The Case for Triadic Trust: Nurses, Patients, & Institutions

In this paper, I show that in the context of nursing, trust isn't a property of the dyadic relationship between nurses and patients, but instead is a feature of nurse-patient-healthcare institution triads. Understanding trust as triadic in the healthcare context is important, I argue, because it emphasizes the pervasive role institutions have on breakdowns in trust between nurses and patients that is otherwise obscured. Nursing exhibits features of both interpersonal and institutional accounts of trust. Nursing demands trust in nurse-patient relationships. And yet, the care nurses provide is a form of labor, highly professionalized, systematized, and resourced by healthcare institutions. Healthcare institutions, such as hospitals, are vested in the experiences of both nurses, their largest workforce population, and patients, their primary consumer. They also play a critical role in shaping the social and physical environments in which patients receive care and nurses work. As such, healthcare institutions are a primary locus for cultivating normative expectations around trust within the nurse-patient relationship. However, the very healthcare institutions that create those normative expectations in the first place, also create conditions that promote trust-betrayal. Thus, healthcare institutions set up expectations for trust relationships between nurses and patients that are nearly impossible for nurses to fulfill. I call this the Dilemma of Professionalized Trust. This dilemma highlights a case of trust that is both interpersonal and institutional, and recharacterizes the nurse-patient relationship from a dyad to a triad, with institutions as a third party, one that intervenes on and shapes the nurse-patient relationship.