For ICU clinicians, establishing trust with patients, or their surrogates, can be challenging. Illness is acute, emotions are high, and the environment is bewildering to outsiders. The number of caregivers is greater than anywhere in the hospital and relationships are episodic. Yet without a foundation of trust, communication becomes difficult, conflict is more likely, and even outcomes can suffer. (See Fig. 1.) (See Table 1.)

Trust can be defined as “the optimistic acceptance of a vulnerable situation in which the ‘truster’ believes the ‘trustee’ will care for their interest” [1]. ICU clinicians must realize that trust is impacted by many factors, some of which are under their control and they can directly modify, and others that are not. The factors that affect trust in the ICU can be divided into three major categories: clinician-specific, patient-specific, and environmental.

Perhaps the most important factor in establishing trust is a clinician's communication skills. Both the content and the manner of our communication impacts trust. Communication styles that patients perceive as “trust-building” include transparent sharing of information, telling the truth even when the news is bad, admitting mistakes, and openness to constructive feedback. Another fundamental component of trust is the perception of a clinician's competence. However, the basis for a patient or surrogate's perception of competence differs markedly from how medical professionals usually perceive competence. While clinicians think in terms of professional credentials (e.g., fellowship training or board certification) patients may use very different criteria – some of which may seem arbitrary. For example, things seemingly as trivial as body language or attire may affect patient perception of physician competence [2,3]. While these may seem atypical ways to judge competence, when there is a large asymmetry in knowledge, non-experts must rely on cues for social standing –or what sociologists call “transmuted expertise,” – to assess the credibility of experts [4].

Trust may also be influenced by non-modifiable clinician factors such age or gender. Outpatient studies suggest that some patients are less likely to trust younger physicians [5] and that patients of female doctors are more satisfied than were those of male physicians [6]. However other studies suggested gender does not have a significant effect on trust [7], and there are no studies specifically examining physician age or gender and trust in the ICU.

Patient factors, such as race, health history, and belief in the healthcare system may also effect trust. Overall, racial minorities report lower trust in healthcare providers compared to white Americans [8] as well as lower trust in the general healthcare system [9]. These low levels of trust may be the result of segregation in care delivery, mistreatment by healthcare professionals, difficulty in access, or experiences with underfunded healthcare facilities.

A patient's education level may influence trust, but studies have shown conflicting results. While educated patients may have higher healthcare literacy this should not be assumed to increase the likelihood of trust. In fact some studies suggest that less educated patients are more trusting than their more educated counterparts [10,11]. Finally, a person's prior general state of health may impact trust levels, with poorer health status associated with lower trust in physicians [12]. Poor health may be the cause of decreased trust (i.e., these patients have more interactions with the healthcare system and therefore more opportunities for negative experiences) or may just be an association. In either case, this fact is relevant as critically ill patients frequently have long-standing chronic medical conditions that may predispose them or their families to mistrust. As distrust in the health care system increases, trust in individual ICU physicians declines [9].

The unique environment of the ICU also impacts trust levels. Personal protective equipment, isolation precautions, and the ubiquity of machines and technology can make the ICU feel sterile and impersonal thereby hindering trust-building. Additionally, frequent handoffs between clinicians provide more opportunity for miscommunication, and the sheer number of providers makes the formation of trust more difficult. While these factors are difficult to modify, ICU clinicians should be aware of their impact on trust.

Lack of trust is directly tied to increases in patient-provider conflict, and may even lead to worsened outcomes. This is particularly true in end-of-life situations, where surrogates with low trust prefer more control of life support decisions and are more likely to disagree with recommendations to limit nonbeneficial treatments [13]. Trusting relationships may also be critical for patient research participation [14]. Furthermore, low trust levels can increase clinician job dissatisfaction and burnout amongst clinicians [15].

Recognizing the components of trust and appreciating high-risk situations better position clinicians to create trusting relationships. The greatest opportunity for increasing trust is focusing on communication skills. The “HICCC” acronym suggests that communication should be Honest, Inclusive, Compassionate, Clear, Comprehensive, and Coordinated [16]. Honesty is strengthened by keeping agreements, admitting mistakes, and maintaining confidentiality. Inclusivity is reinforced by consistently engaging, even in periods of patient stability. Compassion is exhibited by demonstrating some internalization of the patient's experience and perspective before speaking. Clear, Comprehensive, and Coordinated communication is displayed when the entire care team speaks with one voice and consistently provides information that is complete and understandable.

The trust a patient or surrogate has in a physician is of course effected by other, more inherent traits – e,g, personality and belief systems – that are not as easily altered as communication or attire [17]. This review focused on areas effecting trust that it is reasonable to expect an ICU doctor could exert some control over in a typical patient encounter.