Embedding trust in the Canadian health care system
Johny Van Aerde, MD, PhD
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Of the four characteristics of leadership culture, trust is by far the most important. Without it, other aspects of the leadership environment cannot flourish.
When the work environment provides the conditions that nurture growth and development, people thrive. When the opposite is true, people resist change, they don’t reach their full potential, and sometimes they can even experience ill health.1,2 The epidemic number of burned out physicians and their lack of engagement in system transformation3,4 hint that the work environment in the Canadian health care system is less than nurturing. In contrast, when a rich culture of leadership is embedded in an organization or a system, leaders emerge, grow, and succeed.2 Top
Some health care organizations espouse the idea that every physician is a leader.5 Does the Canadian health care system engender leadership in physicians and other stakeholders? How can we create or strengthen a culture in which physicians can emerge and grow as leaders? Top
In their newest book, Learning Leadership, which is based on decades of research, James Kouzes and Barry Posner (who was a keynote speaker at the 2016 Canadian Conference on Physician Leadership) identify four characteristics of leadership culture: opportunities for learning, support for risk and failure, models of exemplary leadership, and trust.2 Of those four, trust is by far the most important characteristic of an organizational or systemic leadership culture; without it, none of the other three characteristics can flourish.2 Top
For people to grow and thrive, for leaders to emerge, we have to trust one another.2 Without trust, the environment is not safe enough to allow openness and honesty, collaboration suffers, and respect for differences in points of view is limited. Distrust of administration and government is one of the barriers for physicians who want to become engaged at a systemic level.6 In some provinces, that trust has been undermined even more during recent conflicts.7 Luckily, pockets of a trusting culture exist in other provinces.8,9 Top
Trust is the foundation of effective relationships, and collaboration occurs through those relationships. Trust is a complex and emotionally provocative concept with different meanings for different people. There are certain core behaviours that build trust, and the “transactional trust” model, developed by Reina and Reina,10 describes a set of behaviours that generate and maintain trust. The model is transactional because it is reciprocal in nature: you have to give in order to get. Its three pillars — contractual trust, communication trust, and competence trust — each has its own trust-building behaviours. Top
Contractual trust is the starting point and establishes the parameters for collaboration.10 Managing expectations, keeping agreements, encouraging mutually serving intentions, and ensuring consistency all build contractual trust. When people understand their responsibilities and what is expected of them, they feel empowered and supported to be successful, which encourages new ways to collaborate. Top
Physicians have a social contract to advocate and care for patients, and the government has to create frames for providing that care to achieve optimal health of individuals and the population within the bounds of available financial resources. However, there has never been a clear understanding of what both parties are responsible for together, i.e., stewardship of the Canadian health care system. If and when leaders start the conversation around contractual trust, the first and most fundamental issue to be addressed is a clear understanding of what health care means in Canada. Do all the parties of the collaboration actually know what we are trying to achieve with our health care system? Does the Canada Health Act provide clarity by defining what health and care mean? Without a clear agreement on what the system’s fundamental purpose is, contractual trust, the starting point for trusting and collaborative relationships, will never exist. Top
Communication trust, the second pillar of trust building, is the ongoing fuel supply for collaboration.10 It contributes to the safety of the environment for sharing information, admitting mistakes, speaking with good purpose, and giving or receiving feedback. It contributes to an environment where risk taking and failure lead to learning. On the opposite side, when the system we created is not forthright in providing that safety, communication breaks down and trust is harmed. Is there communication trust among the stakeholders in the health system we have created? How safe is it to communicate honestly, to talk about mistakes, to give feedback? How do we improve communication trust? Top
The third pillar, competence trust, exists when those collaborating have the ability and the skills to do what needs to be done and, if they don’t, to acquire those skills.10 Do physicians with their expert medical school training, elected and non-elected government officials, and patients have the ability to have the needed conversations around health care and the Canadian system? Do all parties understand the elements of societal and individual health needs, the archetypes and principles of sustainability of a complex system, and the concept of stewardship that goes with all of it? Do all stakeholders have the skills to take the appropriate actions once we have determined what they are? If those skills are not in the system, where can we, together, learn them? Top
In short, the most important characteristic of a leadership organization or system, trust, is missing in the Canadian health care system. Trust can be built or rebuilt transactionally by
Only then will leaders, including physicians, emerge, grow, and succeed in the Canadian health care system for the benefit of us all. Top
1.Marmot M. The health gap. New York: Bloomsbury Press; 2015.
2.Kouzes JM, Posner BZ. Learning leadership. San Francisco: Wiley; 2016.
3.Ladouceur R. Burnout or burn-in? Can Family Physician 2012;58:722.
4.Fralick M, Flegel K. Physician burnout: who will protect us from ourselves? CMAJ 2014;186(10):731.
5.Lee TH. Turning doctors into leaders. Harv Bus Rev 2010;88(4):58.
6.Kaissi, A. Roadmap for trust: enhancing physician engagement. Regina: Regina Qu’Appelle Health Region; 2012. Available: http://tinyurl.com/zq3em8w (accessed 19 Jan. 2015).
7.Preville P. The doctors’ revolt. Toronto Life 2016;28 Sept. Available: http://tinyurl.com/hs2t9lh (accessed 30 Sept. 2012).
8.The future physician role in a redesigned and integrated health system. Regina: Saskatchewan Medical Association; 2016. http://tinyurl.com/hf22c3x (accessed 2 July 2016).
9.Nohr CW. Integrated care: what really matters (president’s letter). Edmonton: Alberta Medical Association; 2016. Available: http://tinyurl.com/gwagzno (accessed 8 Sept. 2016).
10.Reina ML, Reina DS, Rushton CH. Trust: the foundation for team collaboration and healthy work environments. AACN Adv Crit Care 2007;18(2):103-8.
Johny Van Aerde, MD, MA, PhD, FRCPC, is past president of the Canadian Society of Physician Leaders and editor of the Canadian Journal of Physician Leadership.
Correspondence to: email@example.com
This article has been reviewed by a panel of physician leaders.