was perceived as offering opportunities for improvement.

Overall, the quantitative and qualitative data suggested that the climate of trust in this PICU was relatively high. However, the findings on communication trust, particularly in the more experienced cohort, suggest opportunities may exist to intervene to rebuild trust with this group. Also, the “work” relationship between patients’ families and the health care team was an area needing attention. In competence trust, the most problematic behaviors involved acknowledging people’s skills and abilities (TTS, OTS) and involving others and seeking their input (PTS-HCP).

Participants responded with ease to the online survey and did not appear to be deterred by the time required. The decrease in the number of participants during the study period may be due in part to patient acuity and staffing issues and the implementation of system-wide changes. Anecdotal reports that some participants found some “redundancy” in the scales may reflect the use of the Transactional Trust model and similar questions throughout, done purposely to ensure consistent and systematic measurement.

The area at greatest risk for breaking trust within this PICU was communication trust and its 6 behaviors: share information, tell the truth, admit mistakes, maintain confidentiality, give and receive constructive feedback, and speak with good purpose.⁷ The most pervasive behaviors identified as breaking trust included gossip (not speaking with good purpose), breaking confidentiality, and not giving constructive feedback.

Speaking with good purpose refers to going directly to an individual with an issue or concern pertaining to him or her. This behavior reflects integrity, trust in self, a sense of compassion toward others, and an individual’s intent to work through issues in a respectful and responsible manner. When people speak with good purpose, they speak to what happened constructively and affirmatively and stand up for each other. Conversely, when people gossip, criticize, and shun others, trust between individuals, teams, and throughout an organization is undermined.^45,46 Although accurately discerning the intentions of people who gossip is difficult, the items reported here reflect the perceived impact or damage that communication such as negative gossip causes others.

In general, the longer clinicians work in this environment, the greater tendency they have to speak negatively to each other, shoot the messenger, and share information inappropriately. These tendencies indicate a strain on the interpersonal or human side of relationships and may be a result of years of unresolved issues. People who lack the capacity to trust themselves and others tend to project negative feelings outward and into negative behaviors. Clearly, the respondents with more experience were more pessimistic about communication in the unit, perhaps reflecting a tendency among them to use gossip as a coping mechanism. The term gossip is used in organizational development to describe rumor spreading, backbiting, and hearsay.⁷ From a broader perspective, gossip is a much more complex phenomenon.^47,48 Some think that gossip plays a key role in how nurses carry out the emotional labor associated with the nurses’ work,⁴⁹ whereas others consider it a kind of “glue” that holds communities together.⁵⁰ Gossip as speech about others is often compared with nit-picking among primates as a foundationally binding social behavior and evidence of interpersonal engagement. In this sense, speaking with good purpose could be interpreted as positive gossip and not speaking with good purpose as negative gossip.

Negative gossip tends to break trust. Typically, people gossip when they feel they have no place to air their concerns constructively and appropriately. Often people have a need be listened to and heard. As outgrowths of accumulated frustration and pent-up feelings, these gossiping behaviors reflect the tendency to project blame and resort to finger-pointing rather than collaborate and extend generosity. Negative gossip can be an indication of systemic organizational issues and can be a problem if unaddressed. Gossip, both positive and negative, can also be a vehicle for letting leaders know issues exist that need to be dealt with in appropriate, constructive ways.

The cost of broken trust^46,51 is high in critical care. When nurses experience betrayal of this type, their integrity may be threatened, or their work rendered meaningless, and they may disconnect from the essence of whom they believe they really are. This type of corrosive gossip in the workplace is clearly a topic for exploration or interventions in the work setting, and an urgent need exists to create work-places that are trustworthy and healthy and support the integrity of health care professionals.⁵² 

Speaking with good purpose is closely related to maintaining confidentiality. Confidentiality is the behavioral demonstration of respect for a person’s right to control what information is disclosed to others. Confidentiality involves keeping promises made to honor a person’s request that certain information not be disclosed to others and having others honor the person’s choices. Sharing private information without permission breaks trust and can have devastating consequences for individuals, teams, and organizations.

Responses from our participants also indicated that the manner in which feedback is given can either build or break trust. When feedback is given and received in the spirit of supporting the relationship, both parties grow and develop. This situation requires an expanded capacity for trust on the part of both the one giving and the one receiving. The ability to share information and feelings about one’s own or another’s behavior and performance is critical to maintaining effective working relationships and central to expanding a capacity for trust. Our results indicate that confusion about distinctions between (1) information that is shared among unit leaders, preceptors, and mentors and (2) gossip was a potential area for broken trust. Newer nurses who overheard conversations about their own or others’ clinical competence in relationship to making patient assignments, for example, were likely to misconstrue the comments as criticism or negative gossip rather than as intentions to match patients’ needs with nurses’ capacities. Awareness about the potential for broken trust in these contexts offers beneficial opportunities to reduce the incidence and negative impact of such events.

By underscoring the importance of trust as a measure of team and organizational health, our findings honor the core purpose and spirit of why people work in health care. All aspects of the transactional trust model are related to key precepts set forth for the nursing profession,⁵³ professional standards for a healthy work environment,^52,54 and regulatory⁵⁵ and policy⁵⁶ statements. By contributing to work environments where a person’s capacity to trust in self and others increases and the organization’s capacity to perform expands, trust is essential to developing and sustaining relationships; team cohesion and productivity; patient safety; and individual, team, and organizational integrity.^52,56 Because 60% of errors in health care can be attributed to communication failures,⁵⁶ building communication trust is a nonnegotiable imperative. Our findings suggest that new models for developing skills in communication among interdisciplinary teams and with patients and patients’ families are needed. Innovative models of learning based on the transactional trust framework offer promising opportunities to develop more than techniques by addressing the underlying issues that affect the quality of communication, collaboration, and honoring of individuals’ personal capacities. Building sustainable trust through education, systems, and leadership fosters effective relationships, promotes workplace environments that are adaptive and energized, and supports efforts to transform the work environment from one of negativity and competition to one of optimism, healing, and renewal.

This pilot study had limitations. Because we studied a single PICU, the results may not be generalizable to other PICUs or health care settings. A variety of instruments based on the Reina Model were used to measure different levels of transactional trust. Although the instruments have been reliable in business settings, further psychometric evaluation is needed. This study was the first application of the PTS-HCP. Our results indicate the feasibility and relevance of this scale to PICU clinicians, but the scale needs further psychometric refinement, particularly the dimension of contractual trust. In addition, the development of a companion scale to measure the perceptions of patients and their families of the trustworthiness of clinicians, health care teams. and health care organizations is needed. This study is a first step toward the development of such a scale.

We have also introduced a trust construct that is complex and predicated on several deeper constructs that involve the origins of trusting behavior⁶ as well as on the creation of both relationships^57,58 and social structures.⁵⁹ This construct certainly deserves more focused attention and will become increasingly valid with larger and more controlled studies. We also used a hybrid approach, with both surveys and analysis of open-ended narratives. The narratives are unique to the individuals that wrote them and reflect specific experiences and not the general experience of any class of health care practitioners.

The Reina Trust instruments are applicable to PICUs and are useful in measuring trust in that environment. Heretofore, we have lacked theoretically grounded instruments to help clinicians and administrators understand the impact of their behaviors on others’ perceptions of trustworthiness. The data collected with the Reina scales is useful in determining what behaviors build, break, and rebuild trust among PICU clinicians. On the basis of our findings, interventions to build communication trust, particularly to reduce corrosive gossip and judgmental interactions, appear to be a fruitful area of investigation.

We acknowledge the support of Elizabeth Zawarea, Kelly Wilson-Fowler, and Judith Douglas in the overall study administration and manuscript preparation. Participation of the staff and leaders of the PICU, Johns Hopkins Children’s Center, was valuable in the conduct of the study.