The Trust Factor – Key to Implementation Success?

For the next few seconds, I want you to think about your last implementation project. Maybe you were researching or evaluating implementation in a setting or perhaps supporting a manager or practitioner to get something implemented. Maybe you were working with teachers, doctors, nurses

Now, as you worked with these stakeholders how far did you measure trust or psychological safety amongst them? If you were helping them implement how many specific actions did you take to build trust among them? Was it more than five? Less than three? Or maybe none at all?

If you're like most implementation researchers or implementer, you probably weren't paying a lot of attention to measuring trust as a mechanism or outcome, and you probably didn't engage in much trust building activities. This can be quite surprising to some people. Detailed, compliant study protocol? check! Ethics? Check. Research team ready, check! Engaged with sites? Yes more or less.. Built trust? Hmmm, not really...

It’s the same when implementing, we may turn up to meetings on time, project manage accordingly, but again did we build trust?

Keep reading to discover why trust can often be the missing link in implementation and how a few trust-building exercises could completely transform your approach and your outcomes.

The Hidden Force Shaping Implementation Success

Imagine two nearly identical healthcare organizations implementing the same evidence-based practice. Both have similar resources, comparable staff, and equivalent training programs. Yet, six months into the project, one organization is thriving, with high adoption rates and positive feedback from staff. The other is struggling, facing resistance and poor outcomes.

While factors like resource constraints or leadership issues may contribute, there's a critical element often overlooked in implementation science: and that’s trust.

Trust is thought to make a big difference to implementation and performance outcomes.

While traditional approaches to implementation have focused heavily on evidence-based strategies and top-down training, emerging research suggests that the relational aspects of implementation, particularly trust, play a pivotal role in determining success.

Metz et al. (2022) emphasize that while established implementation frameworks tend to prioritize technical elements, the importance of relationships and trust in achieving successful outcomes cannot be overstated. This shift in perspective challenges us to reconsider how we approach implementation projects, what factors we prioritize and what we spend time researching.

The influence of trust on stakeholder engagement and commitment is profound. When team members and stakeholders feel a sense of trust, they are more likely to fully engage with the implementation process, voice concerns, and work collaboratively towards shared goals. This increased engagement can lead to more effective problem-solving and a greater sense of ownership over the implemented practices.

 How can we understand this more?

Relational cohesion theory provides valuable insights into why trust is so crucial. This theory suggests that trust acts as a unifying force in social situations, fostering higher levels of commitment and collectively oriented behavior among implementation teams. In practical terms, this means that teams with strong trust bonds are more likely to persist in the face of challenges and work together to overcome obstacles.

Relational cultural theory also provides us with some linkage to why trust might lead to better outcomes. It speaks to how our ability to understand the perspective of others (i.e., empathy) increases a sense of mutual interdependence and leads to positive affective response, which in turn builds more trust.

By fostering collaboration, mutual empowerment, and psychological safety trust builds and creates a foundation for open communication and inclusive decision-making, aligning stakeholders toward shared goals while ensuring ethical and culturally sensitive practices.

Prioritizing relational dynamics ensures implementation processes are adaptive, inclusive, and effective.

Don't just take my word for it...

A comprehensive meta-analysis by Balliet and Van Lange (2013) examined 212 effect sizes to explore the relationship between trust and cooperation in social dilemmas—situations where individual interests may conflict with collective well-being. The study found a positive correlation between trust and cooperative behavior, with higher levels of trust associated with increased cooperation.

Notably, this relationship was more pronounced in scenarios involving greater conflicts of interest. A comprehensive meta-analysis by De Jong, Dirks, and Gillespie (2016) examined 112 independent studies involving 7,763 teams to assess the relationship between intrateam trust and team performance. 

These findings underscore the critical role of trust in fostering cooperative behavior, particularly in contexts where personal and collective interests are at odds for example in a health system where you have thousands of stakeholders with different needs, goals, problems, desires etc...

As we delve deeper into the role of trust in implementation science, it becomes clear that this often-overlooked factor acts as a hidden force shaping project success. By recognizing and actively cultivating trust within implementation teams and among stakeholders, we can potentially transform the outcomes of our efforts.

In the next section, we'll explore specific strategies for building and maintaining trust in implementation settings, providing practical tools to enhance your approach and improve your outcomes.

The Anatomy of Trust in Implementation Teams

Like me, you may have experienced working with two teams in different places trying to implement the same innovation. Team A exudes confidence, openly sharing ideas and concerns without fear. Team B, however, operates in a climate of caution, with members hesitant to speak up or take risks. This stark contrast often leads to very different outcomes.

One is able to ride the rollercoaster of contextual challenges better than the other. The more open team actually managing to sustain the innovation over time. I've seen multiple teams under the same system working together to create and implement something only to see a lack of trust destroy the effort from the inside out.

To truly understand trust in implementation teams, we need to dissect its components. Trust isn't a monolithic concept; it's a complex interplay of cognitive and affective elements. Cognitive trust relates to our belief in a team member's reliability and competence, while affective trust involves emotional connections and genuine care for others' well-being. Both types play crucial roles in fostering effective implementation environments.

However, measuring and cultivating trust presents significant challenges. The lack of consistent terminology and definitions for relational aspects of implementation complicates our ability to quantify trust. Existing tools like the Interpersonal Communication Assessment Scale and the Trusting Relationship Questionnaire offer some insights, but they may not capture the full spectrum of trust dynamics in implementation contexts.

Psychological safety, a concept closely related to trust, adds another layer of complexity. It not trust in itself, as that tends to be between individuals and you get things like perceived trust, psychological safety is more of a group dynamic and a social condition where team members feel included and safe to contribute without fear of marginalization. So for instance if a trainee nurse spots an error during a consultants ward round will she say something or not? This can get potentially quite serious in healthcare settings because it can mean life or death.

But more generally psychological safety is essential for effective implementation. Yet, measuring this intangible quality remains a challenge for researchers and practitioners alike. I’ll make a video on this but if you want to know more about it check out Professor Amy Edmondson’s book ' The Fearless Organization' and also her Psychological Safety Scale.

Despite these obstacles, understanding how to cultivate trust is crucial for implementation success. Research suggests that addressing power differentials through humility and co-creation can significantly enhance trust-building efforts. Implementation support practitioners (which we will cover in a future video_ play a vital role in this process, bridging the gap between research and practice by emphasizing relational strategies.

So, how can implementation scientists effectively measure and operationalize trust? While we don't have all the answers yet, integrating user-centered design approaches and focusing on both cognitive and affective trust components offers promising avenues. By developing more nuanced measurement tools and prioritizing trust-building activities, perhaps we can create implementation environments that foster innovation, collaboration, and ultimately, better outcomes.

As we move forward, it's clear that trust isn't just a nice-to-have in implementation science—it's a fundamental building block of success. In our next section, we'll explore practical strategies for building and maintaining trust, providing you with actionable tools to enhance your approach and improve your outcomes.

 Blueprints for Building Trust: Strategies That Work

So how do you cultivate something as intangible as trust? We're about to dive into a theoretical model put together by Professor Allison Metz and her team that theorises how relationships and trust can support implementation outcomes.

When it comes to fostering trust in implementation settings, Metz's model categorizes strategies into two main types: relational and technical. Relational strategies focus on interpersonal connections and emotional bonds, while technical strategies emphasize competence and reliability. Both are theorised here as being essential for creating trusting relationships.

Metz, Allison, et al. "Building trusting relationships to support implementation: a proposed theoretical model." Frontiers in health services 2 (2022): 894599.

If you look at some of the specific relational strategies there are five key approaches: showing vulnerability, approaching interactions with authenticity, engaging in co-learning, participating in empathy-driven exchanges, and using bi-directional communication. These strategies move beyond superficial team-building exercises to create genuine connections among stakeholders.

On the technical side, effective trust-building strategies include supporting frequent interactions, demonstrating responsiveness to requests, showcasing expertise, and planning for quick wins. These approaches help establish credibility and reliability, which are crucial components of cognitive trust.

A practical example of these strategies in action comes from another paper published by Allison. Is implementation research out of step with implementation practice? In this study experienced Implementation Support Practitioners (ISPs) reported a significant shift in their approach to implementation over time, moving away from didactic training methods towards more participatory models that emphasize trust-building and co-creation.

One specific technique mentioned is the 'one-to-one' exercise, where team members engage in active listening to identify shared values, fostering connections and trust among diverse stakeholders. I've witnessed Allison carrying this out, and have used it with colleagues in my own work. The effect can be palpable.

It's important to note that it is not always easy to show vulnerability or be authentic within teams but even just five minutes at the start of each meeting can really help build a significant amount of trust over time. It might take months or even a year or two but it can help us achieve our goals.

As implementation researchers we need to research this stuff more. We need to test out theoretical models such as Allison's. We need to learn from ISPs that do this stuff regularly and get it back into the literature.

 Trust as a Catalyst: Transforming Implementation Outcomes

As we've explored the importance of trust in implementation science, a provocative question emerges: Could there be a point where too much trust becomes detrimental to implementation outcomes? This idea challenges us to consider trust not just as a universally positive force, but as a complex moderator of implementation strategies.

It undoubtedly plays a crucial role in shaping implementation outcomes, but it's essential to recognize that it doesn't operate in isolation. Other factors like resource availability, organizational culture, and leadership support also significantly influence the success of implementation efforts. Some experts argue that an overemphasis on trust-building could potentially divert attention and resources from these equally important elements.

However, the evidence supporting trust's positive impact on implementation outcomes is really compelling. In Allison's study examining the role of implementation support practitioners, participants consistently emphasized that high-quality relationships among stakeholders were critical for achieving successful implementation results. These trusting relationships fostered resilience and commitment to ongoing implementation efforts, particularly in the face of challenges.

Trust also facilitates smoother knowledge transfer and skill development,

Longitudinal studies have highlighted the vital role of trust in sustaining implemented changes over time. The Dynamic Sustainability Framework emphasizes the need for ongoing relational connections among team members, suggesting that trust is a key component in maintaining implementation efforts long-term. This underscores the importance of viewing trust-building not as a one-time event, but as an ongoing process throughout the implementation journey.

Looking ahead, the future of implementation science may well hinge on our ability to effectively integrate trust-building practices into our strategies. As we conclude, let's consider: How might our approach to implementation change if we prioritized trust-building as much as we do evidence-based interventions?

 Conclusion

As I wrap this up, it's clear that trust may well form the bedrock of effective and equitable implementation. The relational aspects of our work, often overlooked, are critical to bridging the gap between research and practice. Allison Metz's powerful insight resonates: "relationships are the foundation of this work; you need to build trust, and here's how you build trust: you demonstrate empathy, vulnerability, and humility."

So let’s prioritize trust-building in our implementation efforts lets start focusing more of our research into this area. Let’s test and develop tools that facilitate trust, allow for engaging in continuous reflection on relational dynamics within our teams,

I’ll just leave you with a final thought: How might our field evolve if we treated trust as a primary outcome, rather than just a facilitator of implementation success?