1. Context
Trust is a critical topic in human behavior and relationships, defined as a mutual commitment to achieve a goal and execute behaviors collaboratively (1). Organizational trust comprises two dimensions: Interpersonal (or relational) trust and non-personal (or institutional) trust. Interpersonal trust includes horizontal trust, which relates to trust among employees, and vertical trust, which pertains to the trust between employees and their managers (2). Institutional trust is associated with employees' perceptions and, in some studies, has also been linked to the effectiveness and impartiality of organizational systems (3). Although organizational trust and interpersonal trust are related, they represent distinct concepts. Dinc and Gastmans considered trust in nursing from an interpersonal aspect and defined trust as an attitude patients hold as they confidently rely on and depend on their nurse within a situation where they are experiencing increased vulnerability, believing the nurse holds competence to provide safe care (4).
Each time a nurse encounters a new patient, interpersonal trust must be established from the outset, while developing organizational trust takes considerable time and tends to be relatively stable (5). Research has shown that trust is not a momentary event; rather, it is a series of investments made over time that ensure the organization's success. Individuals are more likely to accept organizational decisions when they trust management actions, even when those actions may not be favorable to them (6). Fulmer and Gelfand define organizational trust as "the positive expectations individuals have regarding the intentions and behaviors of members of the organization, based on organizational roles, relationships, experiences, and interdependencies" (7).
Organizational trust within the nursing profession, as a key component of the healthcare system, holds significant importance. In healthcare systems, nurses serve as the primary link between patients and physicians, and the establishment of trust between these groups can profoundly impact the quality of care provided (1). With increasing economic pressures, rapid changes in information technology, and the necessity to deliver healthcare services that meet patient expectations, organizational trust in nursing may be adversely affected. Lack of trust in the workplace can lead to heightened job burnout and dissatisfaction among nurses, ultimately resulting in a decline in the quality of healthcare services. Furthermore, in situations where nurses must collaborate in teams and across disciplines, the absence of trust can hinder effective communication and information exchange. This issue becomes particularly critical during emergencies, such as managing contagious disease outbreaks (8).
Although numerous studies have been conducted on the importance of relationships within healthcare systems, there has been less focus on interprofessional relationships between nurses and managers, as well as on the concept of organizational trust within nursing (9). There remains a lack of consensus regarding the definition of organizational trust in nursing; for instance, organizational trust and interpersonal trust are often used interchangeably (10). Therefore, it is essential to precisely define the concept of organizational trust in nursing so that its components and attributes can be accurately understood. Concept analysis rooted in nursing research or theory is a vital approach to expanding and developing nursing knowledge.
Limited qualitative research exists regarding the nature of organizational trust in nursing, its dimensions, and determining factors. The understanding of organizational trust in nursing has evolved slowly, with most research focusing on developed countries. However, it is well-known that healthcare environments in Iran and other developing countries are markedly different. Thus, there is a need for the development and analysis of concepts related to organizational trust in nursing based on developing countries like Iran, where social cohesion and solidarity are more pronounced (11).
Walker and Avant regard activities such as constructing, deriving, and analyzing concepts as foundational tasks in the advancement of nursing theories. The primary objective of Walker and Avant's approach is to distinguish between the defining attributes of a concept and those that are unrelated (12). According to the researcher's previous studies in this field and the significance of organizational trust and its frequent application in nursing, despite the search by researchers, a satisfactory and clear definition for this concept in nursing has not been yielded; rather, many definitions have been adapted from other professions (13, 14). This study aims to achieve a clearer and more precise understanding of the concept of organizational trust in nursing using Walker and Avant’s approach.
2. Evidence Acquisition
In this qualitative study, the concept of organizational trust in nursing was analyzed, and its dimensions were identified using Walker and Avant's concept analysis approach (12). This approach also has the capability to clarify an empirical concept by simplifying it (15). The approach consists of eight stages: Selection of the concept, determination of the goal or goals of the analysis, identification of all applications of the concept under analysis, definition of the attributes of the concept, construction of model cases, construction of borderline, related, and contrary cases, specification of the antecedents and consequences of the concept, and demonstration of the empirical illustration of the concept in question (12).
Initially, an internet search was conducted in reputable and accessible databases, including Magiran, SID, ScienceDirect, PubMed, Scopus, and Google Scholar, to find existing literature regarding organizational trust. The search for articles was conducted in two phases. In the first phase, the keywords used were "organizational trust" or related concepts (such as credibility, assurance, belief, conviction, and tools for measuring organizational trust) combined with "nursing" in the title/abstract. In the second phase, the keywords "organizational trust" (title) and "nursing" (title/abstract) were employed. Inclusion criteria included articles available in full text in English and Persian until 2024 that addressed the concept of organizational trust or related concepts such as credibility, assurance, belief, conviction, and tools for measuring organizational trust. Articles focusing on patients or examining organizational trust in non-nurses were excluded. After eliminating duplicates, a total of 35 documents were included in the study, comprising 22 theoretical articles and 13 empirical studies (Figure 1). This study extracted definitions, attributes, antecedents, and consequences of recovery from the reviewed studies, and the data were analyzed inductively.
Figure 1.
Flow diagram for study selection
2.1. Selection of the Concept
The selection of a concept should be done with care, ideally focusing on an area of interest to the researcher (12, 16). Organizational trust in nursing is a significant concept because the nursing profession is profoundly influenced by human interactions, collaboration, and engagement among nurses, managers, patients, and healthcare teams. Trust plays a central role in facilitating workflow processes, enhancing communication, and increasing productivity within healthcare services (10). However, given that organizational trust in nursing encompasses various dimensions, understanding these aspects is not easily achievable. Furthermore, previous studies have not provided a precise and clear definition of organizational trust in nursing (10, 16-18). Therefore, this study aims to clarify the concept of organizational trust in nursing.
2.2. Objectives of Concept Analysis
Concept analysis not only clarifies ambiguous and complex concepts but also elucidates frequently used concepts and distinguishes one concept from similar yet different ones, thereby providing a foundation for conceptual development (12). The concept of organizational trust is often used interchangeably with other concepts such as interpersonal trust; however, it possesses various dimensions. By clarifying the concept of organizational trust in nursing, this study will present its attributes, antecedents, and an operational definition, thereby offering a shared understanding for users of this concept and facilitating its development.
3. Results
3.1. Identifying All Uses of the Concept
Walker and Avant argue that at this stage, the application of the concept should be limited to a single aspect. All facets of the concept's usage are explored, not solely within nursing or medical articles, as this may bias the researcher’s understanding of the essence of the concept. Therefore, the initial goal is to provide a comprehensive overview of the concept in question (12). Studies indicate that there is no precise and clear definition of "organizational trust in nursing" found in the literature. Consequently, existing definitions of "trust", "organizational trust", and "trust in nursing" were examined. Here, we address both general and specific perspectives regarding the concept of organizational trust in nursing.
The term "trust" is defined by the Merriam-Webster dictionary as a firm reliance on the character, ability, strength, or truth of someone or something (19). The Oxford dictionary provides a similar definition: "a firm belief in the reliability, truth, or ability of someone or something" (20). Trust can be viewed as a type of expectation for positive outcomes that one party can receive based on the anticipated actions of the other party in an interaction characterized by uncertainty (21).
According to Mayer and Mulvey, organizational trust is defined as "the willingness of one party to be vulnerable to the actions of another party based on the expectation that the latter will perform a particular action important to the trustor, irrespective of the ability to monitor or control that other party". This definition of trust is grounded in expectations from employees and organizations (22). Lee et al. define organizational trust as "the expectations individuals have regarding communication networks and organizational behaviors" (23).
Trust in nursing is recognized as one of the fundamental pillars of the relationship between nurses and patients. This concept signifies patients' confidence in nurses' abilities, knowledge, and integrity in delivering healthcare (24). Trust, as a human attribute, provides numerous opportunities for establishing effective relationships with positive outcomes in therapeutic environments (8). While research has focused on defining and characterizing trust in nursing, a clear definition of organizational trust in nursing has yet to be found in the literature.
3.2. Descriptive Attributes of the Concept
Identifying the defining attributes of a concept is central to its realization. The aim is to highlight a core set of features that are most closely associated with the concept, allowing the analyst to gain a broader conceptual insight. This stage aids in distinguishing a specific concept from other similar or related ones (12). There appears to be a general consensus regarding six attributes of organizational trust, which include integrity, competence, consistency, benevolence, and empathy.
3.3. Integrity
Integrity refers to the alignment of words and actions, signifying harmony between what an individual says and does. Trust is built upon the understanding of integrity and ethical behaviors. This dimension emphasizes the importance of transparency and ethical practices in organizational interactions, ensuring that team members feel their colleagues act in accordance with ethical standards and proper values (25). In therapeutic environments, where interpersonal interactions and teamwork are crucial, integrity serves as a prime example of ethical behavior and accountability. A lack of integrity can exacerbate tensions and diminish team morale (26).
3.4. Competence
In organizational science, competence encompasses a combination of knowledge, skills, training, social skills, and behavioral attributes utilized to enhance performance (25). Generally, competence is defined as the state or quality of being adequately or well-qualified and possessing the ability to perform a specific role (27). In the context of nursing, competence pertains to aspects such as leadership skills, effective communication abilities, transparent decision-making, and providing necessary support for nurses (28).
3.5. Consistency
Consistency refers to the capability and continuity in the behavior, decision-making, and performance of an individual or organization (25). In healthcare settings, where collaboration and teamwork are critical factors in delivering high-quality patient care, consistency conveys a sense of security and support to nurses (29).
3.6. Goodwill
Goodwill signifies the kind-hearted motivations and degree of compassion an individual has toward a reciprocal group, along with a genuine concern for the well-being of others (30). Kant and Kirchmann introduced it as a fundamental value in relationships, arguing that being benevolent toward others is the most essential foundation for relationships. He stated that "if benevolence is absent, all other values can become detrimental and harmful to any relationship" (31). Within healthcare systems, benevolence as a dimension of organizational trust reflects genuine attention and care for the well-being of patients and staff. This aspect specifically pertains to the commitment of staff and organizations to the health and improvement of patients' conditions as well as the work environment for employees (32). Conversely, benevolence in nursing management involves understanding and addressing the needs and challenges faced by nurses. This benevolence can manifest in various forms, including providing emotional support, offering opportunities for training and professional development, and creating suitable working conditions (13).
3.7. Empathy
The concept of empathy is one of the essential elements in nursing. Being understood is a fundamental human need, and the experience of being understood lays the foundation upon which relationships are built. In the nursing profession, nurses engage professionally with others. Empathy refers to the ability to understand and accept the feelings, needs, and circumstances of individuals. This element can facilitate the establishment and strengthening of mutual trust and positive working relationships. Empathy provides nurses with the assurance that their colleagues and managers possess a deep understanding of the challenges they face (33).
3.8. Model Construction
3.8.1. Case Example
A case example is a representation of the application of a concept that encompasses its entirety. This example can be either real or fictitious (12, 34). On a Wednesday during the morning shift, Nurse Ms. A contacted the head nurse to inform her that due to her child's illness and the need to care for him at home, she would be unable to attend her scheduled shift. The head nurse patiently listened to Ms. A's concerns and expressed her sympathy. After reviewing the monthly staff schedule and considering Ms. B's cooperation and capabilities in delegating tasks, the head nurse contacted Ms. B and requested her assistance during the relevant shift. In exchange, the head nurse agreed to remove Ms. B’s night shift on Friday as per her request. Ms. B accepted the shift change, recalling that a similar situation had occurred previously, and the head nurse had honored her commitment. Consequently, Ms. B's night shift on Friday was removed.
The presented case exemplifies organizational trust in nursing, as it incorporates all the attributes associated with organizational trust. The removal of Ms. B's shift by the head nurse, in accordance with her promise, reflects honesty, while the head nurse's recognition of Ms. B's capabilities in task delegation demonstrates her competence. Ms. B's willingness to assist stems from goodwill. Furthermore, the head nurse's positive track record in fulfilling her commitments indicates stability in her performance. The head nurse’s attentive listening and expression of empathy towards her colleague signify a sense of camaraderie within the team.
3.8.2. Additional Cases
To make the best judgment regarding which attributes provide the most accurate and suitable definition of the concept in question, it is helpful to examine cases that do not align precisely with the concept but are similar or contrary to it. These cases assist in determining what qualifies as a specific attribute of the concept and what does not. They include related marginal cases and opposing cases (12, 34).
3.8.3. Marginal Case
Marginal cases are examples that contain most of the defining features of the examined concept but do not encompass all of them. They may include more or even all defining attributes but differ fundamentally in one aspect, such as duration or intensity (12). Mr. N, a nurse working in the cardiology ward, had not been able to travel with his family for some time due to personal and work-related issues. Consequently, he planned a family trip and subsequently spoke with his supervisor at an appropriate time, who patiently listened to Mr. N's concerns and promised to assist him. With this understanding, Mr. N purchased airline tickets and reserved a hotel for accommodation. At the beginning of the following month, upon reviewing the schedule, he realized that his leave request had been approved; however, the leave was recorded for a different date. This case represents a marginal model of organizational trust in nursing because it contains all mentioned attributes; however, the attribute of integrity—specifically, the alignment between words and actions — was lacking on the part of the supervisor, who did not appropriately address Mr. N's scheduling request.
3.8.4. Opposing Cases
Regarding opposing examples, it can be stated that they represent "clear instances of the absence of the concept" (12). On a working day in the intensive care unit, assistance was accidentally requested from a colleague for performing suctioning procedures by a newly hired nurse. The colleague agreed to help; however, a good track record in training and collaborating with new staff members was not present. When it was time to perform suctioning on the patient, despite the request for assistance, the colleague did not attend to the nurse at the bedside due to being engaged in a phone conversation. As a result, suctioning had to be performed alone. In this scenario, the colleague lacked a positive history of collaboration with staff, failing to meet the criteria for stability and competence. Although assistance was promised, it was not followed through, thus lacking integrity; moreover, by continuing the phone conversation while repeated requests for help were made during suctioning, empathy was not demonstrated. Therefore, this represents an opposing model of organizational trust.
3.8.5. Antecedents and Consequences
Antecedents are events and occurrences that must manifest prior to the emergence of the concept (12). The prerequisites for this concept pertain to organizational, occupational, and employee factors within an organization. The fundamental prerequisites related to organizational factors include attributes such as organizational commitment, organizational support, organizational identity, employee well-being, organizational communication, and organizational justice (35). Organizational support manifests as emotional and practical assistance that employees receive from the organization (36).
Occupational factors encompass job motivation, job satisfaction, job values, career advancement, and job benefits. Employee motivation is influenced by expressions of appreciation or the provision of new challenges; job satisfaction is typically associated with feelings of competence and the utilization of one’s abilities. Job values relate to the alignment of organizational values with individual values, while career advancement reflects the organization’s commitment to the development and progress of its employees. Lastly, job benefits pertain to the provision of fair and appropriate advantages for nurses, which may include financial benefits, professional development programs, and welfare facilities. Overall, these factors are interconnected and can contribute to either the formation or reduction of organizational trust (37).
Employee-related prerequisites include collaboration, sense of appreciation, participative decision-making, mental health, spiritual intelligence, resilience, culture, religion, and ethics. A sense of appreciation arises when the efforts and achievements of employees within the organization are recognized and valued by management and colleagues. Participative decision-making refers to allowing employees to engage in decision-making processes. Mental health pertains to having a healthy and supportive work environment. Spiritual intelligence is associated with the ability to understand and manage the spiritual dimensions of life. Culture refers to transparency, partnership, and mutual respect. Religious and ethical principles can establish frameworks for ethical behaviors in the workplace. Resilience fosters an environment that conveys to employees that they can cope with challenges. These factors, in turn, contribute to enhancing organizational trust (35, 36).
3.8.6. Consequences
Consequences are events that occur following the emergence of the concept (12). According to key literature, the primary consequences of organizational trust include reduced conflict among employees, enhanced cohesion among individuals, increased productivity, stimulation of growth within the organization, improved work morale, decreased absenteeism and turnover rates among employees, and the creation of an environment conducive to innovation (9, 38). Trust in the organization allows for a focus on long-term activities; for example, empowering employees may be a short-term goal but can lead to innovation, improved service quality, increased accountability and competence, enhanced morale, and reduced absenteeism and turnover. Trust is an essential element for effective organizational change (37) (Figure 2).
Figure 2.
Antecedents and consequences of the concept of organizational trust in nursing
3.8.7. Empirical References
Determining empirical references for the defined attributes is the final stage in concept analysis. According to Walker and Avant, when a conceptual analysis is completed, the question arises: "If we wish to measure this concept or determine its existence in the real world, how can we do this?" (12). Empirical references are categories of real phenomena that indicate the occurrence of the concept in question through their presence or existence. Empirical references are not tools for measuring the concept itself; rather, they serve as instruments through which one can recognize or measure the defining attributes. Therefore, empirical references are directly related to the defining features, rather than to the overall concept (12).
Based on a literature review, tools such as McAllister's Trust Questionnaire (1995), the Organizational Trust Questionnaire by Elonen et al. (2008), the Organizational Trust Questionnaire by Kanawattanachai and Young Jin Yoo (2002), and the Organizational Trust Questionnaire by Shockley-Zalabak et al. (1999) are available in relation to organizational trust (39, 40).
Based on the aforementioned points, the authors concluded that organizational trust among nurses can be defined as a positive attitude and deep belief in the capabilities, knowledge, and social and behavioral skills of the organization and their colleagues. This trust is shaped by transparent and ethical interactions within the organization, professional behavior continuity, emotional support, professional development, the establishment of suitable working conditions, and an ability to understand needs, which collectively lead to increased productivity, foster growth within the organization, improve work morale, and create an innovative environment.
4. Discussion
This study clarified the attributes, antecedents, and consequences of organizational trust in nursing through a conceptual analysis and provided an empirical definition of this concept. In light of the definition provided for organizational trust in nursing, summarized as follows, this paper aimed to define and elucidate this concept: The positive attitude and deep belief of nurses in the capabilities and skills of their organization and colleagues arise from transparent interactions, professional behavior, emotional support, and professional development. These factors contribute to increased productivity, organizational growth, improved work morale, and the establishment of a creative environment.
According to Gilbert and Tang, organizational trust is defined as perceived assurance and support from management (41). Davis categorized organizational trust into macro and micro levels. Integrity and benevolence are concepts related to the micro level, while the overall organizational climate of trust pertains to macro levels (42). Fulmer and Dirks defined trust in an organization at the individual level as a psychological state that includes a willingness to accept vulnerability based on positive expectations from the organization (43). Gilbert and Tang describe organizational trust as the sense of trust and support employees feel towards their employer. Employees believe that their employer is flexible and honors commitments. Thus, it refers to employees' faith in organizational leadership and management goals that ultimately will benefit the workforce. This means assurance that the organization will act in a manner that is beneficial or at least not harmful to them (41).
Atkinson and Butcher introduced organizational trust as impersonal trust, defining it as employees' trust in organizational structures and processes, as well as fairness in human resource management policies and decision-making. This necessitates alignment of norms and values between management and employees. However, norms and values are embedded within social and organizational contexts, making organizational trust a context-dependent phenomenon (44). Shockley-Zalabak and Morreale positioned organizational trust and distrust at opposite ends of a spectrum that are inversely related (45). However, Lewicki and Brinsfield presented trust and distrust as separate yet interconnected dimensions (46). Another common conceptualization of organizational trust is interactive trust within an organizational context where interpersonal interactions, oversight, and management are essential components (47).
There is no singular definition of organizational trust. This implies that different authors not only understand trust in various ways but also discuss different structures when referring to trust while using identical or similar terms to describe distinct constructs.
In their study, Kushniryk et al. identified three dimensions of organizational trust: Manifestation of support, advice, and listening (48). Mayer et al. presented one of the most widely used models of organizational trust, introducing the concepts of competence, goodwill, and integrity as the core dimensions of their model. Although these concepts are independent, they interact with one another in such a way that the absence of one can lead to the erosion of trust within the organization (49). Machiry et al. emphasized that employees' perceptions of established foundations of trust within an organization are crucial; these foundations include cognitive bridging, emotional embodying, and inclusive enacting (50). Gustafson noted that employees tend to reciprocate behavior from the organization in a manner they perceive as fair (51).
Each of these definitions points to different aspects of organizational trust and contributes to a better understanding of this complex concept. They underscore that trust is not only an individual element but also a fundamental pillar for the success and sustainability of organizations in today's world. To foster and maintain trust within organizations, it is essential to address all facets of this concept and implement necessary actions to strengthen it. Organizational trust is recognized as one of the key factors for organizational success and plays a significant role in enhancing performance and creating a positive and effective environment. However, organizational trust, as a whole, encompasses both trust in individuals and trust in the organization. Despite this, literature on interpersonal trust has dominated research on organizational trust, with previous studies primarily focusing on trust in managers while neglecting trust among colleagues; thus, a clear definition of organizational trust as an impersonal concept remains unspecified.
A review of research on trust in nursing (24, 52, 53) indicates that most published studies have concentrated on nurse-patient trust, with none describing relationships among healthcare staff. Another article published in 2014 focused solely on the foundations, attributes, and consequences of trust without considering various definitions and related concepts (54). Recently, trust has been explored using concepts from other disciplines, such as art or business, through Watson's theoretical perspective. Examples presented were centered around the nurse-patient relationship as a helping-trust relationship, while relationships between leaders and nurses were not assessed (55). On the other hand, Hadi-Moghadam et al. stated that organizational trust in healthcare serves as a mechanism for healthcare staff to respond to managerial behaviors that empower them to enhance work effectiveness and minimize errors and dissatisfaction (8). Consequently, there is a limited number of studies on trust within healthcare settings, particularly in nursing.
4.1. Conclusions
The analysis of various dimensions of organizational trust revealed that integrity, competence, consistency, loyalty, goodwill, and empathy are fundamental keywords for strengthening trust among nurses. Integrity and transparency in communication, professional competence and abilities, consistency in behavior and decision-making, loyalty to shared goals, goodwill and concern for others' interests, as well as empathy and a deep understanding of colleagues' and patients' feelings and needs all play significant roles in establishing and enhancing organizational trust. Therefore, it is essential for organizations to attend to the needs of nurses and patients and to create an environment where nurses can easily express their opinions and suggestions. The findings of this research also indicate that the level of organizational trust can positively influence the quality of patient care and reduce stress and burnout among nurses. Given the widespread nature of the concept of organizational trust in nursing and its application in clinical practice, it is suggested that this concept be examined using other methods, such as hybrid concept analysis.
4.2. Strengths and Limitations of the Study
In this study, transparent interactions, professional behavior, emotional support, and professional development are identified as antecedents of the concept of organizational trust in nursing within professional relationships. Creating a creative environment and increasing productivity are the outcomes found as a result of reviewing studies and analyzing the concept of organizational trust in nursing. Although efforts were made to include all related articles in this regard, given the existing conditions and the researcher's lack of access to some search databases, it is possible that some articles were not included in the study.
