25.4 Creating an Atmosphere of Trust and Mutual Respect

Factors Influencing Trust of the Health Care System

As discussed in Structural Racism and Systemic Inequities, certain cultural groups have experienced systemic injustices, leading to mistrust of the U.S. health care system. For instance, from 1932 to 1972, the U.S. Public Health Service conducted the Tuskegee Syphilis Study, deliberately misleading Black men about its purpose and withholding penicillin from them when it became available as a treatment. The study had a lasting impact on the Black community’s trust in health care providers and the health care system (CDC, 2022; Freimuth et al., 2001).

Negative stereotypes about certain groups of people have led these groups to mistrust government and institutions. For instance, those living in rural areas with low incomes have been stigmatized since the earliest colonial times. At that time, poor White colonists were viewed as unwanted vagrants who were not entitled to their rights and dignity as American citizens. Rural communities tend to be more skeptical of government and institutions. This is largely because these communities face numerous challenges in obtaining affordable, timely, and quality health care services. Such obstacles often stem from financial limitations, transportation issues, and differences in the quality of health care provided (Rural Health Information Hub, 2022).

Members of the LGBTQ+ community have also been subject to high rates of health care discrimination historically, ranging from harassment and humiliation to being turned away for care. For example, although the Affordable Care Act prohibits discrimination on the basis of sex, including pregnancy, sexual orientation, gender identity, and sex characteristics by federally funded health care providers (U.S. Department of Health and Human Services, 2021), nine U.S. states have laws that allow medical professionals to decline service to LGBTQ+ clients based on religious beliefs (Movement Advancement Project [MAP], 2023b). In 2023, 15 U.S. states banned some forms of best practice medical care for transgender youth, and nine states banned Medicaid from providing coverage for medically necessary health care for all transgender individuals (MAP, 2023a).

Other factors that result in clients’ distrust of the health care system include:

• The impact of cultural beliefs and values surrounding health and healing practices and how they affect an individual’s trust in the system. Certain cultural groups have traditional or spiritual healing practices that may not align with Western medicine, and it is crucial to respect and acknowledge these beliefs to establish trust.
• Communication difficulties and language barriers. Limited proficiency in the dominant language can make it difficult for individuals from specific cultural groups to effectively express their health concerns, understand medical information, or build rapport with health care providers.
• A lack of diversity and representation in the health care workforce hurts trust. When individuals from specific cultural groups do not see health care providers who share their cultural background or resemble them, it can lead to mistrust and a feeling of being misunderstood or disrespected.

Fostering Trust Through Cultural Responsiveness

Eradicating stereotypes and negative perceptions toward certain groups is a necessary step in establishing community trust in the health care industry. This can be achieved when nurses and other health care providers display an understanding of and respect for diverse cultural practices, beliefs, values, and ways of life. Doing so can enhance trust and strengthen the relationship between clients and health care providers.

To promote trust, the nurse can:

• Take steps to learn about the populations they serve (Association of Public Health Nursing [APHN], n.d.).
• Advocate for a workforce that reflects the diversity of the populations served (APHN, n.d.).
• Practice inclusiveness, listen to understand, and recognize the knowledge and power of each individual and group (APHN, n.d.).
• Role model and exemplify the principles of social justice (APHN, n.d.).
• Use effective communication and resolution strategies respectfully to address conflicts (APHN, n.d.).
• Establish community-engaged partnerships, including rural residents from historically marginalized groups (APHN, n.d.).
• Advocate for rural-centered health care delivery models (Lister & Joudrey, 2022).
• Practice with cultural sensitivity by developing a deep understanding of clients’ cultural backgrounds and their impact on health and healing (Seeleman et al., 2015).

Community support and advocacy efforts can play an important role in building trust. When marginalized populations have community organizations, leaders, or advocates actively addressing health disparities and advocating for equitable health care, it can help foster trust and engagement with the health care system.

Recall Nurse Sarah. She is organizing a community health fair to raise awareness about preventive health measures. She wants to ensure that community members feel comfortable and trust the information and services provided at the event. The box below presents actions that Sarah initiates to create an environment of trust.

Sarah’s actions foster an environment of trust within the public health department and its community. She prioritizes open communication, cultural sensitivity, and inclusivity while maintaining professionalism and integrity. Her efforts are instrumental in strengthening relationships, promoting community engagement, and ultimately, improving health outcomes. Such interactions build trust over time. Sarah knows that earning and maintaining trust involves cultivating humility and demonstrating her commitment to culturally responsive care through her actions, words, and consistent efforts. Sarah’s approach involves ongoing self-reflection, a commitment to learning, and a deep appreciation for the diversity within her community. Through these efforts, she fosters sensitivity and humility and contributes to creating a culturally responsive and inclusive health care environment.

Taking Action to Promote Cultural Humility

To create an inclusive, equitable health care environment, nurses should establish goals that encourage cultural humility. It is essential to review and assess these goals frequently, to ensure they align with ongoing growth and development in these areas. Display the goals in a prominent location and replace accomplished goals with new ones. Here are some suggestions for setting these goals:

• Expand cultural awareness: Make it a goal to learn more about different cultures, including their beliefs, values, practices, and health care disparities. This can involve reading books, attending cultural competency workshops or webinars, and conversing with people from different cultural backgrounds.
• Improve cross-cultural communication skills: Set a goal to actively listen, use appropriate language and tone, and be mindful of nonverbal cues. Practice empathetic and nonjudgmental listening to understand clients’ unique cultural perspectives better.
• Reflect on biases and assumptions: Regularly reflect on personal biases, assumptions, and stereotypes that may impact one’s interactions with clients from different cultures. Seek to challenge and unlearn these biases through self-reflection, self-education, and feedback from colleagues or mentors.
• Seek cultural immersion experiences: Actively engage in cultural immersion experiences to deepen one’s understanding of different cultures. This can involve participating in community events, volunteering with diverse populations, or undertaking cultural exchange programs.
• Foster self-awareness: Enhance self-awareness regarding one’s cultural identity and how it influences interactions with others. Explore one’s cultural background, values, and beliefs to better understand one’s cultural perspective and how it may differ from others.
• Build cross-cultural relationships: Seek opportunities to interact and build meaningful relationships with people from different cultural backgrounds within and outside the health care setting.
• Promote cultural competence in practice policies: Advocate for integrating cultural competence into a health care organization’s policies and practices. Suggest implementing cultural assessment tools, providing staff cultural competence training, and promoting a diverse and inclusive work environment.
• Engage in ongoing education: Commit to learning and professional development related to cultural competence. Stay informed about emerging research, best practices, and evolving cultural dynamics. Attend conferences, seminars, or online courses to expand knowledge and skills in providing culturally sensitive care.