Specialty differences in the association between health care climate and patient trust

Medical Education 2011: 45 : 905–912 CONTEXT Previous studies have suggested that there is a positive correlation between doctors’ emotional intelligence (EI) and patients’ trust in their attending physicians; however, there is only limited evidence of specialty differences between internists and surgeons for such an association. OBJECTIVES This study examined the association of nursing director assessments of doctors’ EI, outside observer assessments of doctors’ health care climate (HCC) in the examining room and patient‐rated trust in internists and surgeons. Health care climate refers to a key component in communication and reflects the extent to which patients perceive their health care providers as supporting patient autonomy rather than controlling the provision of treatment. METHODS In this observational study, 2702 patients seen by 110 internists and 2642 patients seen by 101 surgeons were surveyed in face‐to‐face interviews by trained nurses in two teaching hospitals in Taiwan. Using hierarchical linear modelling, we examined the association between EI and HCC as well as patient trust in doctors working in the specialties of internal medicine and surgery. RESULTS We found a significantly positive correlation between doctor EI and patient trust for all patients (p < 0.01). In addition, although HCC was positively associated with patient trust for internists (p < 0.01), it was not so for surgeons. CONCLUSIONS We conclude that doctors might benefit from training programmes aimed at improving EI and that differences in patient expectations might be considered when hospitals attempt to evaluate doctors in different specialties.     

Counselling uncertainty: genetics professionals’ accounts of (non)directiveness and trust/distrust

In genetic counselling, uncertainty is central to the client–professional relationship where decisions are made on the basis of risk information/assessment. For various historical reasons, genetic counsellors adopt an ethos of ‘nondirectiveness’ to communicate risk and offer support without advising their clients on what decisions to reach. However, nondirectiveness remains an ambiguous and contested concept that has acquired a negative meaning of ‘not influencing clients’ or ‘adopting an indifferent stance’. We argue that nondirectiveness also implies a positive sense of acknowledging genetic counselling as a process of influence. Drawing on interview data (n = 25) involving professionals from England and South Wales (UK), accounts of genetic testing indicate a dynamic relationship between managing uncertainty on the one hand and negotiating trust and distrust on the other. In the counselling process, trusting and distrusting are coexisting techniques of assessing clients’ motivations, expectations and reasons for genetic testing. Using rhetorical discourse analysis as our analytical approach, we identify a pattern of accounting whereby professionals justify a directive stance when they are not confident whether clients have considered the uncertainty of the situation. More than a veneer of neutrality and indifference, we argue that nondirectiveness is a technique by which genetics professionals explore whether clients can be trusted to make autonomous decisions within a climate of uncertainty. Eliciting confidence and establishing trust within the context of genetic counselling are enabling, pastoral strategies for configuring risk and emotion.     

The everyday risk work of Dutch child‐healthcare professionals: inferring ‘safe’ and ‘good’ parenting through trust,as mediated by a lens of gender and class

Amidst intensifying policy concerns with children's wellbeing and development, healthcare professionals are required not only to assess risk of abuse and neglect, but to manage risk of ‘poor parenting’ more broadly. Drawing on 15 in‐depth interviews and non‐participant observations of 61 professional‐family interactions, across four preventative public health services for children in the Netherlands, we explored how professionals accomplished such risk work amid intractable uncertainties. Building inferences from brief encounters with families, professionals gauged the extent to which they trusted parents to care ‘appropriately’. This trust developed most readily with parents experienced as ‘familiar’ by the largely middle‐class female professionals. Harnessing Schutzian phenomenology, we analyse the related manifestations of social structure within the interactional‐dynamics and lifeworlds of risk assessment. We argue that social structures of gender, class and ethnicity can be seen as influential both through the differing potential for ‘we‐relationships’ to be formed and via the generalising and stereotyped knowledge applied in their absence.     

Navigating the cartographies of trust: how patients and carers establish the credibility of online treatment claims

Digital media offer citizens novel ways of ‘enacting’ health and illness, and treatment and care. However, while digital media may so ‘empower’ citizens, those searching for credible information will be confronted with various, often‐conflicting claims that may have ‘disempowering’ effects. This article uses Gieryn's concept of the ‘cultural cartography’ to explore the criteria that patients and carers employ in establishing the credibility of information on alleged treatments. Drawing on data from interviews with Australian patients and carers who have travelled or considered travelling abroad for unproven commercial stem cell treatments, the article examines how individuals assess rival sources of epistemic authority – science‐based and non‐science‐based – as they search for credible information. As we argue, in a context where conventional treatment options are perceived to be limited or non‐existent – which is likely to be the case with those suffering severe, life‐limiting conditions – and the credibility of sources uncertain, matters of opinion and belief are prone to being interpreted as matters of fact, with potentially far‐reaching implications for citizens’ health. Revealing the mechanisms by which individuals ascribe credibility to health information, we conclude, has become crucial as digital media assume a growing role in health and healthcare and governments encourage citizens to become ‘digitally literate’.     

Regulating the gene: From genetic consumption to regulatory trust

In this article, we examine the changing terms on which genetics-based technologies in two areas agriculture (Genetically Modified Organism, GMOs) and health (genetic diagnostics) have been regulated. These are used to illustrate and examine the proposition that shifts in the politics of governance and regulation (associated in part with the advent of the negotiation state) have meant that the responsibility for the social management of new technology is increasingly shared between the state and the consumer. However, this redistribution of the social management of risk, we argue, fails to establish a sufficient basis for a legitimate regulatory trust. We suggest that trust will depend on embedding broad social values and a self-critical agenda within the regulatory regime itself.     

Compliance and risk-taking: the case of alcoholic liver disease

This paper describes an exploratory study of ‘compliance’ with doctors’ advice in an extreme situation: reduction of drinking, or abstention from alcohol, in patients with alcoholic liver disease. A preliminary postal survey had suggested that at least three-quarters of these patients continued to drink. An intensive interview study explored the reasons for this. Only a minority of the patients were identified as alcoholic, or had a history suggesting dependence. It was concluded that communication between doctor and patient, and factors involved in the patients’ perception of their illness, were crucial first steps towards a change of behaviour. The statements of doctors had to be reinforced by a subjective appreciation of danger. Even if advice about the management of their condition was understood and accepted, however, what then constituted ‘compliance’ in the patients’ eyes depended very much upon social norms. Even then, the success or failure of attempts to follow the doctors’ advice depended crucially upon the circumstances of the patients’ lives. The model of ‘compliance’ or ‘non-compliance’ which thus emerges is a complex one which has several stages.     

Concepts of trust among patients with serious illness

This paper examines conceptions of trust among three groups of respondents diagnosed with either breast cancer, Lyme disease or mental illness. Interviews were carried out using an open-ended interview guide to explore how patients made assessments of trust in their doctors and health care plans. The guide followed a conceptual approach that asked questions about competence, agency/fiduciary responsibility, control, disclosure and confidentiality. Respondents were given ample opportunity to raise other areas of concern. The data were organized using the NUDIST software package for the analysis of non-numerical and unstructured qualitative data. Patients viewed trust as an iterative process and commonly tested their physicians against their knowledge and expectations. Interpersonal competence, involving caring, concern and compassion, was the most common aspect of trust reported, with listening as a central focus. Most patient comments referred to learnable skills and not simply to personality characteristics. Technical competence also received high priority but was often assessed by reputation or interpersonal cues. Patients were much concerned that doctors be their agents and fight for their interests with health care plans. Disclosure and confidentiality were less common concerns; most patients anticipated that doctors would be honest with them and respect their confidences. Patients' responses also appeared to vary by their disease, their socio-demographic characteristics, their involvement with self-help groups, and how their illness conditions unfolded.     

Patients who use e-mediated communication with their doctor: new constructions of trust in the patient-doctor relationship

The introduction of information and communication technology (ICT) into the patient-doctor relationship represents a significant change in modern health care. Communication via computers-e-mediated communication-is affecting the context of patient-doctor interaction, touching core elements of the relationship. Based on data from a qualitative study conducted among Norwegian patients who had used ICT to communicate with their doctors, the authors argue that patients' use of ICT and the element of trust in the patient-doctor relationship influence each other. Furthermore, they contend that patients' constructions of trust in this relationship can be understood in light of basic mechanisms in modern society. The study sheds light on some potential concerns and benefits as communication technology increasingly is integrated into the patient-doctor relationship.     

How do lay people come to trust the Automatic External Defibrillator?

Defibrillators are now widely installed in a variety of public places for the immediate treatment of people who have collapsed with a suspected cardiac arrest. These initiatives are predicated on the defibrillator being used by ‘lay’ volunteers. This presents a problem of trust, as the volunteer rescuers need to trust an unfamiliar technology to diagnose and treat an immediately life-threatening condition they are unlikely to have encountered before. Based on qualitative interviews with volunteers and defibrillator trainers, we show how trust in the defibrillator is constructed and maintained as a social process. This trust is a complex phenomenon, placed in technology, people and institutions, all of which work together to enable the volunteer, when an emergency occurs, to ‘push the button.’     

Trust but Verify: The Interactive Effects of Trust and Autonomy Preferences on Health Outcomes

Patients’ trust in their physicians improves their health outcomes because of better compliance, more disclosure, stronger placebo effect, and more physicians’ trustworthy behaviors. Patients’ autonomy may also impact on health outcomes and is increasingly being emphasized in health care. However, despite the critical role of trust and autonomy, patients that naïvely trust their physicians may become overly dependent and lack the motivation to participate in medical care. In this article, we argue that increased trust does not necessarily imply decreased autonomy. Furthermore, patients with high levels of trust and autonomy preferences are most likely to have the best health outcomes. We propose a framework for understanding simultaneous trust and autonomy preferences and for recognizing their interactive effects on health outcomes in the dynamic medical encounter. This framework argues that policy makers and health care providers should make efforts to foster not only patients’ trust but also their preferences for autonomy and thus gain the best position for achieving health-related goals.     

Risk,morality and emotion: social media responses to pregnant women who smoke

In this article, we use qualitative data to examine the shape and nature of the online ‘moral outrage’ that was directed at a research trial that used financial incentives to encourage pregnant mothers to quit smoking. Mai Frandsen developed the research trial in Tasmania, a small island state in Australia characterised by high rates of smoking in pregnancy. In this article, we draw on data from 121 online text comments posted in relation to three Australia-wide media stories relating to the research trial in 2015. Two of the online stories came from popular Australian independent ‘mummy’ website ‘Mamamia’. We found that the intense negative moral judgement directed at the programme and the women it benefited was driven by an individualised risk discourse drawing on ideologies of the ‘good’ and ‘intensive’ mother. We argue in this article that the over-emphasis on risk in relation to pregnancy produces a conservative morality that demonise women, fails to account for the social determinants of health and diminishes care for the Other. We argue that the research programme with its incentive component was a useful alternative to more punitive risk approaches as it promoted reward rather than blame and shame and acknowledged the importance of including emotions and morality in analysing the relationship between risk, health and society.     

The excesses of care: a matter of understanding the asymmetry of power

The aim of the article is to illustrate concrete problems in the asymmetrical nurse–patient power relationship. It is an ethical demand that the nurse is faced with the challenges that the power in the relation is administered so that the patient's room for action is expanded and trust maintained. It is an essential message in care philosophy, but in clinical practice, success is not always achievable. A hidden and more or less unconscious restriction of the patient's room for action may result in the excesses of care. Three selected aspects: dependence, trust, and power described by the Danish philosopher K.E. Løgstrup and the Norwegian nursing philosopher Kari Martinsen's care philosophy has inspired this empirically based examination of some current barriers in the asymmetrical nurse–patient relationship. On the basis of qualitative interviews with six patients and six nurses, the research thus provides an identifying and problem‐exploratory examination of some current obstacles in which the handling of trust and power reflects the excesses of care. The findings develop three themes. ‘Being a burden’ acknowledges that the balance of power will always tip to the nurse's advantage. The second theme, ‘Doing only what's absolutely necessary’, shows how a fixation with ‘technicalism’ creates a distance between people that may constrain the patient's room for action. The last theme is concerning the nurse's ability to navigate between closeness and distance is essential in avoiding ‘the excesses of care’, paternalism, and overprotectiveness. A situation in which distance takes the upper hand and care turns into paternalism. A different situation would arise if the nurse's emotions became sentimental or intimate with the result that closeness gets the upper hand. To avoid a harmful exercise of power and the excesses of care, the findings have demonstrated that a relationship‐based caring is a demand for situation‐specific sensitive attention skills.     

信任源理论在医患关系管理中的运用

信任是建立良好医患关系的基础。作者运用信任源理论，认为医院可从三方面建立医患信任关系：①医院作为被信任方时，提高交往过程中留给患者的感知可信度；②医院作为信任方，强化自身的信任倾向特征，发挥医患关系构建中的主动作用；③从调节医患关系入手，建立和执行有助于医患相互信任的制度。这三方面的结合将促进医院赢得患者的信任和社会的好评。     

Risk,trust and patients’ strategic choices of healthcare practitioners

Research on patients’ choice of healthcare practitioners has focussed on countries with regulated and controlled healthcare markets. In contrast, low‐ and middle‐income countries have a pluralistic landscape where untrained, unqualified and unlicensed informal healthcare providers (IHPs) provide significant share of services. Using qualitative data from 58 interviews in an Indian village, this paper explores how patients choose between IHPs and qualified practitioners in the public and formal private sectors. The study found that patients’ choices were structurally constrained by accessibility and affordability of care and choosing a practitioner from any sector presented some risk. Negotiation and engagement with risks depended on perceived severity of the health condition and trust in practitioners. Patients had low institutional trust in public and formal private sectors, whereas IHPs operated outside any institutional framework. Consequently, people relied on relational or competence‐derived interpersonal trust. Care was sought from formal private practitioners for severe issues due to high‐competence‐based interpersonal trust in them, whereas for other issues IHPs were preferred due to high relationship‐based interpersonal trust. The research shows that patients develop a strategic approach to practitioner choice by using trust to negotiate risks, and crucially, in low‐ and middle‐income countries IHPs bridge a gap by providing accessible and affordable care imbued with relational–interpersonal trust.     

Re-thinking accountability: trust versus confidence in medical practice

In seeking to prevent a reoccurrence of scandals such as that involving cardiac surgery in Bristol, the UK government has adopted a model of regulation that uses rules and surveillance as a way of both improving the quality of care delivered and increasing confidence in healthcare institutions. However, this approach may actually act to reduce confidence and trust while also reducing the moral motivation of practitioners. Accountability in health care is discussed, and it is suggested that openness about the difficult dilemmas that arise when practitioners have a duty to be accountable to more than one audience may be an alternative means of restoring trust. A greater emphasis on the sharing of information between individual health professionals and their patients would increase trust and would allow patients to hold their doctors to account for the quality of care they receive. Concentrating more on developing trust by the sharing of information and less on the futile search for complete confidence in systems and rules may improve the quality of care delivered while also nurturing the moral motivation of professionals upon which the delivery of high quality health care depends.     

医院公信力对患者抱怨行为层次的影响

本研究旨在探讨医院公信力对医疗服务抱怨行为层次的影响,以期为医疗公信力的践行提供理论依据。331名有过不满意就诊或住院医疗服务抱怨经历的患者参与了线上问卷调查。结果显示:(1)医院公信力对一般抱怨水平和是否向第三方抱怨有正向影响;(2)医院公信力对一般抱怨水平和是否向第三方机构抱怨的影响机制不同,对一般抱怨水平高低的影响主要通过患者就诊的不满意度,而对是否向第三方抱怨则通过抱怨的预期收益影响;(3)医院公信力对是否向第三方抱怨的影响效果(0.301)要大于其对患者一般抱怨水平的影响效果(0.060);(4)医院公信力也会通过对医疗服务质量的期望落差、患者对医生的信任对一般抱怨水平与是否向第三方抱怨同时产生影响,但相比其直接通过患者就诊不满意度、抱怨的预期收益的影响要小,尤其是通过患者对医生的信任产生的间接影响很小。这表明医院公信力践行离不开微观层次的抱怨管理,一方面可能通过基于关系的医患沟通培训提升医生沟通技能及抱怨管理人事来改善患者对医疗服务的信任,另一方面更应该通过改善医疗服务报怨管理制度与机构设立来提升。     

基于数字共情视角下的在线医患交互对医患信任影响因素研究

目的：本研究选取在线医患交互的独有特征,从数字共情的角度探索在线医患信任的形成机制,为促进在线医患关系的良好发展提供实践指导。方法：挖掘好大夫在线医疗平台上的客观医患交互数据,构建影响在线医患信任建立因素的假设模型,采用统计软件SPSS24.0对假设进行验证。结果：研究结果表明医生共情、医患会话累计量、医生回复框平均字数和医患会话比率都能正向影响医患信任的建立,其中医生共情是最积极的影响因素。结论：医生提高医患沟通技巧、患者积极反馈、优化医疗APP功能设计、相关部门完善相关政策是促进在线医患信任建立的重要途径。     

Trust matters: A narrative literature review of the role of trust in health care systems in sub-Saharan Africa

This article makes a contribution to the debate about health service utilisation and the role of trust in fostering demand for health services in sub-Saharan Africa. It is framed as a narrative literature review based on a thematic analysis of nine empirical, qualitative studies. For the purposes of this article trust is defined as a voluntary course of action, which involves the optimistic expectation that the trustee will do no harm to the trustor and is increasingly perceived as an important influence on health system functioning. The article looks at trust issues in interpersonal, intergroup and institutional situations. The findings of the review point to four elements that are important for trust to develop in health sector relationships: the sensitive use of discretionary power by health workers, perceived empathy by patients of the health workers, the quality of medical care and workplace collegiality. When trust works in health sector encounters, it reduces the social complexity and inherent uneven distribution of power between clients and providers. The article concludes that understanding and supporting trust processes between patients and providers, as well as between co-workers and managers, will improve health sector collaboration and stimulate demand for health care services.     

Factors Influencing Communication with Doctors via the Internet: A Cross-Sectional Analysis of 2014 HINTS Survey

Based on Street’s (2003) ecological framework of communication in medical encounters, this study examined personal, interpersonal, and media factors that could influence patients’ use of the Internet to communicate with doctors. Results from data analysis of responses from the 2014 Health Information National Trends Survey showed that patient activation and ease of Internet access were two positive predictors of online doctor-patient communication. In addition, patients’ trust in doctors positively moderated the relationships between patient activation and online doctor-patient communication, and between perceived health status and online doctor-patient communication. Finally, the quality of patients’ past experiences communicating with doctors had a positive moderation effect on the association between health information seeking behavior and online doctor-patient communication. Implications and limitations are discussed.     

Mandates of trust in the doctor-patient relationship

We examine the conditions for trust relationships between patients and physicians. A trust relationship is not normally negotiated explicitly, but we wanted to discuss it with both patients and physicians. We therefore relied on a combination of interviews and observations. Sixteen patients and 8 family physicians in Norway participated in the study. We found that trust relationships were negotiated implicitly. Physicians were authorized by patients to exercise their judgment as medical doctors to varying degrees. We called this phenomenon the patient's mandate of trust to the physician. A mandate of trust limited to specific complaints was adequate for many medical procedures, but more open mandates of trust seemed necessary to ensure effective and humane treatment for patients with more complex and diffuse illnesses. More open mandates of trust were given if the physician showed an early interest in the patient, was sensitive, gave time, built alliances, or bracketed normal behavior.