Trust as an important factor in patients' psychological well-being during hospitalization

Introduction

A good relationship between the patient and the caregiver has a large impact on hospital stay, perception of disease, and better coping with treatment. If trust between the patient and caregiver is impaired for various reasons, it is very difficult to regain it. Trust is part of psychosocial support, it is the basis of mutual productive communication in the nurse-patient relationship during the nursing process. By gaining trust, the nurse contributes to optimizing the treatment process and more qualitative, easier problem solving for the patient by the healthcare professional. A constructive and positive approach by both the patient and healthcare staff shortens hospital stay, improves communication between patient and staff (10). Trust can be defined as reliance on others, a certain expectation of future situations, expectation of an honest exchange, or an authentic relationship with comprehensible communication (4). During patient care it is not meaningful to search for a cooperation focus unless a sufficiently trusting and open relationship has been established and the patient is still in uncertainty (7). Trust requires that care be based on integrity, available when needed, and professionally applied so that any possible risk of patient harm is excluded (3). The demands on nurses' work are constantly increasing and require, in addition to professional competence, the best possible psychosomatic condition and well-being (2).

Aim: In this cross-sectional study we addressed 190 patients with cardiovascular disease (CVD) where, as part of the nursing process, we wanted to determine the level of patients' trust in healthcare staff, and also verify the satisfaction of psychosocial needs during hospitalization.

Methodology: We conducted the study at the Department of Acute Cardiology and Coronary Care of the National Institute of Cardiovascular Diseases in Bratislava. We anonymously invited 190 patients with CVD. The obtained variables were tested for normality of distribution with the Kolmogorov-Smirnov goodness-of-fit test against the normal distribution. For comparison of means of numerical variables we used the non-parametric Mann–Whitney U test and Kruskal–Wallis analysis of variance. All tests were performed at a significance level of α = 0.05.

Demographic characteristics: The sample included 31% women and 69% men; mean patient age was 57.38±9.59 SD years, youngest patient was 30 and oldest 80 years. In the group with an average level of trust, mean age was 55.4±11.82 SD years; in the group with high trust level, mean age was 58.09±8.59 SD years. In terms of education: 4% had elementary education, 24% secondary vocational, 40% secondary with maturity exam, 32% university education. The average length of hospitalization was 4.8±3.03 SD days.

Results: Based on questionnaire scoring we assigned 26% of patients to group 1 (S1) with an average level of trust and 74% to group 2 (S2) with a high level of trust toward healthcare staff. Selected psychosocial needs during hospitalization were evaluated on a scale from 1 to 5, where 1 is the lowest and 5 the highest value. In the observed sample, 71% of patients gave value 5 for sense of certainty, 69% for feeling safe, 69% for help and support, 53% for understanding and 52% for comprehension.

Figure No. 1 Patient trust level toward healthcare staff

Figure No. 2 Value 5 for selected psychosocial needs during hospitalization

The perceived intensity of stress during hospitalization was assessed on a scale from 1 to 10, where 1 is the lowest and 10 is the highest intensity. In comparison of the two largest groups, 51 patients with value 1 and 45 patients with value 5, we found that 82% of patients with value 1 and 62% of patients with value 5 reported a high level of trust /p=0.028*/.

Figure No. 3 High level of trust in relation to perceived stress intensity

In the age-group comparison, 41% of patients aged 30-55 years and 59% of patients aged 56-80 years, we found high trust in the older age group in 79% of patients, while in the younger group it was 66% /p=0.055/. As for sex differences, 75% of men and 71% of women reported a high level of trust. In terms of achieved education, a high level of trust toward healthcare staff was reported by 75% of patients with primary education, 70% with vocational secondary education, 78% with maturity exam, and 72% with university education.

We also compared the fulfillment of selected psychosocial needs during hospitalization, such as perception of stress, satisfaction of psychological needs, overall appraisal of support from healthcare staff, information about illness and treatment, and assessment of communication and approach.

Table No. 1 Comparison of patients with high and average trust levels

Figure No. 4 Perception of stress during hospitalization and trust level

Figure No. 5 Full satisfaction of psychological needs and trust level

Figure No. 6 Very good overall support and trust level

Figure No. 7 Very good information about illness and treatment and trust level

Figure No. 8 Very good level of communication and approach and trust level

Patients in S1 experienced stress significantly more intensely than patients in S2. Patients in S1 rated satisfaction of psychological needs as inadequate. Patients in S1 rated total support during hospitalization less positively than patients in S2. Patients in S1 were significantly less informed about illness and treatment compared with patients in S2. Patients in S1 assessed communication and approach by healthcare staff significantly worse than patients in S2.

Discussion: Nearly three quarters of S2 patients reported a high level of trust toward healthcare staff during hospitalization, which allowed easier cooperation, establishment of a positive relationship, and barrier-free communication in the nurse-patient relationship during the nursing process. More than one quarter of S1 patients reported an average level of trust toward healthcare staff during hospitalization. Patients in S1 perceived stress more intensely. Because this is a specific patient type in a workplace with above-standard conditions, among whom, besides chronic patients, often are young people in productive age pulled away from full health and normal life, their response during hospitalization can be highly differentiated and paradoxical. A lower level of trust can in fact be one of the causes of perceiving excessive stress intensity during illness and hospitalization. Excessive stress experience arising from the illness and hospitalization itself has a major impact on patients' mood, how they feel, their positive or negative experience, behavior, perception of health, and overall well-being during hospitalization.

Chronic stress or excessive stress from hospitalization may worsen patients' health status (1). Hospital stressors, which could be regulated and limited with an appropriate approach, often have negative effects both on psychological experience and the patient's somatic condition. Excessive stress causes release of higher levels of stress hormones, which evoke feelings of weakness, anxiety, and depression (5). Psychological and physical stress in the body potentiates the neuroendocrine response triggered by acute illness. Therefore, stressors characteristic of intensive care situations such as acute illness, inflammatory processes, invasive procedures, fatigue, fear, pain, discomfort, and sleep deprivation (13) should not be ignored. This must be considered for all hospitalized patients, especially for those with obvious signs of excessive stress and anxiety. Appropriate psychosocial nursing interventions have a significantly positive effect not only on psychological experience, but also on minimizing negative emotions and overall psychological well-being (6), and are important for treatment adherence and recovery. In patients with excessive experience of negative emotions, correct supportive strategies should be chosen. Suitable psychosocial interventions are effective in alleviating stress-related difficulties and may positively influence the course of the disease (1). Patients in S1 rated satisfaction of psychological needs as insufficient, which contributed to their psychological discomfort and may have led to greater negative psychological experience. All limitations in meeting psychological needs are connected with feelings of uncertainty and neglect, affect mental state, and evoke sadness, restlessness, and feelings of disappointment, anxiety, and irritability, which can be experienced very intensely. Positive feelings of safety and certainty have a positive impact on every patient's psyche (11).

The basis of mutual effective and productive communication is trust as one of the important conditions for meeting psychological needs. During hospitalization, patients emphasized especially the sense of certainty, safety, help, understanding, and comprehension. It is important that in routine clinical practice nurses know how to provide and ensure meeting of these needs during care as fully as possible, thereby contributing to increased levels of patients' psychological well-being. Lack of knowledge and insufficient information about illness and further treatment often triggers feelings of fear, anxiety, and uncertainty. Every patient suffers a certain uncertainty, never knowing exactly what lies ahead; anxiety is experienced due to unpleasant changes and anticipation of further difficulties the illness may bring (9). If patients do not have sufficient information about their illness and treatment, planned examinations and procedures, this may lead to feelings of anxiety, hopelessness, and overall apathy (10), and worsens treatment compliance. Therefore, providing appropriate information in a suitable way within professional competence is important. If a patient does not know at least the framework of their illness, uncertainty and threat rise, as does the risk of conflict. Any unpleasant medical procedure, or side effects of treatment whose purpose the patient does not understand, is perceived as threatening, with all psychological and physiological consequences (9). Adequate patient information about illness, planned examinations, procedures, prevention, and the continuation of treatment is an important part of supporting psychological well-being during hospitalization. It is an appropriate strategy for minimizing excessive stress, anxiety, and fears. One of the basic and important ways to establish contact during patient care is appropriate verbal and non-verbal communication. Communication forms the basis of all nursing care. Every healthcare professional uses the ability to communicate with the patient as part of professional training (11). Appropriate communication fosters patient trust and creates a positive atmosphere for further activities. During communication it is important to listen attentively, speak clearly, ask questions, allow the patient to speak about difficulties as part of psychological hygiene, and preserve respect for the patient and their opinions (12). In many cases, communication and approach by healthcare staff may be inadequate, with reluctance to communicate, failure to inform the patient about therapeutic procedures, interventions, and treatment, and unwillingness to help, which in the patient evokes feelings of loneliness, social isolation, fear, anxiety, but also defiance, hostility, and aggressiveness. Such an approach harms the patient both psychologically and somatically. This is not usually caused by insufficient professional preparation, but rather by insufficient personal well-being and condition of healthcare professionals. Loss of trust and unwillingness to cooperate often follow. This may worsen cooperation between patient and provider and negatively affect the entire treatment process. Improper and inappropriate care can cause loss of trust in professionals, deterioration of patient health, and even development of new illness or threat to life. Hospitalization in acute wards also has a significant iatrogenic potential, because the iatrogenic psychological-traumatic trigger is often everything that evokes fear of illness, deterioration, threat to life, and death (8). A proper approach can, to a large extent, calm the patient, ease and neutralize negative emotions, and on the other hand give a feeling of help, emotional support, understanding, certainty, comprehension, thereby facilitating trust in the patient. Appropriate communication and approach by healthcare staff can prevent many conflict situations and increase the effectiveness of therapeutic interventions, and in their consequences favorably influence disease course (11). Gaining patients' trust is a key nursing competence, especially in situations where the patient has great confidence in their professional knowledge and skills (3).

Conclusion

Clinical practice in acute wards and intensive care units places increased demands on nurses, not only for professional skills but also for holistic perception of the patient, so they know and accept the patient's needs in all areas. If healthcare professionals do not apply a holistic approach, the patient may feel disinterested in his or her person. This can severely disturb the patient-nurse relationship and thereby worsen collaboration. In situations where the nurse provides patient care, it is necessary to appropriately inform the patient about the illness and further treatment, to support the patient as appropriately as possible, to choose the right supportive strategy and communication technique, and to adopt a proper approach, thereby contributing to minimizing the perception of negative emotions during hospitalization. By using psychosocial interventions, the nurse contributes to more comprehensive and higher-quality nursing care, a better nurse-patient relationship, and thus greater trust from the patient.

Recommendations:

• professional care depends on the psychological well-being and condition of healthcare professionals,
• mutual respect during the nursing process,
• respect for the psychosomatic unity of the patient,
• active integration of health psychology knowledge into nursing care,
• maximally possible assurance of meeting patient needs.

Authors: PhDr. Gabriel Bálint PhDr. Dušan Selko, CSc., MPH

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