The Program for the Study of Health Care Relationships funded 11 researchers in CT to study various aspects of health care relationships and adherence. The individuals listed below each received grants for one year (2001-02). They were awarded funds on the basis of a competitive review process and the scientific merit of their proposals. The wide range of disciplines they represent and their research interests demonstrated the diversity and complexity inherent in studying health care relationships.

• Development of an Instrument to Measure Patients' Trust of Health Care Providers
• Exploration of the Effect of Nausea, Self-Efficacy, and Health Care Relationships on Medication Adherence in HIV/AIDS Patients
• Advance Care Planning: A Team Approach
• Assisting Older Adults To Communicate Their Pain After Surgery
• The Effect of a Specialized RN Intervention Designed to Maximize Patient-Provider Relationships on Adherence to Anti-Depressant Medication
• Pilot Study of Rapid Electronic Adherence Reporting with Provider Feedback on Adherence to Antiretroviral Therapy (HCR 01-12)
• Development of a Measure of Family Management of Childhood Chronic Illness
• The Contribution of Health Care Professionals to Parent and Child Self-Management of Type 1 Diabetes
• Enhancing Treatment Access and Adherence among Women of Hispanic Origin: The Roles of Relationships and Cultural Responsiveness in Behavioral Health Care
• Elicitation of Patient with Adaptive Conjoint Analysis

Development of an Instrument to Measure Patients' Trust of Health Care Providers

Carol Bova PhD, RN, ANP, Kristopher Fennie, PhD, Edith Watrous, RN, Kevin Dieckhaus, MD and Ann B. Williams, EdD, APRN

The ability of patients to trust their health care providers is one of the most important aspects of health care delivery. Understanding factors that influence how patients develop trust in their health care providers and being able to measure patient-provider trust in a simple, consistent way are important first steps in improving health care delivery now and in the future. The specific aims of this study were to: (a) identify factors associated with patient trust within multidisciplinary health care relationships, (b) examine the similarities and differences in patient trust of health care providers from different disciplines, (c) generate items that measure patients' trust in multidisciplinary health care providers, and (d) develop and conduct preliminary psychometric testing on the Health Care Relationship (HCR) Trust Scale.

For the first two specific aims three focus groups and ten individual interviews were conducted with twenty-five persons who are living with the chronic illness of HIV infection. The average age of the participants was 41.5 (range 31-57, median = 43). The majority of the participants were women (72%), 48% were African American, 40% were Caucasian, 8% were Hispanic, and all lived in Connecticut. Note-based analysis and content analysis of focus group and individual data were conducted with this sample. Results indicated that the form of trust needed between patient and health care provider when dealing with a chronic illness is different from "absolute trust" or "basic trust." Instead, trust in health care providers, among patients with chronic illness, is built over time and involves an intricate process of collaboration. We call this form of trust, "collaborative trust." Building blocks lay the foundation for the development of collaborative trust. According to our data, the building blocks are made up of six key components: knowledge sharing, emotional connection, professional connection, respect, honesty and partnership. Each person may "stack" the blocks in a slightly different order but all of the blocks are necessary to the development of collaborative trust.

Two specific skill sets were identified from the data. There is a skill set that is necessary to nurture collaborative trust and one that represents non-trusting behaviors. When trust is not present patients begin to think about changing health care providers, feel cheated, believing that others are getting better care, or even consider and talk about taking legal action because of perceived wrongdoings. These last three behaviors are all hallmarks of a complete lack of trust and should be a red flag for health care providers that action needs to take place.

Overall, there was no difference in the development of collaborative trust according to provider discipline (MD, NP, PA). Only two subjects indicated that they had greater trust in physicians. One subject stated: " I don't care about the book learning thing Ð just can this person talk to me so I can understand Ð does she care about me as a person Ð that is what's important." In addition, there was no appreciable difference in the themes that emerged from the focus groups, even though the groups were purposefully organized according to the credentials of the participants' health care provider (group 1 = PA/NP, group 2 = MD only, group 3 = mixed). It is possible that individuals seek out a certain type of professional or may be "assigned" to a professional initially, and once this occurs, the hard work of establishing collaborative trust begins regardless of the health care provider's background.

Finally, few subjects believe that organization issues influenced the development of patient trust. Most were willing to overlook organization problems if a trusted professional cared them for. One subject described this in the following way: "I was fuming Ð I waited 2 hours in the waiting room Ð the secretaries were gossiping - and I waited Ð but as soon as I got in the room with her, I forgot all of it."

Results of the qualitative portion of this study indicated that the development of trust has more to do with the emotional component of human relationships than credentials, education, or perceived expertise. These data also elucidated a skill set that could be taught to health care providers (and students) that would improve patient-health care provider trust.

Next, 58 items were generated, from the responses of the focus group and interview participants, that measure the major components of trust. Five experts rated these items as to clarity and relevance. Items achieving a content validity index less than 0.80 were discarded. A revised item pool of 30 items was then administered to a pilot sample of HIV-positive adults. No changes were made to the instrument based on the responses of these pilot participants. The 30-item instrument was then administered to 99 HIV positive adults. The pilot sample included 50% females, 43% Caucasians, 39% African Americans, 13% Hispanics and 4% other ethnicity. The psychometric properties of the 30-item HCR Trust Scale were accessed and the instrument was reduced to a 15-item version.

The 15-item HCR Trust Scale had a Cronbach's alpha of 0.92 and a test-test reliability coefficient of 0.60 (p < .01). The level of social desirability bias was low (correlation with the Marlow-Crowne was .20) and there was no correlation with adult literacy (r = -.18). No differences were found in HCR Trust Scale scores according to age, gender, race/ethnicity, illness stage, length of time with health care provider, or provider discipline. Trust was not related to self reported antiretroviral adherence. However, higher scores on the HCR Trust Scale were significantly correlated with lower scores on the CESD, indicating that greater patient trust is related to less depression.

In conclusion, the HCR Trust Scale measures patient trust in multidisciplinary health care providers and has established reliability and preliminary validity among HIV-infected adults. The HCR Trust Scale needs to be administered to a larger, more diverse, chronically ill population before it is ready for widespread use.

Copyright 2003Yale University School of Nursing, Yale University, New Haven, CT 06536All Rights Reserved