LeadingAge Magazine · January-February 2017 • Volume 07 • Number 01

Trust: the Foundation of the Person-Centered Provider

January 24, 2017 | by Gene Mitchell

The best and most successful organizations know how to build and maintain high levels of trust—among both staff and residents/clients.

Josie Browning Haney, administrator at Ohio Living Mount Pleasant in Monroe, OH, was hoping the difficulties that she and her nursing team were having could be solved relatively quickly, perhaps with a staff retreat.

What she heard from Nancy Pettigrew, a consultant hired by Ohio Living to help managers improve their workplaces, was most assuredly not that simple.

“I audibly gasped when she said it would take a year,” says Haney. “But every minute we’ve invested has benefited residents tenfold.”

The nursing staff at Haney’s community had been wrestling with communication difficulties for some time.

“We had a very talented team of 7 or 8 nurse leaders but we were struggling with how to use our talents together,” says Haney. “Some were very frustrated and burned out; we had trouble delegating. We couldn’t have results-focused conversations. We were having conflict with each other rather than [between] our ideas.”


Trust as a Foundation

Dana Ullom-Vucelich, chief human resources and ethics officer for Ohio Living, puts a priority on trust as one of the most important elements of a well-functioning organization.

“Our aim is to try to build vulnerability-based trust; the core of this is that building trust teaches you how to have healthy conflict with each other,” she says. “In our relationships, we believe there is nothing more important than investing in people to get their desired outcomes and organizational results.”

Ullom-Vucelich hired Pettigrew, founder of The Healthy Workplace, Ltd., after hearing her speak about how people deserve to feel valued in the workplace. One of Pettigrew’s approaches involves the Everything DiSC® system, a set of profile assessments designed to provide insights into behavioral preferences and personality styles.

Ullom-Vucelich and Pettigrew are also admirers of Patrick Lencioni’s work on team-building, which is incorporated into Wiley’s Five Behaviors of a Cohesive Team™ model. (Pettigrew is an accredited facilitator of the model.) It uses a pyramid-shaped graphic in which “Trust One Another” is the foundation and starting point. “Vulnerability-based trust” (in contrast to predictive trust, i.e., knowing that if a person is asked to do something she will do it) can be built when co-workers learn to become transparent and honest with each other.

“We used the [Everything DiSC] profile, and we realized that if we could focus on the diversity of our team and use it to our advantage, we’d be stronger,” says Haney. “We were clearly not using that diversity to our benefit, and staff could see that there was a rift, or something not ‘clicking’ from the leadership.”

Ullom-Vucelich notes that her organization works hard and spends a lot of money to find great talent, and needs to work just as hard to support that investment.

“We had some 2-steps-forward, 1-back moments,” says Haney. “We’d fall into old patterns of behavior; there would be meetings outside of meetings. We had some brutally honest conversations. It took practice to be comfortable being uncomfortable. You have to have intention when directing conversations like that. It was emotionally exhausting at times.”

A year of work, meetings and self-assessments rebuilt trust and cohesion among staff, says Haney. Only one nurse has left since then, because of a family move.

“We’re a cohesive team and we enjoy coming to work again,” she adds. “We’ve encountered some big challenges, including a fire on the campus, but came through in great shape.”


Do My Best Interests Matter to the Organization?

For Pettigrew, the “Five Behaviors” model isn’t the only pyramid of interest. When she works with organizations navigating change, she calls on the work of psychologist Abraham Maslow, known for his “hierarchy of needs” illustrated with its famous pyramid. It illustrates 5 levels of personal needs, beginning with the most basic at the bottom and moving up to higher ones: physiological, safety, social, esteem, and at the top, self-actualization.

Her model adds two additional scales (trust and morale/effectiveness) to correspond with the 5 Maslow levels. The levels of the trust scale, bottom to top, are none, some, conditional, substantial and unconditional.

“When trust is low, morale and productivity are also low,” Pettigrew says. “In order for people to accept and navigate change effectively, they need to trust that their leaders truly value them and care about their success as individuals and as contributors to the organization.

“When you think of the Maslow hierarchy, in terms of physiological needs, there are many in the long-term care workforce that may be struggling in their personal lives. However, the employer has little direct impact on the home life of employees. The role of managers then is to do all they can to ensure the work experience helps employees move up the Maslow [hierarchy].”

When people are in that lowest level of needs, she says, “they’re in a sense of survival, worrying about their jobs. What will that do to their ability to even trust you? For instance, when it comes to team building, when people are in survival mode it’s like they’re drowning in the ocean, they are only thinking about themselves and not necessarily trusting that anyone else will have their well-being in mind. Then when they get to the safety needs, there’s a little more security there and trust is building a little. But it’s not until they get to social needs, that sense of belonging, that they are really a part of a team mindset.”

For Michele Holleran, whose company does engagement and satisfaction research and consulting in senior living, trust is a component of engagement, and she believes engagement measures are required to quantify it. This kind of research can be done with staff or with residents.

“Those [trust] models can be boiled down into 3 things,” she says. “Does the constituency feel the organization is competent? Does it feel there’s credibility in the organization—fairness, reliability, dependability and ethics? Do I believe the organization and leaders have my best interests in mind?”

She says the first two questions are usually measured by satisfaction measures while the third is measured by engagement factors.

“We’ve been measuring [attitudes about] competency and credibility for a long time,” says Holleran. “In the last 2 years, we’re just starting to measure whether we have the best interests of residents and employees in mind. Those are more soft measures; for instance, is there a perception that this organization cares about me?”

Engagement research tries to measure 4 things, Holleran says: voice, connection, well-being and fulfillment.

Voice measures include: whether people have real input into how their communities operate; the transparency of communication and decision making; and how well they are represented, e.g., by a resident association or resident representation on the board.

Connection measures are concerned with how well the organization facilitates social connections for residents and staff, volunteer opportunities or activities within the community or outside. “This is an important part of building trust too,” says Holleran, “because as you allow people to connect with others you’re supporting their ability to live in a way that denotes care.”

Well-being measures include feelings about safety and security, psychological and emotional health and all the 7 dimensions of wellness. “These measure whether you have my best interests in mind,” Holleran says. “What is my emotional connection to this organization?”

The fourth set of questions is about fulfillment—a sense of purpose in life and how well the organization facilitates it.

“These dimensions of engagement really seal the deal with trust,” Holleran concludes. “These are game changers: whether you’re offering residents or staff the ability to truly feel you have their best interests in mind.”


Inducing Trust Among Staff

Among employees—especially in situations where communication problems crop up­­—building vulnerability-based trust is essential to really solving interpersonal problems rather than sweeping them under the rug.

“When you get to healthy conflict, that’s when you get all those [problems] out,” says Pettigrew. “Often people don’t want to go there because of fear of damaging relationships or experiencing a backlash to what they say.”

Haney asks, “Do I trust you enough to talk to you about [a conflict], or do I go to 5 other people to complain about it? Are we going to a supervisor and saying harsh things or do we go right to the person and call them on it? [This process is] saying ‘I trust you enough to hold you accountable.’”

Ullom-Vucelich says Ohio Living tries to get leaders into every conversation. “How can we allow a safety net and exchange views?” she asks. Noting that the organization won an award from the Better Business Bureau, she calls attention to one of the BBB’s Six Principles of Trust: Treasure People.

“If you genuinely treasure people, you’re saying I deserve to be treasured and you deserve that as well. We can collectively have healthy conflict and conversation about what we collectively agreed we would do.”

Pettigrew says simple things like communication styles can make a big difference in creating staff trust. Listening is the key behavior for people feeling understood and valued for who they are. When people feel valued, trust, morale and productivity increase.

“It’s surprising, the emails that go around when people don’t think about how [they] might be received,” she says. “Think about how someone is going to feel after you’ve communicated to them, then work on how you can [better] promote the way you hope they will feel. If they come away feeling they are valued and that you care, it’s a lot different than if it’s just another order you’re adding to their to-do list.”

Pettigrew says leaders and staff have to ask hard questions of themselves: Am I approachable? Do people ask questions? Do I have people offering to help? Do they invite me to be a part of a team because they value my talent and insight?

“If they don’t, perhaps you are not creating a trusting environment where they feel safe with you. You may deliver predictability but as for being someone who can help [them] grow, they don’t get that from you.”

Pettigrew often asks clients to think about memorable teachers or mentors they’ve had, and say what made them so. “It’s always 3 things: First, they feel they were a resource and a guide—they modeled values that [the person] wanted to embrace. But most significant is that in [the teacher’s] presence [they] felt more capable. They trusted them.”

For Ullom-Vucelich, building trust isn’t just a way to fix problems, but a way for any provider to get better.

“This isn’t about poor-performing organizations,” she says. “It’s about good organizations becoming great, re-energized, re-directed, re-connected. All of us should welcome that type of growth opportunity. Recognition and trust go hand in hand; I don’t know which feeds the other first, but they do go together.”

One way leaders can build trust is by recognizing and appreciating staff, she adds. Highly recognized staff members stay longer, are more engaged and produce better outcomes in areas from increased resident satisfaction to quality outcomes.

Ultimately, Pettigrew says, trust is a feeling: “Lots of people grow up believing you should leave your feelings at the door; they don’t belong here. But passion, urgency—all those things—are attitudinal and are based on feelings, not on a checklist.”

Gene Mitchell is editor of LeadingAge magazine.