CONTRIBUTOR / Kelly Michelson
ASSOCIATE PROFESSOR OF PEDIATRICS, DIRECTOR OF THE CENTER FOR BIOETHICS AND MEDICAL HUMANITIES
FEINBERG SCHOOL OF MEDICINE / Pediatrics
Research shows that open lines of communication create trust, and vice versa, and that trusting relationships are key to better healthcare outcomes. One study, for example, has shown that poor communication among the staff in a pediatric hospital influenced their trust levels and how they cared for patients. In another study, clinicians who worked in an intensive care unit were trained in how to conduct a family meeting, specifically in empathetic listening. Family members who met with these clinicians had less depression and post-traumatic stress after their loved one had died.
Research about trust in the healthcare setting has generally taken two approaches: the first is to look at it in a qualitative fashion, so to hear personal anecdotes and learn what we can from that; and the other is to look at it in a more quantitative fashion, using scales and measures to see how trust relates with specific outcomes or specific variables.
From the qualitative research, we know that things like developing partnerships, developing relationships, demonstrating competence are all very important components of establishing trust in the relationship.
Most of the quantitative data related to trust in a healthcare setting use trust scales to compare a measure of trust to a particular variable — looking at things like, do women tend to be more trusting than men of their healthcare provider? Are there racial differences related to trust? Are there differences in providers’ and healthcare settings’ relationship to trust?
And these concepts help us to think about how we act — in a clinical setting, for example — and what we teach trainees about how to build trusting relationships with their patients or with others in the healthcare team.
BUMPER: Trust and Communication
Much of what we know about trust in the pediatric intensive care unit comes from literature that looks at communication and how communication unfolds in this particular setting.
We know from some qualitative work, from Carnevale et al., that trust is a really important part of communication in the pediatric intensive care unit.
These authors interviewed physicians, nurses, and parents about communication, identified three different components of communication. And of note, one of them was relational communication. And one key factor in developing relational communication that they identified was fostering trust.
And in another work by Ames et al., we find that trust is not only an important component for healthcare providers to focus on but also for parents.
In this work, the authors interviewed parents of children who were in the pediatric intensive care unit and asked them about their roles. And one of the three roles that they identify was actually that the parents should be trying to establish a trusting relationship with the healthcare providers in the PICU.
In another study done by Vivian et al., we learned about the importance of communication among staff members in the pediatric intensive care unit.
In that study, staff members were interviewed, and we found that poor communication among caregivers within in the intensive care unit can impact trust and therefore impact how they care for patients.
So, again, we’re seeing the importance of trust between providers and patients (or, in my case, parents) but also among providers.
BUMPER: Trust in Critical Decision-Making
In terms of decision-making in the intensive care unit, much of the literature has focused on issues related to pretty challenging decisions for children who are very sick, things like withdrawing or withholding life-sustaining efforts if a child was seriously ill — some pretty serious decisions.
Some of the research I’ve done, for example, has looked at what kind of influencers contribute to a parent’s deciding whether or not to withhold or withdraw life-sustaining therapies if their child was so sick that that became something to consider.
And what I found was that distrust was one of nine important factors that parents are weighing in terms of making that kind of decision.
In another study, Meert et al. interviewed parents of children who had died in the pediatric intensive care unit to find out more about their experiences. And they found that parents who felt that clinicians were withholding information also had a sense of betrayal or distrust towards those physicians.
BUMPER: Enhancing Trust in the Intensive Care Unit
But it’s really important not just to know what happens in the intensive care unit and where trust fits into communication and decision-making; now that we have all that information, we really want to try to impact trust and to enhance better trust and better communication and hence better decision-making in the intensive care unit.
For example, Curtis et al. looked at an intervention where he tried to change multiple components of what was going on in the intensive care unit, including identifying champions for this work, providing feedback to clinicians.
Interestingly, he didn’t find that that intervention changed his primary outcome.
In another effort done by Lautrette et al., they actually educated clinicians about how to conduct a family conference.
And they came up with this mnemonic called VALUE, and each of the letters stand for something different — specifically that you should value and appreciate what the family is saying during a meeting, acknowledge their feelings and emotions, that you should listen to what they say, that you should try to understand their situation and their values, and that you should elicit questions from them.
So, they actually taught clinicians a little bit about how to focus their communication during family conferences in the intensive care unit. And they actually did find a difference.
They found that for families who had family conferences with clinicians who were trained in this manner, those surrogates to the patients in adult ICUs had less anxiety and depression after their loved one had died and less symptoms of post-traumatic stress.