Background
In healthcare interactions, nurses, as members of the medical group who have the most frequent contact with patients, are prone to conflicts with patients, resulting in tensions in the nurse-patient relationship [1]. The tense relationship between nurses and patients is often caused by the crisis of interpersonal trust between nurses and patients [2, 3]. Trust is critical in nurse-patient relationships. A high nurse-patient trust can not only lead to positive patient outcomes but also improve nurses’ career success [4]. For instance, empirical studies suggested that trust in nurses was positively related to patient satisfaction and emotional well-being [5, 6]. In the long run, nurse-patient trust is important in creating a healthy medical system [7]. Therefore, improving interpersonal trust between nurses and patients is a key way to resolve nurse-patient conflicts and establish a harmonious nurse-patient relationship.
Given the complexity of nurse-patient trust, Luhmann proposed expectation as a key factor for understanding trust [8]. Möllering further defined trust as a state of positive expectation regarding other people’s intentions and actions [9]. Expectation refers to a belief about what is to happen. In reality, individuals build interpersonal trust relationships through their expectations of each other [10, 11]. Expectation of others could be positive or negative. Positive expectation means that someone holds positive beliefs about another person’s actions and intentions, whereas negative expectation relates to a person’s negative beliefs about others’ behavioral tendencies. In medical field, a large number of studies from the perspective of patients have found that patients’ positive expectations of nurses contribute to the establishment of nurse-patient trust [12‐14]. Yet, expectation is a reciprocal process, during healthcare interactions, nurses also have expectations of patients. Nurses’ expectations of patients (hereafter, nurses’ expectations) refer to the beliefs of the role and behavior of patients held by nurses [15]. In medical interactions, nurses may expect patients to be compliant, cooperative, responsible for conveying relevant information, and understanding what they are told (i.e., positive expectations) [16]. Previous researchers proposed that nurses’ negative expectations undermine nurse-patient trust, whereas nurses’ positive expectations facilitate nurse-patient trust [17]. Therefore, it is essential to build nurse-patient trust by enhancing nurses’ positive expectations of patients. However, it is surprising that little attention has been paid to doctor-patient expectations from nurses’ perspectives, leaving a poor understanding of the influencing factors of nurses’ expectations [18].
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In an era of frequent doctor-patient crises, medical institutional trust has an important role in enhancing nurses’ positive expectations of patients and promoting nurse-patient trust [19]. Institutional trust refers to trust in social institutional norms, laws, and regulations. Medical institutional trust, as a kind of institutional trust, is individuals’ trust in the medical institution. Previous researchers proposed that institutional trust forms the basis for forming positive expectations of others [20, 21]. A qualitative meta-analysis conducted by Patent and Searle suggested that institutional trust could influence individuals’ expectations of others [22]. In sum, although extant qualitative research has only tentatively explored the relationship between institutional trust and the expectations of others, it is reasonable to expect that medical institutional trust may be an important influencing factor in nurses’ expectations.
Except for the direct effects of medical institutional trust on nurses’ expectations, communication may play a mediating role in the relationship between medical institutional trust and nurses’ expectations. Communication refers to the activity or process of expressing thoughts and feelings or providing information to people in various ways [23]. On the one hand, communication helps individuals form positive expectations of others and build interpersonal trust [24]. The theory of interpersonal trust building proposes that the key to establishing and maintaining positive expectations of others and interpersonal trust lies in the perception of positive relationship signals in interpersonal interactions, particularly communication [25]. On the other hand, institutional trust is also closely related to communication. When healthcare workers hold a high level of medical institutional trust, they believe that the existing medical institutions could create a harmonious environment, which could beneficial for learn various communication skills and use those skills during healthcare interactions [26]. Taken together, these findings suggest that nurse-patient communication may play a mediating role between nurses’ medical institutional trust and nurses’ expectations.
Noteworthy, although there may be significant relationships between medical institutional trust, communication, and nurses’ expectations [22, 24], the patterns of these relationships may vary across major-risk environments [26]. Previous researchers hypothesized that under a major-risk environment, even if people believe the institutions are reliable and trustworthy, serious threats to their safety and unfulfilled low-level needs (i.e., security needs) increase individuals’ negative expectations and distrust of others in unpredictable and extreme situations [26]. The outbreak of the COVID-19 pandemic puts great risks toward nurses’ physical and mental well-being. On the one hand, nurses are on the front lines caring for COVID-19 patients, putting them at high risk of contracting the virus and death. On the other hand, increased workload, witnessing patient suffering, and fear of infection during the pandemic may lead to nurses’ anxiety, depression, and burnout [27, 28]. Furthermore, previous studies suggested that COVID-19 has complex consequences for institutional and interpersonal trust and nurse-patient communication. Increased uncertainties during the pandemic may undermine interpersonal trust [29], but empirical evidence suggests that the COVID-19 pandemic increased people’s trust in science, police, and politicians and enhanced people’s satisfaction with government performance [30]. These results indicate that COVID-19 may have opposite effects on nurses’ beliefs, attitudes, and expectations toward medical institutions and patients. In addition, the pandemic alters the ways that nurses interact and communicate with patients [31]. Therefore, the COVID-19 pandemic may change the relationship among nurses’ medical institutional trust, communication, and nurses’ expectations.
Drawing on the literature reviewed above, this study aimed to investigate the relationship between medical institutional trust and nurses’ expectations from the perspective of nurses and to explore the mediating role of communication in this relationship. Importantly, this study also investigates the patterns of relationships between medical institutional trust, communication, and nurses’ expectations in different major-risk environments (i.e., before and after the outbreak of the COVID-19 pandemic). By thoroughly exploring these effects, we can gain a deeper understanding of the effects of medical institutional trust on nurses’ expectations and its mechanisms, which could offer valuable insights to devise targeted strategies aimed at improving nurses’ positive expectations and nurse-patient trust. In light of the above rationale, we proposed the following hypotheses:
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Hypothesis 1
Nurses’ medical institutional trust will positively correlate to communication and nurses’ expectations.
Hypothesis 2
Communication will mediate the relationship between nurses’ medical institutional trust and nurses’ expectations.
Hypothesis 3
The relationship between medical institutional trust, communication, and nurses’ expectations will be different before and after the outbreak of the COVID-19 pandemic.
Methods
Study sample
The current study conducted two cross-sectional surveys from November to December 2019 and January to April 2020, and recruited 2581 nurses in China. Nurses are recruited through more than 20 partner hospitals in East China, South China, Northeast China, Central China, North China, Northwest and Southwest China. Questionnaires were distributed through the online platform during the testing process. Participants anonymously completed an internet-based questionnaire if they agreed to participate in this survey. The responses are administered online, allowing patients to fill out the questionnaire at their convenience and have the opportunity to ask the researcher questions. All study data were collected anonymously and confidentially. After the data collection was completed, members of the group manually proofread the collected data and then deleted the questionnaires whose response time was outside the plus or minus three standard deviations of the average response time. This study was approved by the Ethics Committee of the university to which the corresponding author belongs. Finally, a total of 2520 valid questionnaires were collected from nurses. There were 1752 valid questionnaires before the COVID-19 epidemic. The average age of subjects was 32.14 years (SD = 7.62). After the COVID-19 pandemic, there were 768 valid questionnaires. The average age of subjects was 29.48 years (SD = 5.51).
Measures
Nurses’ expectations scale
Nurses’ expectation was measured by a self-designed nurses’ expectations scale. The scale consists of three items (e.g., “I expect the patient to follow the nurses’ instructions,” “I expect patients to be reasonable,” and “I expect patients to explain exactly what they are feeling”). The participants rated each item on a 5-point scale ranging from 1 = strongly disagree to 5 = strongly agree. The higher scores indicated a higher level of nurses’ positive expectations. In this study, the Cronbach’s alpha of this scale was 0.91. Moreover, due to the strong association between empathy and nurses’ expectation (Pérez-Fuentes et al., 2020), this study used empathy as a criterion of validity and found a significant moderate correlation between empathy and nurses’ expectation (r = 0.60, p < 0.01), suggesting that nurses’ expectation has good validity.
Medical institutional trust scale
The medical institutional trust held by nurses was measured by a self-designed medical institutional trust scale. This scale consists of 33 items (e.g., “The current medical institution is reasonable”). The participants rated each item on a 5-point scale ranging from 1 = strongly disagree to 5 = strongly agree, with higher average scores indicating a higher level of medical institutional trust held by nurses. In this study, the Cronbach’s alpha of the scale was 0.90. Additionally, considering that empathy is closely related to medical institutional trust (Moudatsou et al., 2020), this study used empathy as a validity criterion and found that there was a significant moderate correlation between empathy and medical institutional trust (r = 0.47, p < 0.01), which suggests that there is a good validity of the medical institutional trust.
Communication skills scale
Nurses’ communication skills were measured by The SEGUE Framework developed by Makoul [32] and revised by Guo and Wang [33]. This scale consists of 25 items (e.g., “Greet patient appropriately”). The participants rated each item on a 5-point scale ranging from 1 = Never to 5 = All the time. The final score of each item is the actual score minus 1 and the total score ranges from 0 to 100. The higher average scores indicated a higher level of nurses’ communication skills. In this study, the Cronbach’s alpha of the scale was 0.96. In addition, given the close relationship between empathy and communication (Babaii et al., 2021), this study used empathy as a criterion of validity and found a significant moderate correlation between empathy and communication (r = 0.58, p < 0.01), indicating that communication has good validity.
Statistical analyses
SPSS 23.0 software was used to analyze the data. Firstly, descriptive analyses and correlations of the sample were conducted. Secondly, to explore the relationship between medical institutional trust and nurses’ expectations and examine the mediating role of communication, the mediation analysis was conducted using the PROCESS macro model 4. Thirdly, to investigate whether the relationship between medical institutional trust, communication, and nurse expectations differed before and after the outbreak of the COVID-19 pandemic, we established two mediation analyses that were accomplished using the PROCESS macro model 4. The study used the bootstrapping method to test the significance of indirect effects. If the 95% confidence intervals of the various path coefficients did not contain 0, the indirect effect of communication skills was significant.
Results
Descriptive statistics
Demographic characteristics of the participants were shown in Table 1. Pearson correlation coefficients of the study variables were shown in Table 2. There were significant correlations among various variables. Specifically, significant positive correlations were found for pairwise combinations of medical institutional trust, communication, and nurses’ expectations (rs ≥ 0.40, ps < 0.01).
Table 1
Demographic characteristics of the participants (N = 2520)
Variables | Before the pandemic (n = 1752) | After the pandemic (n = 768) |
|---|---|---|
Age, M (SD) | 32.14 (7.62) | 29.48 (5.51) |
Sex | ||
Male | 40 | 381 |
Female | 1712 | 387 |
Education level | ||
Primary school | 68 | 16 |
Middle school | 572 | 186 |
Undergraduate | 1103 | 551 |
Master’s degree | 9 | 13 |
Doctor’s degree | 0 | 2 |
Table 2
Descriptive statistics and correlation of variables
Mean | SD | 1 | 2 | |
|---|---|---|---|---|
1. Medical Institutional Trust | 3.56 | 0.45 | ||
2. Communication | 4.22 | 0.56 | 0.55** | |
3. Nurses’ Expectation | 4.33 | 0.57 | 0.42** | 0.53** |
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Mediation analysis
A mediation model with medical institutional trust as the independent variable, communication as the mediator, and nurses’ expectations as the dependent variable was conducted to explore the relationship between medical institutional trust, communication, and nurses’ expectations. The results showed that the direct effect of medical institutional trust on nurses’ expectations was significant (β = 0.18, t = 9.03, p < 0.001), which supported Hypothesis 1. Additionally, there was also a significant positive association between medical institutional trust and communication (β = 0.54, t = 32.60, p < 0.001), and a significant positive association between communication and nurses’ expectations (β = 0.43, t = 21.86, p < 0.001).
Furthermore, the mediation analyses showed that the indirect effect of medical institutional trust on nurses’ expectations via communication was significant, indirect effect = 0.24, SE = 0.01, 95% CI = [0.21, 0.26], which supported Hypothesis 2 that communication mediated the association between medical institutional trust and nurses’ expectations.
The relationship patterns in different major-risk environments
To investigate whether the relationship between medical institutional trust, communication, and nurses’ expectations differed before and after the outbreak of the COVID-19 pandemic, we developed two mediation models. The results are shown in Fig. 1. Specifically, before the outbreak of the COVID-19 pandemic, there was a significant positive association between medical institutional trust and nurses’ expectations (β = 0.27, t = 10.68, p < 0.001). Medical institutional trust was significantly positively associated with communication (β = 0.49, t = 23.59, p < 0.001). Additionally, communication was also significantly positively associated with nurses’ expectations (β = 0.19, t = 7.42, p < 0.001). Furthermore, as shown in Table 3, the mediation analyses found that the indirect effect of medical institutional trust on nurses’ expectations via communication was significant, indirect effect = 0.09, SE = 0.01, 95% CI = [0.07, 0.12], effect size = 0.25, which indicating that communication partly mediated the association between medical institutional trust and nurses’ expectations.
Fig. 1
The relationship between medical institutional trust, communication, and nurses’ expectations before the outbreak of the COVID-19 pandemic
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Table 3
Results of mediation analyses
Model pathway | Effect | SE | BC 95%CI | |||
|---|---|---|---|---|---|---|
Lower | Upper | |||||
Before the outbreak of the COVID-19 pandemic | Medical institutional trust→communication→nurses’ expectations | 0.09 | 0.01 | 0.07 | 0.12 | |
Direct effect | 0.27 | 0.03 | 0.00 | 0.22 | ||
Total effect | 0.36 | 0.02 | 0.00 | 0.32 | ||
After the outbreak of the COVID-19 pandemic | Medical institutional trust→communication→nurses’ expectations | 0.29 | 0.03 | 0.23 | 0.35 | |
Direct effect | 0.01 | 0.03 | -0.06 | 0.07 | ||
Total effect | 0.30 | 0.03 | 0.00 | 0.23 | ||
Additionally, after the outbreak of the COVID-19 pandemic, the results were shown in Fig. 2 and revealed that medical institutional trust was significantly positively associated with communication (β = 0.48, t = 15.12, p < 0.001) and communication was also significantly positively associated with nurses’ expectations (β = 0.61, t = 18.81, p < 0.001). However, the association between medical institutional trust and nurses’ expectations was not significant (β = 0.01, t = 0.21, p = 0.83). Furthermore, as shown in Table 3, the mediation analyses indicated that the indirect effect of medical institutional trust on nurses’ expectations via communication was significant, indirect effect = 0.29, SE = 0.03, 95% CI = [0.23, 0.35], effect size = 0.97, which indicating that communication completely mediated the association between medical institutional trust and nurses’ expectations. In sum, the above results showed that communication was partially mediated the relationship between medical institutional trust and nurses’ expectation and the effect size of indirect effect was 0.25 before the outbreak of the COVID-19 pandemic. However, after the outbreak of the COVID-19 pandemic, communication was completely mediated the relationship between medical institutional trust and nurses’ expectation and the effect size of indirect effect was 0.97. These results supported Hypothesis 3 that the relationship between medical institutional trust, communication, and nurses’ expectations was different before and after the outbreak of the COVID-19 pandemic.
Fig. 2
The relationship between medical institutional trust, communication, and nurses’ expectations after the outbreak of the COVID-19 pandemic
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Discussion
Nurses’ positive expectations of patients in medical interactions constitute an important component of nurse-patient trust and can foster good nurse-patient relationships [9, 17]. This study reveals a positive association between nurses’ institutional trust and their expectations of patients. Moreover, the current data suggest that nurse-patient communication plays a mediating role in this relationship, especially in a major-risk environment (e.g., during the COVID-19 pandemic). These findings add knowledge to the existing literature on nurse-patient trust and have important implications for nursing practice.
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Patent and Searle previously indicated a close relationship between institutional trust and the expectations of others in a qualitative meta-analysis [22]. This study provides support for the results of Patent and Searle’s study in a medical context, revealing that nurses’ institutional trust is an important factor in promoting their positive expectations of patients. Positive expectation constitutes an important aspect of interpersonal trust [9]. The current results add knowledge to a large body of literature suggesting that institutional trust was positively associated with interpersonal trust [26, 34]. Trust in medical organizations can enhance nurses’ organizational commitment and job satisfaction as well as reduce depersonalization and malfeasance in nurse-patient interaction [34‐36]. These positive impacts of increased organizational trust may have downstream effects on nurse-patient relationships [37]. Overall, the current results highlight the importance of nurses’ medical institutional trust in improving nurse-patient relationships. However, there is a significant dearth of research shed light on the influencing factors of nurses’ trust in medical institutions [38]. Future studies should investigate factors that nurture and undermine healthcare workers’ trust in medical institutions.
Furthermore, the results suggested that nurse-patient communication plays a mediating role in the relationship between nurses’ institutional trust and positive expectations toward patients. Previous researchers proposed that communication could deliver positive relational signals, which are essential for building positive expectations and interpersonal trust [25]. This result strongly confirms the theory of interpersonal trust building, and further suggests that even in the face of the harsh changes in the social environment brought about by the new crown epidemic, especially the extreme deterioration or even temporary collapse of the healthcare environment (e.g., the influx of patients has brought the healthcare system to the brink of paralysis in many areas, the lack of equipment, space, space, manpower and protective gear shortages, etc.), the existing crisis communication policies and procedures across healthcare organizations is imperative to to preserving quality patient care and supporting optimal nursing practice.
Empirical studies found that institutional trust may lead individuals to believe that the environment for interpersonal interaction is safe, which is beneficial for generating interactive behaviors between individuals such as communication [39]. A systematic review revealed a strong positive correlation between institutional trust and employees’ work performance [36]. In a healthcare context, nurses’ who hold higher levels of institutional trust may be more enthusiastic about their work and more likely to communicate to patients in favorable ways. The results highlight the role of communication in Nevertheless, there could be other possible explanations for the association between medical institutional trust and nurses’ expectations. For instance, previous studies suggested that trust in institutions can improve interpersonal trust by enhancing people’s feelings of security [26]. In healthcare settings, a trustworthy institution could make nurses feel that they are working in a safe and stable environment, which reduces their feelings of uncertainty and thus fosters a tendency for them to hold positive beliefs about others’ intentions and actions.
Finally, the results indicated that a major-risk environment (e.g., the COVID-19 pandemic) altered the association between nurses’ institutional trust and nurses’ expectations. More specifically, the significant positive correlation between nurses’ institutional trust and nurses’ expectations before the COVID-19 pandemic turned out to be nonsignificant after the outbreak of the pandemic.
The theory of flexible work practice attribution finds that individuals have the ability to choose the reasons for flexible work practice, thereby reducing work pressure and work expectations, and increasing work sense of accomplishment [40]. Previous research have found that nurses working in hazardous work environments, such as intensive care units and emergency departments, can reduce their reliance on the conventional healthcare system by promoting positive work attributions through productivity-enhancing methods such as flexible scheduling and reward systems [41, 42]. In the face of the major outbreak, nurses took the initiative to bring innovative solutions to outbreak management. They implemented flexible scheduling, centralised operations as much as possible, and arranged supplies in a logical manner. At the same time, the nurses’ anti-epidemic alliance based on good nurse-patient communication strategies played a key role [43, 44].
It’s worth noting that despite an absence of direct correlations, nurses’ medical institutional trust can indirectly influence nurses’ expectations of patients through nurse-patient communication. This result highlights the role of interpersonal communication in trust-fostering in risky situations. In a major-risk environment such as the COVID-19 pandemic, although nurses hold high levels of medical institutional trust, there is a great deal of unpredictability in patients’ behavior due to the immense panic and increased globally uncertainty [29]. In this situation, an important way to increase nurse-patient trust and improve nurse-patient relationships is to boost nurses’ communication skills.
Implications and limitations
To our knowledge, this study is the first to explore communication and major-risk environments in the relationship between medical institutional trust and nurses’ expectations from the perspective of nurses in the field of medicine. This study not only enriched the research on the relationship between healthcare workers and patients from the perspective of nurses but also enhanced the understanding of how and when medical institutional trust affected nurses’ expectations. Practically, the findings of this study enlighten us that it is urgent to improve the relationship between healthcare workers and patients by establishing a series of convincing medical institutions. Additionally, the study suggested that despite the protection of medical institutions, healthcare workers still need to strengthen their communication skills.
Several limitations of this study should be noted. First, although this study collected data before and after the outbreak of the COVID-19 pandemic, it is still a cross-sectional study. Future research could consider a longitudinal study to explore in depth the longitudinal relationship between institutional trust and nurses’ expectations, as well as the impact of high-risk environment on the patterns of these relationships. Second, this study only used Chinese nurses as participants, thus limiting the generalizability of the findings. Nurses in different countries may have different levels of medical institutional trust. Future studies can explore the relationship between institutional trust, communication, and nurses’ expectations using multicultural samples. Finally, the main variables of our study were measured by self-reported questionnaires, which may lead to bias in our results. Further research could use more objective ways to measure these variables and validate the relationship pattern uncovered here.
Conclusions
This study investigated the relationship between nurses’ medical institutional trust, nurse-patient communication, and nurses’ expectations of patients before and after the outbreak of the COVID-19 pandemic. The findings suggest a significant positive correlation between nurses’ medical institutional trust and their expectations of patients, with nurse-patient communication serving as a mediator of this relationship. During the COVID-19 pandemic, the association between nurses’ medical institutional trust and expectations of patients was nonsignificant; however, a significant mediating effect of nurse-patient communication remained between nurses’ medical institutional trust and expectations of patients. Healthcare managers should devote strategies to enhance nurses’ trust in medical institutions to boost their positive expectations of patients and ultimately foster favorable nurse-patient relationships. Furthermore, the results highlight an urgent need for interventions and training courses to improve nurses’ communication skills, especially when encountering major risk circumstances.
Acknowledgements
We are acknowledging the financial support from the Major Bidding Program of the National Social Science Foundation of China (17ZDA327). We are also very grateful for the understanding and support of all the nurses and related departments involved in this study.
Declarations
Ethics approval and consent to participate
The study was approved by the Academic Ethics Committee of Shanghai Normal University. Verbal informed consent was obtained from all subjects in the study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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