Trust in the aged care system in Australia: Some

conceptual considerations
Andrew Simon Gilbert
a.gilbert@nari.edu.au
National Ageing Research Institute

Introduction
In a recent survey by independent researchers in Australia, only 18% of respondents said
they had trust in formal aged care services (Faster Horses, 2018). This is a concerning
statistic because, as I will argue in this article, aged care is an example of a social institution
that heavily depends on relations of trust to function successfully. A deficit of trust in aged
care services has significant implications for the uptake of services, the well-being of users
and their families, the morale of the workforce, and the operations of service providers,
regulators, etc. Decades of sociological research has shown trust to be a complex and multi-
faceted phenomenon (Bachmann & Zaheer, 2006), and while these survey results are
certainly suggestive, the ways and degrees in which people (dis)trust formal aged care
cannot be captured in a single statistical variable. The sociology of trust is a well-established
and theoretical sophisticated field, but it has yet to be applied to contemporary issues
around formal aged care systems in a detailed way.
The above mentioned survey was published in the context Royal Commission into the aged
care industry, initiated in October 2018 by the Australia Federal Government. The Royal
Commission was launched to pre-empt an investigative report by the ABC television
program Four Corners which claimed that the Australian aged care industry was “in crisis”.
The report drew on crowd-sourced stories from members of the Australian public,
documenting some very disturbing incidents of neglect and abuse in residential aged care
facilities, dysfunction in the regulation and quality assurance of the aged care industry, and
“every day stories of neglect and inattention, poor quality food, lack of personal care,
boredom and heart-breaking loneliness” as typical of much of the industry (Connolly, 2018).
The Royal Commission itself has called for further stories from the public, through hearings
and submissions, and these have prompted more media reports of incidents of abuse,
neglect, mismanagement and systemic failure.
Media scandals have a deleterious impact on the public’s trust in the affected institutions
(Alaszewski, 2003; Gille, Smith, & Mays, 2017; Gilson, 2003). Moreover, the current Royal
Commission is the latest in a long line of government and independent probes into
Australia’s aged care industry and its failings, which have been prompted by previous
scandals in the media (Productivity Commission, 2011)(Background paper). Over two
decades of negative coverage and political reaction have shaped Australia’s aged care
system into what it is today, such as the Quality Commission, which were subject to critique
in the Four Corners documentary. Reaction to scandals is often to increase regulation and
surveillance, the assumption that front line workers are culpable and if they are managed
better by the authorities, then consumers will trust the system more. But Brown suggests
the opposite is the case, as management incursions into day to day practices colonizes the
spaces of interaction between workers and consumers, eroding their ability to cultivate
interpersonal trust relations. Given all this, there is an urgent need to apply the conceptual
tools of trust research to the formal aged care sector.
The aim of this paper is to tease out the ways in which trust research can be applied to
contemporary issues facing the aged care sector. There are a great many empirical studies
which discuss the role of trust in aged care, and I will draw on some of them here. However,
the purpose of this paper is not empirical but rather conceptual: to tease out a preliminary
sketch of theoretical matters in the hope that it inspires further research.

Conceptualizing trust
Trust is

Trust and care

People typically utilize formal aged care when they require support to perform routine
physical, emotional or social actions that they would otherwise be expected to perform
autonomously, and their significant others are unable or unwilling to provide that support
informally. Svendsen, Navne, Gjødsbøl, and Dam (2018) define this relation as “substitution”

formal aged care is an example of a social institution that depends heavily on relations of
trust to function successfully.
important because it is the way we navigate social institutions that are more complex and
multifaceted than we can know
important because it is the way we navigate social institutions that are more complex and
multifaceted than we can know.

Trust in aged care system embedded in our culture, a system that is relatively recent, that
people don’t consider much because they don’t want to think about death, poor working
conditions, ageism, bad regulation, captive consumers.
Need for sociology of trust. Conceptual considerations which expand trust out of a single
variable and explores how it occurs on a micro- and macro-sociological level.

On September 2018 the Australian Prime Minister Scott Morrison announced a Royal
Commission to examine issues of quality and safety in aged care. The move pre-empted the
airing of a two-part investigation by Four Corners, a current affairs television programme on
Australia’s public broadcaster the ABC, which documented crowdsourced stories of neglect,
abuse and systemic failure in Australia’s aged care sector. Some of the most impactful
footage was of disturbing scenes of verbal and physical abuse and neglect of aged care
residents by staff, obtained after residents’ family members had installed hidden cameras in
the facility. Footage obtained by hidden cameras has previously led to criminal convictions
against aged care workers in Australia (Crouch, Novak, Gailberger, & Robertson, 2016), and
the
Cameras suggest a lack of trust between families and care staff/organizations/system. Their
use will further undermine that trust (Trigger & Gregory, 2018).
Aged care, like all forms of social care, depends on trust. When people
Faster Horses data. Does not say very much – there is a need for a more fine-grained
analysis of trust in aged care services. Crisis of trust?
There exists a growing theoretical literature on the concept of trust within the social
sciences, yet this concept has yet to be applied to the aged care system in a theoretically
informed way. The purpose of this article is therefore to introduce this theoretical literature
within the context of considering the aged care system.
Division between interpersonal, organizational and systemic levels is theoretically
constructed to analysis, and should not understood as referring to three distinct and
separate “worlds”. This point is important to emphasise because, as we will see, the three
forms of trust discussed here are intertwined and interdependent.
What is trust?
Utilizing aged care services, whether community or residential, always involves some
uncertainty about the quality of appropriacy of the service for one’s needs, as well as some
uncertainty about the people and organizations providing it. It is not possible to have
comprehensive knowledge about the actions and relations one commits oneself to ahead of
time, just as it is not possible to foresee everything that that the future will hold. Trust is our
way of managing this uncertainty in order to avoid it becoming incapacitating.
Survey research of older people has reported a positive relationship between higher levels
of self-reported trust in people and institutions and higher indicators of well-being and life
satisfaction (Piumatti, Magistro, Zecca, & Esliger, 2018). This suggests that improving and
sustaining interpersonal, organizational and systemic dimensions of trust in relation to aged
care services should be an important quality consideration.
Pioneering work by Luhmann in the 1970s, which is still highly influential in the study of
trust.

Interpersonal trust

Trust is built when residents feel that care workers are familiar with their personal needs,
habits and preferences, and have the capacity to cater for them individually (Lung & Liu,
2016). Verbal expressions of concern in the residents’ life, knowing their name, family
members, their life history. These are interpreted by residents as an effort to establish an
interpersonal relationship which goes beyond a simple task-based orientation to care (Lung
& Liu, 2016). “Mutual concern” cultivated between residents and staff. Describe Luhmann’s
theory of trust in this context and supererogatory performances. Goes beyond doing you
“duty” and extends to a interpersonal relationship. When people have trusting
relationships, feel more open to expressing themselves and their emotions, supporting the
provision of emotional aspects of care (Lung & Liu, 2016).

When family members report trusting the nursing staff, they are more likely to see aged
care staff as responsive the person’s individual needs and saw less of a need for formally
defined care goals (Rosemond, Hanson, & Zimmerman, 2017). More receptive to input from
care staff and see care goals as produced by ongoing interaction between staff and person
in care, which shift over time. Conversely, when there was a lack of trust between family
members and care staff, the former were more critical of care, concerned that defined care
goals were not being adhered to, and staff not receptive to discussions with family
(Rosemond et al., 2017). Decline in interpersonal trust means people place more trust in
organizational or institutional procedures.
Staff morale negatively impacted by family members and residents verbalising distrust in
them (Majerovitz, Mollott, & Rudder, 2009). This occurs when family members assume the
staff do not have the residents’ best interests as a priority, do not have an investment in
minimizing discomfort and maximising quality of life, and family member needs to be there
to check on them. Lack of time? Lack of processes which allow personalized care to be
performed. Positive communication and negative communication: the former expresses
trust that the worker prioritizes residents’ best interests, has a personal commitment to
ensuring quality of life, despite other constraints. Latter assumes that staff are not
concerned with QoL, are there for the money, don’t care, see family as an annoyance.

Lower trust when not involved in decision to move.

Mystifying conceptualizations of trust. Jakobsen, Sellevold Gerd, Egede-Nissen, and Sørlie

(2019) argue that trust is a “life manifestation” that “cannot be created” but rather emerges
spontaneously when other people meet our expectations. On the contrary, trust is worked
for and managed through deployment of symbols - facework. Interpersonal trust is gained
by exceeding professional expectations. The relationship between expectations and trust is
complicated. For example, British people in Spain who trust the Spanish medical system
because the staff are warm and caring, even when they encountered medical errors.

“Distrust” happens when expectations are not met – on the contrary, distrust is an
expectation.

Nurses see gaining trust from residents as more important to providing good quality care
than residents do (Tuckett, Hughes, Schluter, & Turner, 2009). Residents expected staff to
be attentive to their needs, but staff thought this was better facilitated when they had
interpersonal trust with residents and they disclosed their problems to them. Tuckett at al
suggest that residents have a realistic perspective and recognise that interpersonal trust is
constrained by organizational limitations, such as lack of time.

Tension between facework and system trust: Brown describes how top-down managerial
processes intended towards establishing system trust erode the spaces and scope for
facework between doctors and patients (Brown 2008). Tension between different notions of
time: process time and clock time (Eyers 2007). Process time is the time it takes to perform
a task in a satisfactory way, while system time is the time allocated to completing the task.
Establishing facework puts demands on process time, because the performance of care
gives rise to unpredictable events – talk, unforeseen difficulties, etc. – and it is being
responsive to the unpredictable that serves as the basis for facework. Clock time is
institutionalised so that people can expect when things will happen, in what order, etc. The

Organizational trust
Facework and procedural. The presence of a rating on the quality commission website is
part of the facework of organizations, and when this is seen to not reflect actual practices,
the system is distrusted.
Organization needs to acknowledge that care is not simply a medical task, but that the
facility is the residents’ home (McCormack, Tillock, & Walmsley, 2017). Allow staff, residents
and families the scope to develop interpersonal relationships. Different kind of trust to
medical care, which is about treating or living with an illness and therefore has a less
emotional mindset (Mol). In residential care, chit-chat and other seemingly superfluous
communication is important to building rapport, and establishing interpersonal familiarity.
Facework is based on building a “mutual concern” between residents, staff and families
(Lung & Liu, 2016). But what makes staff not do this? Lack of time. Over-regulation. Poor
morale.

Facework is both external and internal.

Externally – management of brand image, disclosure of information, self-presentation, etc.
Advertising, word of mouth, internet presence (website, social media, ratings on Google
reviews, staff recruitment advertising, etc). Quality commission has become an involved
with facework by putting up a rating on website – Four Corners report as well as testimonies
to Royal Commission suggest that this is untrustworthy -cases of neglect do not result in
change in rating. Effects people’s decisions about where to enter case – effects decisions
about possible staff.
Internally – facework occurs between residents and the organisation, family members and
the organisation, staff and the organisation.
Procedural – lack of trust in procedures reflects dissatisfaction with services. Too rigid and
concerned with organisational priorities over the care of residents. Effects staff’s morale,
likelihood of reporting incidents, commitment to the work.
One of Luhmann’s most important insights concerned the temporal aspect of complexity.
Routines of care home may not seem, on the surface, very complex. Especially considered
next to expert knowledge such as biomedicine. Yet when taken together the allocation of
time to different tasks within social care constitutes a complex organization. Family
members and residents do not need comprehensive knowledge of the distribution of time
across the organization, and this only becomes a problem when it is seen to interfere with
their interests.
Lack of staff trust in the organization can produce an every man for himself scenario, of
avoiding risky situations and allocating blame to others.
Channels and “forced choice” – relate to Nusem
Forced choices related to organizations and facilities takes place against a backdrop of
system trust. In order for choice of provider to be forced, there must be some level of trust
in the system itself.

Residential aged care in Australia has traditionally been provided by large, non-profit, organizations,
which are often connected to religious entities or charities, and provide a continuum of care across
different streams. These organizations use their size and their established philanthropic reputations
to promote trustworthiness to users. However, Nusem, Wrigley, and Matthews (2017) have argued
that these traditional providers present barriers to innovation in the aged care industry. They are
subject to high regulation and bureaucracy, and this typically manifests in task-focused and poorly
personalised care. This is compounded by a lack of competition between these traditional providers,
as their users are a "captive audience" directed to their services via formal channels such as the My
Aged Care system, based on the proximity of their home to the aged care facility (Nusem et al.,
2017, p. 401). This constitutes what Brown and Meyer (2015) define as a “forced option”, where
people place their trust in services reluctantly, in the absence of any other apparent possibility.
When choices are forced, trust between the user and the organization and staff is likely to be
volatile, and users are more likely to feel dissatisfied with their care, more likely to verbalize their
distrust of care workers and the organization, and may engage in (often subtle) forms of resistance
as an expression of their agency.

It represents a modicum of institutional trust that utilizing residential aged care is better than doing
nothing at all. A complete breakdown of institutional trust is apparent when people say they would
“rather be dead” than enter residential aged care services (The Guardian, 2019).

as a form of trust which is

rather than competing commercially by offering services.

System trust
Systems are
System trust is a both a precondition of and reproduced through interpersonal and
organizational trust-building.
History of aged care – the “myth” of a decline in family solidarity (life expectancies have
risen). Large scale aged care is a fairly recent institution.
Lack of trust would mean people remain at home, avoid entering care. May even avoid
things like doctors or social workers (ACAS) out of fear that they will be involuntarily put
into care. Lack of trust in the system can have a larger impact.
Routine expectations contribute to trust. Allow someone to hold onto probable
expectations about the future based on consistent experiences in the past.
People in aged care homes report feeling more secure, because they do not see themselves
as exposed to as many safety risks.
Studies on technology monitoring older people’s safety in their homes – i.e. to reduce the
needs for care – suggests they require trust that family or friends will monitor them (Lie,
Lindsay, & Brittain, 2016).
System trust relates to lack of faith that incidents of abuse are dealt with in an effective
manner. Exposure of incidents by the media effect trust-building at the interpersonal,
organizational, and systemic level.
CALD people: Montayre and colleagues (2018) found that among older Filipinos in NZ
institutional trust was relatively high. However, some respondents lacked trust in NZ
residential aged care. Result of media reports documenting incidents of neglect and abuse,
had negative preconceptions about residential aged care services, doesn’t serve best
interest. Lack of trust motivating decision to migrate back to home country, rather than live
in residential care in NZ. Lack of awareness of culturally appropriate services, lack of
exposure to aged care facilities. Lack of institutional trust in residential aged care points in a
particular context to a motive for migration in later life. Care is mediated through culturally
appropriate language and actions, this can effect trust formation (Gilbert, et. Al 2019).
Interpersonal, organizational and institutional level.

Quality commission provides a way of reviewing aged care providers with a rating system.
These rating have come under criticism when people report that incidents of neglect and
abuse have failed to result in a downgrading of ratings of implicated service providers.
Consumer trust in online comparison websites may already be low (Konetzka & Perraillon,
2016).
Ethnic minorities. Fear of “diminishment” if utilizing aged care services when a family
member has dementia. Being patronized, facing discrimination, losing agency. Often they
recognise that they need help, but avoid formal services because they fear that there will be
harmful implications (Baghirathan et al., 2018).

Public trust

Prospects for further research

Social inequality
Cross cultural comparisons
Forced options
Increased surveillance promoted as a way of increasing trust in aged care services by
monitoring for abuse and poor quality of care. Needs to be treated with caution as
monitoring can be considered a violation of privacy by older people, and contribute to
distrust of the system (Lie et al., 2016).
Self-reporting measures of trust “do you trust?” are limited because as I’ve hoped to sure
trusting is as much an action as a disposition. This question can be interpreted as calling
upon a moral judgement of the trustee, but trust is not necessarily moral and can be related
to knowledge, access, time, appropriacy. Also people’s perceptions about trust in an
interview or survey situation are not necessarily representative of how they practice trust.
Also, trust is variegated into different theoretical dimensions, so it becomes necessary to
observe how trust is practiced, and what underlies the processes of trust formation and
maintenance. “Do you trust?” cannot do this.
Conclusions

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