Shivering in the bathtub at 1:30 in the morning, I couldn’t reach the shampoo. It was on the shelf, just over an arm’s length away. I was too cold and too spent to lift my arm that far after thirty-six and a half hours on the Cruel Jewel trail in the north Georgia mountains.
My husband, Bert, had been awake for almost that long too. He drove me to the race a day and a half earlier. He waited for hours at remote aid stations on back roads, missing me at the first one because I came through faster than we expected, then waiting through the next day as my pace slowed. Every time I popped out of the woods to resupply, he greeted and supported me with care. He drove me home at 1 am.
He was finally sitting down with a beer and chips when I called from the bathroom: “Bert. Can you get me the shampoo?”
He got up and got me the shampoo.
“Thank you, Bert.”
Six weeks later, I crewed him at the Western States 100. I walked with him to the start line before dawn. I drove tight, winding roads, parallel parking our massive SUV like a ninja into impossible spots, fire-scarred sequoias overhead, sharp drop-offs on the other side, just to get three minutes with him at the Robinson Flat aid station. I brought him mashed potatoes. I made him scrambled eggs and tater tots after the race. The next day, when he realized he left his drop bags at Auburn High School after the race, I went back with him to retrive them.
The two races bridged our tenth wedding anniversary. The two races reciprocated trust.
What Creates Trust
Two factors impact trust in health care workers: reciprocity and anomie. Reciprocity builds trust. Anomie undermines it.
Reciprocity is the strongest predictor of trust. It’s cultivated when people feel their organization supports them. When people feel supported, trust grows.
Anomie is a breakdown in norms, studied during the pandemic (Allgood, 2024). When goals are unclear and change is frequent, it’s hard to maintain or adjust expectations and reliably enforce standards. Change and uncertainty outpace people’s ability to adapt. That leads to confusion, uncertainty, and overwhelm. Left unaddressed, that becomes disengagement. And disengagement erodes trust.
Physicians report having the lowest trust in their own organizations of any health care worker group. This is likely because they sit closest to the anomie drivers and furthest from the decisions. They absorb changes directly, and they often operate semi-autonomously, somewhat removed from day to day leadership. Distance makes it harder for physicians to understand the reasoning behind a decision, and harder for leaders to grasp how that decision impacted the providers implementing it.
Leaders have two levers to reciprocate trust and reduce organizational anomie: behaviors and operational decisions. The two most important behaviors are honest, regular communication and treating people with respect. Trust also depends on decisions and appropriately designed operating models that are adequately flexible. A leader who listens but has no authority to act or no incentive to manage for the long term doesn’t create trust. She’s structurally not able to or not incentivized to. Instead, trust thrives in environments where leaders listen and can then act or delegate on an appropriate time horizon.
“In my first 24 hours on the job, I heard directly from the CEO about the crisis we were in. She gives us straight answers.”
“She sent us the actual message she’d sent to the regulator about our problems.”
This is communication that builds trust.
“It felt like we finally became a cohesive team once we defined the goals in language that made sense to us.”
This is an operational change that builds trust.
The Business Case for Trust
Trust drives clinical and financial outcomes.
Trust makes care safer: Psychological safety, tied to trust, means fewer care-team errors, and patients who trust their clinicians show better treatment adherence (Birkhäuer et al., 2017).
Trust lowers expenses: A departing physician can cost $1–1.3M in lost revenue and recruiting expenses, and take 118 days to replace on average (Merritt Hawkins, 2019; AAPPR, 2025). High-trust organizations outgrow peers by 6.4% in revenue (Accenture, 2022).
Trust is a P&L matter, not just a culture matter. It shows up in retention cost, revenue growth, and safety incidents. It should be reflected on KPIs.
This playbook lays out research-backed principles and best practices for leadership behaviors and operational decisions that build trust. With it, leaders can build, maintain, and extend trust in many scenarios, and make trust a repeatable capability that scales.
Trust Design Principle
Act and behave in ways that reciprocate trust and minimize anomie. Do this in both interpersonal interactions (a two-minute conversation in the hallway) and when making decisions (routine choices and more strategic decisions).
Based on this principle, every decision can be filtered through two questions:
Does this reciprocate trust, yes or no?
Does this minimize anomie or increase it?
Answering those consistently well builds trust.
A manager might look at a decision and think it will have little impact on trust one way or the other. Most of the time, that's not true. The vast majority of decisions affect trust.
Hypothetical Example
A nurse raises an ED supply gap on the night shift to his service chief. He raises it again the next month, then the month after that. Each time, the service chief agrees it’s a problem. Nothing changes.
What’s happening:
Interpersonal: The nurse is heard, but nothing changes. That erodes trust.
Structural: The leader needs to get clear on goals and roles, then act. Either turn the nurse's feedback into a change, or tell him straight why the change can't happen and that they need to find a workaround to the problem.
Three Trust Scenarios
Leaders generally face one of three situations: repairing trust, maintaining trust through a change, or extending trust into a new relationship, like an acquisition or a new teammate. The design principle and filter (does this reciprocate trust? does this minimize anomie?) applies to all three; the tactics differ.
Scenario 1: Restore Trust
Interpersonal
Acknowledge the trust damage directly, without defensiveness. “Trust wobbles” happen. They’re a normal part of life and teamwork.
Understand root causes through structured listening, using tactics like nonviolent communication. Get to the need underneath the feeling. This reveals root causes that an engagement survey often misses, and builds trust through the act of listening itself.
Structural
Once you understand what’s causing the damage, a behavior or an element of the operating model, decide what you can act on and acknowledge what you can’t change. Then prioritize fixes to the most urgent root causes first, rather than trying to fix everything at once.
Clarify and communicate your plan to address the important, non-urgent root causes over time.
Build enduring systems, like a regular cadence of open, listening-based conversations, to sustain trust once it’s rebuilt.
Scenario 2: Keep Trust
Interpersonal
Communicate change long before it starts and repeat your messages. Avoid announcing change when it’s imminent. Explain why the change needs to happen and acknowledge that it may be hard to absorb.
Engage workers and ask for process preferences before rolling out change. Announcing a finished plan undermines engagement (Reynolds & Lewis, 2017).
Extend an olive branch: pair a difficult change with a specific gesture of goodwill or address another need workers have.
Structural
Build in the ability to adjust plans and processes after launch, rather than treating execution as final.
Scenario 3: Build Trust
Interpersonal
Give the newly joined team an early, tangible trust proof point before asking them to extend trust. This could be as simple as visibly acting on the first thing they raise.
Structural
Use systems as bridges. For example, Comprehensive Quality Planning (introduced here) is a goal-setting framework that gives a newly combined organization a single shared goal hierarchy from day one, instead of negotiating a hybrid of what each team had, or asking one team to adopt the other’s.
Why this builds trust: Adopting the acquirer’s system asks the acquired culture to accept priorities it did not set, which fails reciprocity. Merging two existing goal systems erodes trust, because a negotiated hybrid is more likely to create unclear goal conditions that drive anomie. A neutral, quality-centric framework like Comprehensive Quality Planning tracks workforce wellbeing as a co-equal goal alongside regulatory metrics, protecting the priorities of workers at both organizations.
Measuring Trust
Anyone can build a sense for trust. You don’t need a validated scale to intuit how its going. Leading indicators are behavioral (what’s heard, seen, and felt):
Open communication (“I found out from the all-staff email.”)
Owned mistakes (“That was my call.”)
Daily autonomy (“I have authority to do this.”)
Feedback that’s sought and used (“I heard I need to speak more slowly. I’m doing that.”)
Lagging indicators are retention numbers, tracked monthly against national benchmarks: physician annual turnover around 7.3%, nurse annual turnover around 17.6%.
How to Build More Trust Today
Reflect and empower: When do you need to do less leading and more empowering to get better results? Who do you need to empower? What’s stopping you from empowering them and trusting their leadership?
Think trust at every decision: Does this reciprocate trust? Does this minimize anomie or increase it? If a decision will damage trust, decide how to mitigate it.
Learn from your data. Compare retention rates against your own history and benchmarks, then establish a trust hypothesis. Which scenario are you in? What root causes are contributing?
Listen. Spend twenty minutes with a clinical team and use a structured listening approach based on nonviolent communication. What did you learn?
Trust work is hard, and far from frictionless. It’s hard because it takes humility. It requires making mistakes and having uncomfortable conversations. It often also requires change, sometimes more than you’d like. But that’s the daily work that creates trust, like asking for the shampoo. It’s honest, open communication, and a willingness to sit with discomfort instead of letting murky realities lead into anomie.
Appendix: Research at a Glance
Reciprocity and anomie drive trust: feeling supported by your organization builds trust; unclear goals and frequent, unexplained change erode it (Allgood, 2024).
Physicians report the lowest trust of any health care worker group, likely because they sit closest to change and furthest from the decisions that create it (Greene et al., 2025).
What builds trust, ranked: honest, regular communication (78%); being treated well and paid fairly (44%); patient care visibly prioritized (28%) (Greene et al., 2025).
What erodes trust fastest: poor communication, named more than any other reason (60%), along with poor treatment, deprioritized patient care, and a lack of integrity (Greene et al., 2025).
Leaders default to what’s measurable: but 76% of executives say interaction and collaboration, not structure, is the real barrier to execution (Reynolds & Lewis, 2017).
Managers disengage from soliciting input when they lack both the authority to act and a long-term incentive to care, not from ego (Sherf et al., 2019).
Voice measurably reduces turnover: a randomized field experiment found a 20% drop in quitting among workers given a voice channel (Adhvaryu et al., 2019).
Trust and safety are linked: patients who trust their clinicians show better treatment adherence (Birkhäuer et al., 2017); psychological safety, closely related to trust, correlates with fewer care-team errors.
Without a listening culture, concerns go underground: Boeing’s 737 Max communications show staff venting to each other while staying silent with leadership (Edmondson, 2020).
References
Adhvaryu, A., Molina, T., & Nyshadham, A. (2019). Want fewer employees to quit? Listen to them. Harvard Business Review. Reprint H04WY6.
Allgood, A. (2024). Erosion of trust in healthcare leadership: An analysis of anomie and social exchange during the COVID-19 pandemic. All ETDs from UAB. 3840. https://digitalcommons.library.uab.edu/etd-collection/3840
Accenture. (2022). Healthcare Technology Vision 2022. https://www.accenture.com/us-en/insights/health/digital-health-technology-vision
Association for Advancing Physician and Provider Recruitment (AAPPR). (2025). Physician recruitment teams face consistent demand and lengthy search times, according to AAPPR report. https://aappr.org/2025/09/10/physician-recruitment-teams-face-consistent-demand-and-lengthy-search-times-according-to-aappr-report/
Birkhäuer, J., Gaab, J., Kossowsky, J., et al. (2017). Trust in the health care professional and health outcome: A meta-analysis. PLoS ONE, 12(2), e0170988. https://doi.org/10.1371/journal.pone.0170988
Edmondson, A. C. (2020). When employees are open with each other, but not management. Harvard Business Review. Reprint H05D44.
Greene, et al. (2025). Trust in healthcare leadership. Joint Commission Journal on Quality and Patient Safety. https://pubmed.ncbi.nlm.nih.gov/39419728/
Merritt Hawkins. (2019). Physician Inpatient/Outpatient Revenue Survey.
NSI Nursing Solutions. (2026). National health care retention & RN staffing report. https://www.nsinursingsolutions.com/documents/library/nsi_national_health_care_retention_report.pdf
Reynolds, A., & Lewis, D. (2017). Closing the strategy-execution gap means focusing on what employees think, not what they do. Harvard Business Review. Reprint H03WB1.
Sherf, E. N., Tangirala, S., & Venkataramani, V. (2019). Research: Why managers ignore employees’ ideas. Harvard Business Review.
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