The crisis of public trust in governance and institutions: Implications for nursing leadership

Trust is a valuable social capital, essential for dependable relationships and a healthy society. It is hard earned, not guaranteed and easily lost (O'Neill, 2002). Historically public opinion has held the healthcare system and healthcare providers in high trust. There are indications that this trust may be on the decline—particularly trust in private healthcare. This decline reflects the global trend towards distrust of government and of institutional leadership. In recent years, a number of significant events and crises, such as the European migration crisis, the Brexit vote in the United Kingdom (UK) and the political polarisation of the United States of America (USA) following the Trump election have been characterised as watershed events in public leadership and trust (Brookes, 2017). Public trust in business, government, public institutions and their leadership are at an extraordinary all-time low (Edelman, 2017). In a period when the delivery of healthcare is increasingly under scrutiny, and public trust in institutions is apparently in decay, understanding the contribution nurse leaders make to the public's trust in nursing is important. To date little to no attention has been given to the broader picture of nursing leadership and public trust in healthcare and healthcare institutions. Should nurse leaders be concerned about the erosion of public trust in institutions, what are the implications and what can be done to assure the pursuit of trustworthy healthcare? Most definitions of trust reference a willingness to be vulnerable (Mayer & Gavin, 2005), where those placing trust are optimistic that those they trust will care for their interests (Luhmann, 2000). Trust can be placed at an individual levels (i.e. in individual nurses) and/or in the systems individuals represent (the service or health care system). Applied to service provision, trust involves the belief that service provides will act with integrity and competence in pursuing the interests of service users. In a systematic review of building trust in mental health services Gaebel et al. (2014) reported trust is a pervasive influence on all aspects of therapeutic relationships, with service users feeling trust is essential to good service. Trust has also been described as an enhancer of the patient experience and linked to overall patient satisfaction (Naylor et al., 2013). In the UK, public perceptions of trust in nurses is higher amongst those who have had recent contact with a healthcare service, suggesting public trust in nursing is relational (The King's Fund, 2015). Similarly a Canadian study reported that individual experience and personal anecdotes are used by the public to form generalisation about trust in the health system (Abelson, Miller, & Giacomini, 2009). Thus, interpersonal trust with individual care providers is an important cornerstone of trust in the system. In 2017, the Edelman barometer reported credibility for company Chief Executive Officers was at an historical low (Edelman, 2017). In two-thirds of the countries surveyed, less than half of respondents trusted business, government, non-government organisations or the media to do what is right. Alongside the erosion of trust in institutions, the credibility of experts also declined, with technical experts rated equally with peers as a credible source of information, and peers rated as more credible than a CEO or government official (Edelman, 2017). In the USA, the crisis in trust in healthcare reflects repeated scandals, rising costs and the large numbers of people without health insurance (Gille, Smith, & Mays, 2015). Built upon instrumental conceptions of trust, ensuring and rebuilding trust in healthcare has largely become a project of clinical governance and audit. In the last decade we have seen a revolution in accountability, control, and audit and performance scrutiny. At the same time, public mistrust in healthcare has grown. O'Neill (2002) earlier suggested that this culture of audit driven accountability may damage trust by fostering a culture of suspicion rather than trust. Importantly, audit and accountability cultures in healthcare fail to acknowledge that trust goes beyond a rational appreciation of system performance. Instead, trust is dependent upon the nature and quality of interaction with care providers (Brown, 2008). Against the backdrop of eroding trust in political and institutional leadership, the public's trust in nursing and nursing leadership is vital. Surveys of consumer sentiment conducted in Australia, the United States and United Kingdom (UK) have for many years reported that nursing is the most highly trusted profession in terms of honesty and ethical integrity (Morgan, 2017; Gallup, 2017). While long-standing, this trust is not immune to erosion. A comparison of results from the British Social Attitudes survey for the years 2002 and 2014 showed that, while nurses remained the most trusted group overall, the proportion of the public reporting that they trusted nurses “just about always” fell 9% over the period (The King's Fund, 2015). What is less clear in these public opinion polls is whether this trust in nurses reflects a similar trust in nursing leaders and nursing management. The UK social attitudes survey reported that trust in NHS managers is much lower than that of nurses, with less than a third of the general public reporting trust in managers most of the time (The King's Fund, 2015). Although trust is recognised as an important feature of nursing practice, less attention has been given to understanding trust in nursing leaders and how this links to nursing practice and public trust in nursing. In their comprehensive review of trust between nurses and managers in the critical care context, Mullarkey, Duffy, and Timmins (2011) report trust is an essential component of nurse-patient relationship, but little attention has been given to trust among staff and management. To date there have been few explicit studies of trust in nursing leadership. From the studies conducted, it is evident that nurses' levels of organisational trust and their citizenship behaviours are linked to trust in nursing management, and is associated with increased conscientiousness and altruism (Altuntas & Baykal, 2010). Whereas Wong and Giallonardo (2013) report that nurses who have higher levels of trust in their managers also report less adverse patient outcomes. Similarly, trust in nurse managers influence the work engagement and voice behaviour of nurses (Wong, Spence Laschinger, & Cummings, 2010). Another study noted that nurses' trust in their manager (measured through two items) was associated with improved safety organizing and reduced medication errors (Vogus & Sutcliffe, 2007). Importantly, widely employed theoretical frameworks and measures of nursing leadership such as transformational leadership do not explicitly foreground trust as a characteristic of leadership. Instead, trust is inferred to develop through the relationship between leader and follower (Bilal & Mariam, 2017). Other less commonly investigated leadership frameworks such as the person-centred situational leadership framework, explicitly describe trust as a feature of nursing leadership (Lynch, McCance, McCormack, & Brown, 2017). The authentic leadership model posits leaders build trust through making just decisions and role modelling honesty, integrity, and high ethical standards in leader-follower relationships (Wong & Cummings, 2009). Similarly, aesthetic leadership is said to involve a trust component. Aesthetic leaders foster trust, which facilitates linkage between nurses and administrators and between nurses and patients (Mannix, Wilkes, & Daly, 2015). When practiced by clinical leaders, servant leadership has also been positively associated with trust in nursing managers and trust in the organization (Bobbio & Manganelli, 2015). Although the evidence for the “crisis in public trust” is far from robust, what we know suggests nurse leaders should heed the warning. There are important trust related issues that are central to the purpose of nursing leadership that require thoughtful debate. Considering the underlying importance of trust in the provision of nursing care, there has been far too little research into understanding how trust can be protected and what can be done to foster trust. Researchers and scholars could give more thoughtful attention to understanding the link between leadership characteristics, the nursing work environment, perceptions of trust (both nurses and the public) and high quality patient care. Nurse leaders would do well to be concerned for protecting the health of the public through enabling the factors that foster trust in nurses and in the system. What we know suggests that trust in nursing is relational and leaders can positively shape the nursing work environment in ways that enable this trust. Leaders clearly have a role in cultivating the right conditions for trust. In a climate where the public are increasingly suspicious of experts and the truthfulness of reported data, the increasing focus in healthcare of audit and compliance may foster suspicion rather than build trust. Leaders may do well to focus less upon central control and perceptions of public accountability, and more on fostering forms of leadership and governance that allow nurses to deliver care in a trustworthy manner.

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