A measure of and predictors for veterinarian trust developed with veterinary students in a simulated companion animal practice

Abstract

Objective:
To gain a better understanding of the role of interpersonal trust in veterinarian-client interactions during routine health-care visits, develop a measure of trust uniquely suited to the context of veterinary medicine, and interpret the actions, beliefs, and perceptions that capture client trust toward veterinarians.

Design:
Correlational study.

Sample:
103 veterinary students and 19 standardized clients with pets from a college of veterinary medicine at a large public Midwestern university.

Procedures:
measure of trust specific to veterinarian-client interactions was constructed on the basis of preexisting conceptualizations of the construct and administered to veterinary students and standardized clients following interactions in 2 medical scenarios in a high-fidelity simulated animal health clinic. Exploratory and confirmatory factor analytic techniques were used to validate the measure of trust, and hierarchic linear modeling was used to explore indicators of standardized client trust perceptions in one of the scenarios.

Results:
Factor analysis revealed that the measure captured 2 perceptions indicative of trust in veterinary contexts: professionalism and technical candor. Students who had behaviors reflecting these factors as well as those who were perceived as more technically competent were seen as more trustworthy by standardized clients.

Conclusions and clinical relevance:
The development of trustworthy relationships between clients and veterinarians is important to the continued growth and success of the profession. By identifying characteristics of veterinarian trustworthiness and developing related measurement tools, proactive approaches to monitoring veterinarian-client relations can be implemented and incorporated into veterinary training and practice programs to identify areas for improvement.

Full text

322 Vet Med Today: Special Report JAVMA, Vol 242, No. 3, February 1, 2013
Both intuitive and systematic observers of social in-
teraction and exchange have typically placed trust
among the most fundamental qualities of human rela-
tionships.1 Whether in the context of spousal partner-
ships, dealings with coworkers and employers, simple
transactions among strangers, or even interfacing with
inanimate machinery, developing, producing, and in-
terpreting perceptions of trust are an important and
daily part of the human social condition.2–4 However,
honing and maintaining a trusting relationship are no
easy feats in the face of current societal trends. Socio-
logical research reveals that Americans’ overall level of
trust in other individuals and larger institutions has
been steadily decreasing since the 1980s.5 Speculation
as to why this decrease has been observed varies widely;
for example, greater accessibility to negative media cov-
A measure of and predictors for veterinarian
trust developed with veterinary students
in a simulated companion animal practice
From the Department of Psychology, College of Social Science
(Grand, Ilgen), and the Departments of Large Animal Clinical Sci-
ences (Lloyd), Small Animal Clinical Sciences (Abood), and Patho-
biology and Diagnostic Investigation (Sonea), College of Veterinary
Medicine, Michigan State University, East Lansing, MI 48824.
Address correspondence to Dr. Grand (grandjam12@gmail.com).
erage and electronic entertainment, increased pressures
placed on time and money, exposure to implausible
marketing and advertisement campaigns, and changes
in corporate attitudes toward employment and down-
sizing have all been posited as potential explanations
for diminishing levels of trust.6,7
Regardless of its drivers, such developments have
potentially troubling implications for the veterinary
profession. For example, the declining trend in trust
parallels a similar decrease in the frequency of client
visits to veterinary care providers over the past 25 years
that has become a cause of widespread concern in the
field.8 Although evidence of a causal relation between
these 2 patterns has not been established, there is little
doubt that trust between veterinary practitioners and
their clients can play a major role in clients’ attitudes
Special Report
James A. Grand, PhD; James W. Lloyd, DVM, PhD; Daniel R. Ilgen, PhD;
Sarah Abood, DVM, PhD; Ioana M. Sonea, DMV, PhD
Objective—To gain a better understanding of the role of interpersonal trust in veterinarian-
client interactions during routine health-care visits, develop a measure of trust uniquely
suited to the context of veterinary medicine, and interpret the actions, beliefs, and percep-
tions that capture client trust toward veterinarians.
Design—Correlational study.
Sample—103 veterinar y students and 19 standardized clients with pets from a college of
veterinary medicine at a large public Midwestern university.
Procedures—A measure of trust specific to veterinarian-client interactions was construct-
ed on the basis of preexisting conceptualizations of the construct and administered to
veterinary students and standardized clients following interactions in 2 medical scenarios
in a high-fidelity simulated animal health clinic. Exploratory and confirmatory factor analytic
techniques were used to validate the measure of trust, and hierarchic linear modeling was
used to explore indicators of standardized client trust perceptions in one of the scenarios.
Results—Factor analysis revealed that the measure captured 2 perceptions indicative of
trust in veterinary contexts: professionalism and technical candor. Students who had be-
haviors reflecting these factors as well as those who were perceived as more technically
competent were seen as more trustworthy by standardized clients.
Conclusions and Clinical Relevance—The development of trustworthy relationships be-
tween clients and veterinarians is important to the continued growth and success of the
profession. By identifying characteristics of veterinarian trustworthiness and developing re-
lated measurement tools, proactive approaches to monitoring veterinarian-client relations
can be implemented and incorporated into veterinary training and practice programs to
identify areas for improvement. (J Am Vet Med Assoc 2013;242:322–334)
ABBREVIATIONS
HLM Hierarchic linear modeling
ICC Intraclass correlation coefficient

JAVMA, Vol 242, No. 3, February 1, 2013 Vet Med Today: Special Report 323
toward and perceptions of veterinarians and the vet-
erinary profession, which can considerably influence
the likelihood of future visits. As noted in the human
health-care and service industry, the importance of trust
between patient and practitioner is a central component
in creating and sustaining effective medical relation-
ships.9–11 Greater trust in physicians has been shown
to be meaningfully related to reductions in patient
turnover, higher willingness to recommend a physician
to others, fewer disagreements over treatment sugges-
tions, and greater perceptions regarding effectiveness
of care delivery.9 An additional benefit of the positive
trust relationship for both veterinarians and physicians
is higher compliance rates among clients and patients
to recommended treatment programs and regimens.10–13
For example, Jansen et al14 describe how trust plays a
vital role in dairy farmers’ motivations toward seeking
out and complying with veterinarian treatment recom-
mendations. On the basis of qualitative interviews and
thematic analyses, Jansen et al14 report that clients and
their behaviors and attitudes toward a veterinarian’s
treatment plans can be classified according to whether
those clients were generally open to external informa-
tion sources (ie, recommendations from veterinarians)
and whether they trusted the information provided by
those sources to be accurate and intent on improving
animal health.
Perhaps most indicative of the importance of trust
to the veterinary profession are recent research and
state of the industry reports released by the American
Animal Hospital Association, which emphasize the
importance of developing positive practitioner-client
communication channels and increasing compliance as
critical areas through which veterinarians can improve
their level of care provided and grow revenue,15,16 both
of which are intimately related to the trust-building ef-
forts engaged in by veterinary professionals.11–14 Despite
its noted importance, little is known about the percep-
tions of clients or the behavioral actions of veterinar-
ians that contribute to the development of trust in the
context of veterinary medicine. One cannot examine
this issue without first considering precisely what is
meant by trust and how it is perceived by and demon-
strated to others.
Objectively defining trust and the manner by which
it is observed, is produced, and exerts influence on
meaningful outcomes is a complicated endeavor. For
example, trust perceptions are often idiosyncratic and
situationally bound such that one’s level of trust toward
a person under one set of circumstances (eg, an inexpe-
rienced veterinarian conducting a routine physical ex-
amination on a household pet) may differ dramatically
from perceptions of trust toward that individual under
different conditions (eg, an inexperienced veterinar-
ian performing a complex surgical procedure).17 Given
these complexities, considerable effort has gone toward
identifying fundamental components of trust percep-
tions that are applicable across persons and situations.
Trust can most generally be defined as a “psycho-
logical state comprising the intention to accept vulner-
ability based upon positive expectations of the intentions
or behaviors of another.”18 There is general agreement
that all perceptions of trust are accompanied by 2 basic
psychological experiences of the trustor (ie, the indi-
vidual attempting to trust another person)—confident
expectations of positive outcomes and a willingness to
be vulnerable to the actions and behaviors of the trustee
(ie, the individual being trusted).17 These essential ele-
ments are relayed through both observable behaviors
by the trustee and broader, subjective evaluations of a
person’s trustworthiness by the trustor. In the case of
the former, trustworthy behaviors are any actions that
generally attenuate the risk and uncertainty that the
trustor may hold about the likelihood of their obtain-
ing a desired outcome.19,20 These specific actions will
vary depending upon the situational circumstances of
the interaction and purpose of the relationship; for ex-
ample, trust in a veterinarian may improve following
observations of a well-performed medical diagnosis,
procedure, or treatment of an animal.
With respect to the more subjective evaluations
of trustworthiness, previous research has identified 3
psychological perceptions related to a person’s interpre-
tation of trustworthiness.17 The first facet, perceptions
of ability, is related to the observation of competent
performance and reflects the trustor’s evaluation of a
trustee’s domain-specific knowledge and skills. Such in-
formation conveys that the trustee is capable of helping
the trustor obtain his or her desired goals and outcomes
and can be related even if one has never seen the trustee
perform (eg, education and awards are indirect indica-
tors of performance capability). The remaining 2 facets
do not concern the trustee’s actual or perceived compe-
tence. The extent to which a trustee is believed to want
to do good to or for the trustor aside from any profit
motives is also an important consideration. Broadly
characterized as benevolence, this perception is syn-
onymous with concepts such as caring, supportiveness,
openness, loyalty, and selflessness. Lastly, integrity in-
volves whether the trustee is perceived as adhering to
moral and ethical principles that the trustor finds ac-
ceptable and includes notions such as fairness, prom-
ise fulfillment, justice, and consistency. Meta-analytic
evidence combining the results of > 100 studies has re-
vealed that each of these 3 facets (ability, benevolence,
and integrity) uniquely contribute to an individual’s
perceptions of trust toward another.21
Despite empirical support and the availability of
generalized measures for this 3-facet model of trust
indicators, there are several pragmatic and conceptual
reasons for why investigating trust specific to veterinar-
ian-client interactions is warranted. For example, the
meta-analytic validation of the 3-facet model was based
almost entirely on trust relationships in the work-
place between an employee and his or her coworkers
or supervisor in the context of everyday job tasks ag-
gregated across multiple interactions.22 However, the
development of veterinarian-client trust likely differs
considerably relative to these peer-to-peer and subor-
dinate-supervisor relations that are not reflected in the
meta-analytic data. In veterinary contexts, there are ap-
preciable and normatively accepted differences in the
expertise, power (ie, the relative influence of one’s posi-
tion), and perceived control over outcomes between the
interacting parties that influence the characteristics of
the interaction. Furthermore, the nature of the service

324 Vet Med Today: Special Report JAVMA, Vol 242, No. 3, February 1, 2013
relationship between veterinarians and clients, wherein
the former’s primary role is to first and foremost pro-
vide adequate animal health care, implies that the rela-
tive importance and meaning of the facets of perceived
trustworthiness may differ as well. These characteris-
tics likely also interact with situational factors (eg, con-
sequences associated with not complying with a rec-
ommended procedure for one’s animal and balancing
financial considerations of a suggested course of action
with immediate vs long-term health consequences for
one’s animal) that may further impact how trust is per-
ceived, transmitted, and interpreted within a veterinar-
ian-client interaction.9,10 In short, the unique domain
and situational circumstances under which physicians
and veterinarians professionally and personally engage
with clients implies that the dynamics of the trust rela-
tionship likely differ in important ways.
In sum, traditional conceptualizations of trust may
not be appropriate or accurate for veterinary contexts. A
better understanding of how to capture, document, and
interpret the veterinarian-client trust relationship may
thus be beneficial to enriching the services and quality
of care veterinarians are able to provide. Therefore, the
aims of the study reported here were to develop a mea-
sure of the psychological trusts facets specific to and
that can be easily administered in veterinary contexts,
examine the validity of this measure, and present pre-
liminary evidence of the influence these psychological
facets and other demonstrative behaviors exert on the
manifestation of trust between veterinary students and
standardized clients interacting in a high-fidelity clini-
cal simulation.
Materials and Methods
Participants and setting—Data were collected
from 103 veterinary students (91 females and 12 males)
enrolled in the AVMA–accredited College of Veterinary
Medicine at Michigan State University. The sample was
primarily composed of first-year students in the sec-
ond semester of their Doctor of Veterinary Medicine
education program. As part of the first-year educational
curriculum, courses related to normal structure and
function, animal nutrition, and physiology required
students to participate in high-fidelity clinical simula-
tions with human standardized clients and their pets.
High-fidelity simulation, commonly used to train phy-
sicians and nurses in human medicine, is an instruc-
tional technology that provides participants with op-
portunities to practice, learn, and receive hands-on
experience applying important domain knowledge and
skills under realistic conditions in a controlled and safe
environment. Most simulations follow a standardized,
structured script that presents participants with a re-
alistic problem (or series of problems) that must be
addressed using only their expertise and equipment
and resources typically available in an actual clinical
setting. In the present study, the simulated scenarios
were developed by educators from the Michigan State
University College of Veterinary Medicine and required
the veterinary students to interact with a standardized
client to apply their knowledge and skills to complete
the required tasks. The present simulations took place
in a dedicated center on campus and were conducted in
simulated examination rooms. In addition to the equip-
ment one might expect to find in a standard veterinary
examination room, these rooms were also equipped
with video and audio recording equipment as well as
computer workstations for collecting data from stu-
dents and standardized clients.
Each of the students in the sample was enrolled in
2 classes that required visits to the simulation center on
separate occasions to complete 2 scenarios. The task
complexity of both scenarios was low. The first scenario
asked students to collect a diet history and complete a
routine, minimally invasive physical examination of a
healthy pet (58% of students interacted with a dog and
42% with a cat) with the standardized client present.
The second scenario asked students to interpret and
explain the results of diagnostic medical tests to the
owner of a fictitious dog that had been brought in to the
clinic with health problems (clinical signs consistent
with either mitral insufficiency or Addison’s disease).
The standardized clients were 19 experienced actors (9
females and 10 males) used by the simulation center
who had received extensive training as evaluators for
simulation-based educational settings; the training fa-
miliarized standardized clients with the measures ad-
ministered during the simulations and how to identify
relevant behaviors that the veterinary students would
be performing as well as how to respond to them and
provided direction on the generic script and dialogue to
accompany the simulated scenarios. Standardized cli-
ents were also made aware that they would be asked to
fill out an additional measure for research purposes, but
they were not specifically instructed that this measure
examined trust perceptions. Two actors participated as
standardized clients in both scenarios, but no student
visited with the same standardized client twice. Conse-
quently, 11 standardized clients were used in the diet
history and physical examination scenario and 10 were
used in the medical problem scenario.
Because the students were participating in the sim-
ulated interactions as part of normal classroom activi-
ties, institutional review board approval was granted to
treat all data collected in the simulations as preexisting,
deidentified data (ie, the student and standardized cli-
ent data belonged to the instructors of the class and
were collected for and incorporated into the normal
conduct of the class). Prior to participation, all students
were informed that their interactions would be record-
ed and 100% of the student sample consented to the
use of their questionnaire responses for research and
instructional purposes in the aggregate. Standardized
clients were not required to provide consent given that
the questionnaire content was consistent with the pur-
pose of the courses and their role as evaluators. Nev-
ertheless, all standardized clients were also informed
of and did not object to the use of their responses to
the administered measures for research. Once the data
from students and simulated clients were matched, all
personal identifiers were stripped from the data set to
maintain the confidentiality of students and standard-
ized clients.
Questionnaires—Given that a primary goal of the
present study was to develop a valid measure of trust
that could be generalized to veterinarian-client interac-

JAVMA, Vol 242, No. 3, February 1, 2013 Vet Med Today: Special Report 325
tions, a number of steps were taken to create a measure
of trust suitable to the context. First, items from a ques-
tionnaire created and used by the authors of the origi-
nal 3-facet trust model were examined for use in vet-
erinary settings.17,22 This questionnaire was originally
designed to measure employees’ perceptions of trust in
upper management teams along the dimensions of abil-
ity, benevolence, integrity, and overall trust in the work-
place; consequently, the referents, level of analysis, and
actions indicative of trust were not particularly well
aligned with the context of the present study. Thus, 2
sources of guidance were used to adapt the measure to
the veterinarian-client relationship. First, the course in-
structors of the students participating in the study were
asked to review, provide feedback on, and contribute
additional items to the original 3-facet trust measure
on the basis of their extensive experience observing
interactions between veterinary students and standard-
ized clients in similar scenarios. Second, exemplar data
on difficulties veterinarians had when attempting to
develop trust with clients, the types of communica-
tion and relationship-building strategies used, and ef-
forts taken to improve client compliance were gathered
from a small, informal focus group composed of private
practice veterinarians and technicians. The purpose of
this activity was to seek out general exemplar behaviors
that typified veterinarian-client interactions to roughly
gauge the applicability of the 3-facet model of trust in
veterinary contexts (ie, whether behavioral and com-
municative episodes involving themes of ability, be-
nevolence, and integrity could be identified) and thus
provide at least indirect support for the face validity of
the measurement approach.
These efforts resulted in the creation of a 30-item
questionnaire pertaining to aspects of veterinarian-cli-
ent interactions believed to contribute to the develop-
ment of trust. To reduce the length of the questionnaire
and the load placed on standardized client raters, a
short form of this measure was created. Decisions re-
garding which items to remove were guided by the fol-
lowing priorities:
1. The items and measure should be as generalizable
as possible; thus, questions were removed when
they reflected specific conditions that may not be
present in all situations (eg, “the veterinary student
physically interacted with my animal in a manner
that clearly demonstrated he or she knew what he
or she was doing” or “the veterinary student kept
my animal calm and relaxed during the interview”).
2. Items should be consistent with the stated defini-
tion of trust or related facets as opposed to general
communication skills or verbal ability. The latter
items were expected to demonstrate criterion va-
lidity with a measure of trust, but not construct
validity (eg, “the veterinary student greeted me
pleasantly using my name,” “the veterinary stu-
dent did not appear rushed or hurried and spoke
at a comfortable pace,” or “the veterinary student
asked me whether I had any questions at the end
of the visit”).
3. Items should not require a respondent to make
evaluations of the accuracy and validity of any
diagnoses, claims, or terms (eg, “the veterinary
student answered my questions correctly without
hesitation” or “the veterinary student explained
the purpose of the visit clearly and accurately”).
The final product was an 11-item measure orga-
nized across the 3 facets of trust (ability, benevolence,
and integrity) as well as general perceptions of trust
(Appendix) that specifically referenced the student–
standardized client interaction. In addition, a self-
report version of the measure was also created for the
veterinary students, asking them to indicate the extent
to which they believed they had demonstrated these
same trustworthy behaviors or the extent to which they
believed the standardized client had observed these be-
haviors during their interactions. Because of a comput-
er error at the simulation center, the self-reported trust
measure was only administered to students following
the diet history and physical examination scenario. Re-
sponses to both the standardized client and self-report
measure were provided on a 5-point Likert-type scale
ranging from 1 (strongly disagree) to 5 (strongly agree);
scale scores were computed by calculating the mean of
responses to arrive at a single score for each subscale.
Perceived behavioral performance measures were
also completed by the standardized clients for both
scenarios, although for the purposes of this study, only
those administered during the diet history and physical
examination scenario were analyzed. For this scenario,
the standardized clients completed a dichotomous 10-
item physical examination performance checklist by
indicating (yes or no) whether the veterinary student
completed certain medically relevant behaviors. Similar
to most clients in a real veterinary visit, the standardized
clients were not medical experts and did not possess the
technical skills that would qualify them to judge wheth-
er a student was correctly performing or neglecting im-
portant aspects of the physical examination; however,
standardized clients were instructed on what actions
and behaviors to look for during the scenario that were
broadly indicative of the student’s technical capability
(eg, “the veterinary student looked at both of my ani-
mal’s eyes” and “the veterinary student felt my animal’s
front or hind limbs”). The mean for items on this mea-
sure was computed to form a single indicator of perceived
technical competence that described standardized clients’
observations of the student’s performance capabilities.
Additionally, standardized clients also responded to a 10-
item general communication skills checklist by indicating
(disagree, agree with reservation, or agree) whether the
veterinary student performed various positively valenced
communication behaviors during the clinical visit; ex-
ample items from this measure included “the veterinary
student allowed me to tell my story uninterrupted” and
“the veterinary student greeted me pleasantly (asked or
said my name; shook my hand).” The score for communi-
cation skills was computed by calculating the mean rating
for each item to form a single scale score.
Procedures—The diet history and physical exami-
nation scenario was completed over the course of 2 days
with approximately half of the sample participating in
the simulation on the first day and the remaining half
participating in the simulation the second day. A similar
schedule was followed with the medical problem sce-

326 Vet Med Today: Special Report JAVMA, Vol 242, No. 3, February 1, 2013
nario, which took place approximately 1 week later. The
students were informed of the general technical nature
of the scenarios they would be completing, although no
specific details were provided until arrival at the simu-
lation center; furthermore, the students were aware that
they would be completing an additional measure for re-
search purposes but were not informed that it measured
perceptions of trust developed with the standardized
client. As students arrived for their scheduled scenario
run, they were led to a waiting room where they were
briefed on what they would be doing during the simula-
tion and received their examination room assignments.
The standardized clients were individually located in
separate examination rooms awaiting the beginning of
each scenario.
Once the scenario was ready to begin, a single wave
of 10 to 11 students would enter their individually as-
signed examination rooms and participate in the sce-
nario. Each student was given 15 minutes to interact
with the standardized client and complete the scenario
in full, although they were allowed to conclude the visit
and exit the room if they finished before the time limit
expired. The mean number of students that each stan-
dardized client interacted with was 9.4 (range, 6 to 11)
and 10.3 (range, 9 to 11) during the diet history and
physical examination and medical problem scenarios,
respectively, with no standardized client interacting
with > 6 students on any given day. After the student
had left the room, the standardized clients logged into
the computer workstation located inside the examina-
tion room and completed the trust, perceived technical
competence, and general communication skills ques-
tionnaires; similarly, the veterinary students responded
to the self-reported measure of trust by logging into
a computer workstation outside of the examination
room. Students were then free to leave the simulation
center after finishing the scenario, while the standard-
ized clients remained in the examination room to pre-
pare for the next veterinary student.
Statistical analysis—Analyses were performed in 2
stages. First, properties of the trust measure were evalu-
ated by comparing the latent factor structures of the
standardized client ratings gathered during the diet his-
tory and physical examination scenario with that gath-
ered during the medical problem scenario. Second, the
data gathered during the diet history and physical ex-
amination scenario was used to provide a preliminary
exploration of the predictors of standardized clients’
trust in the veterinary students. Unless otherwise stat-
ed, standard statistical softwarea was used to conduct
the analyses.
The first step of the measure validation process in-
volved conducting an exploratory factor analysis (prin-
cipal axis factoring) with standardized clients’ responses
to items from the 3 facets of the trust measure (ability,
benevolence, and integrity) collected in the diet history
and physical examination scenario. Exploratory factor
analysis is a multivariate statistical technique used to
extract patterns and clusters among item responses in-
dicative of ≥ 1 latent construct tapped in a measure;
typically, these item clusters are then given a label by
the researcher that reflects the semantic meaning of the
underlying construct. Because there are no rigidly fol-
lowed rules for interpreting the results of exploratory
factor analyses,23 commonly used procedures based on
Kaiser’s criteria (eg, factors with eigenvalues > 1) and
examination of scree plots (graph of the eigenvalues
associated with each factor) were used to determine
the appropriate number of factors to extract from the
data. Once the factor structure was estimated, a vari-
max rotation was applied to the results; the rotation is
an orthogonal transformation of the extracted factors,
which produces a more easily interpretable factor solu-
tion, making it easier to describe and identify response
patterns in the data.
The final step of the measure validation procedure
used confirmatory factor analysis to cross-validate the
factor structure with standardized clients’ trust data from
the medical problem scenario. Confirmatory factor anal-
ysis is a specialized case of structural equation modeling
that produces parameter estimates of a factor model by
specifying a priori relationships between some number
of latent factors and observed indicators of those fac-
tors.23 In this case, the trust data provided by standard-
ized clients from the medical problem scenario were fit
to the factor model suggested by the exploratory factor
analysis results; to the extent that these data adequately
fit the model, one can conclude that the measure is cap-
turing similar facets of trust in both scenarios. Again,
there are no agreed upon methods for assessing the fit
of a confirmatory factor model, although most research-
ers take into consideration the χ2 difference statistic (P >
0.05 indicates acceptable fit) and additional goodness-
of-fit indices. On the basis of recommendations from the
extant literature,24 the following indices and benchmarks
were used to assess model fit in the present study: the
standardized root mean square residual (≤ 0.08 indicates
good fit), the root mean squared error of approximation
(≤ 0.05 indicates close fit, between 0.05 and 0.08 repre-
sents moderate fit, and > 0.10 reflects poor fit), and the
comparative fit index (> 0.90 indicates acceptable fit).
Structural equation modeling softwareb was used to con-
duct the confirmatory factor analyses.
For the preliminary analyses exploring which factors
were most predictive of standardized clients’ general rat-
ings of trust, an HLM approach was used. Hierarchic lin-
ear modeling (also known as multilevel modeling, mixed
model regression, or random coefficient regression) is an
extension of traditional ordinary least squares regression
that is useful for analyses in which data are clustered and
nested or otherwise nonindependent (eg, longitudinal
data or data in which lower level units are nested within
higher level units).25 If a different standardized client had
been used to rate every student in the study, then HLM
would not be necessary because the data for each student
would be independent from each other. In the present
study, however, individual standardized clients provided
ratings for multiple veterinary students; thus, the relation-
ship between trust and relevant predictors could be dif-
ferent for each rater as a result of systematic differences
between standardized clients (eg, some standardized cli-
ents may be consistently less trusting than others or more
lenient raters of perceived technical competence).
Hierarchic linear modeling first involves identifying
the appropriate number of nested levels within the data.

JAVMA, Vol 242, No. 3, February 1, 2013 Vet Med Today: Special Report 327
In the present study, veterinary students are nested with-
in each standardized client; thus, students are considered
the level 1 units and standardized clients are considered
the level 2 units. The basic HLM approach then proceeds
by specifying a common regression equation for the level
1 units. As the perception of overall trust toward a vet-
erinary student was the dependent variable of interest,
this outcome is regressed onto the trust facet subscales,
perceived technical competence, and general communi-
cation skills. This process results in an estimate of level
1 regression intercepts and slope terms that specifies the
relation between each of these predictors and trust for
each level 1 unit (ie, the students). These parameters are
subsequently used as the dependent variables predicted
in the level 2 analysis. Here, the values of the estimated
level 1 intercept and slope terms for each predictor vari-
able are separately regressed onto the means provided by
each standardized client for those variables; thus, unique
regression equations predicting each parameter of the
level 1 model are analyzed. The result of this regression
procedure with clustered data produces mean estimates
of the relationship between each predictor variable and
overall trust perceptions that accounts for between-rater
differences in the model variables.
The results from the HLM procedure provide 2
unique pieces of information.26,27 First, they produce re-
gression parameter estimates that describe the relation-
ship between each independent variable and the de-
pendent variable controlling for clustering in the data.
Second, they produce estimates of the amount of vari-
ance in a variable attributable to observed differences
between students and the amount of variance in a vari-
able attributable to differences in each standardized cli-
ent’s perceptions of the students. These latter estimates
are useful for determining the amount of clustering in
the data through the computation of the ICC, which,
in the context of this study, provides a measure of the
degree to which students rated by a single standardized
client were more similar to each other than they were
to other students. The ICC is calculated by dividing the
between-rater variance in a variable by the sum of the
between-rater and within-group variance. Intraclass
correlation coefficients range from 0 to 1, with larger
numbers indicating higher degrees of clustering (ie,
systematic differences between standardized clients ex-
ist). An ICC even as low as 0.05 can have a significant
effect on the results of statistical analyses that do not
control for clustering if level 1 sample sizes are small25
(as they were in the present study).
Two HLM models were fit to the data. The first, la-
beled the unconditional cell means or null model, esti-
mates the level 1 regression equation with no predictor
variables and is based solely on the standardized clients’
means for overall trust. This model is used to evaluate
the level of clustering in the data for the overall trust
measure and provides an indication as to whether sub-
sequent HLM analyses including predictor variables are
warranted. The second model, labeled the predictor
model, introduces the level 1 predictors into the equa-
tion; in this model, the intercept terms of the level 2 re-
gression equations provide an estimate of the relation-
ship between each predictor variable and overall trust,
taking into account any potential clustering in the data.
All predictor variables were grand-mean centered prior
to being analyzed26,27; as such, all regression coefficients
should be interpreted as the amount of change expect-
ed in the dependent variable for every 1-unit increase
above the mean in the independent variable. The HLM
regression coefficients are interpreted exactly like stan-
dard regression coefficients, with P values < 0.05 in-
dicating that the estimated relationship is significantly
different from zero. Specialized statistical softwarec was
used to perform the HLM analyses.
Lastly, Cronbach’s coefficient α was computed to
examine the internal consistency reliability of the mea-
sures used in the study. Coefficient α ranges from 0
to 1 and indicates the extent to which the items in a
measure reflect variation in an underlying factor versus
random error. Values of α > 0.70 are generally consid-
ered acceptable for research. Basic descriptive statistics
(means and SDs), partial correlations (Pearson correla-
tion with dummy codes to partial out rater effects), and
paired-samples t tests were also computed to examine
differences between students and standardized clients
perceptions of trust; for all inferential statistics, values
of P < 0.05 were considered significant.
Results
Measure validation—Trust ratings were not pro-
vided by standardized clients for 7 veterinary students
during the diet history and physical examination sce-
nario, leaving a total sample size of 96 for the explor-
atory factor analysis and subsequent descriptive and
inferential analyses. Results from the first step of the
measure validation process in which standardized cli-
ents’ responses to the ability, benevolence, and integ-
rity items were submitted to exploratory factor analysis
were summarized (Table 1). The results show that this
measure appeared to be tapping 2 underlying response
patterns from standardized client respondents. The first
factor was composed of the 3 items from the benev-
olence subscale and 1 item from the ability subscale.
These items generally seemed to depict standardized
clients’ perceptions of the degree to which the veteri-
nary students had a respectful, approachable disposi-
tion and communicative tone; as such, this factor was
labeled professionalism. The second factor, composed
of the 2-item integrity subscale and the remaining abil-
ity item, appeared to collectively describe standardized
clients’ perceptions about a veterinary student’s compe-
tence and willingness and capability to communicate
honestly his or her knowledge about the medical and
diagnostic aspects of the visit. This factor was therefore
labeled technical candor.
This 2-factor model was then tested via confirma-
tory factor analysis to determine the extent to which
this same response pattern captured standardized cli-
ents’ trust perceptions toward the veterinary students
during the medical problem scenario as well. Both the
χ2 fit index (χ2[12] = 16.9; P = 0.15) and the goodness-
of-fit indices (standardized root mean square residual =
0.05; root mean squared error of approximation = 0.06;
comparative fit index = 0.98) indicated that the data fit
the model exceptionally well. The reported indices are
based on a factor model in which the error terms for 2

328 Vet Med Today: Special Report JAVMA, Vol 242, No. 3, February 1, 2013
items (“the veterinary student did not talk down to me
or above my head” and “I believe the veterinary student
would readily seek the advice of others if he or she had
doubts about his or her diagnosis or recommendations
for treatment” [Appendix]) were correlated to improve
model fit. Given the high interrcorrelation among items
in the trust scale and the fact that this scale had not been
published elsewhere, this path was added to the confir-
matory factor analysis. An analysis in which the original
3-facet model was fit to this data failed to produce an
admissible solution. Together, this evidence suggests that
the trust facet measure was largely capturing the same 2
factors in the medical problem scenario that were identi-
fied in the diet history and physical examination scenar-
io. In sum, the results of the cross-validation procedure
demonstrated that although the 3 predicted factors (abil-
ity, benevolence, and integrity) believed to underlie gen-
eralized perceptions of trust were not reproduced, the
measure reliably captured 2 interpretable factors (pro-
fessionalism and technical candor) specific to the trust
relationship during the veterinary student–standardized
client interactions across 2 situations and points in time.
On the basis of the results above, scale scores for
the professionalism and technical candor facets were
formed by computing the mean of the responses from
each subscale. The means, SDs, reliability coefficients,
and partial correlation coefficients for the standard-
ized clients’ trust-related perceptions, the veterinary
students’ trust-related perceptions, and the perceived
technical competence and communication skill vari-
ables measured during the diet history and physical
examination scenario were summarized (Table 2).
An examination of the reliability coefficients reveals
that all measures were fairly internally consistent,
although the technical candor and the general com-
munication skills measures were somewhat low. With
respect to the technical candor scale, this result is not
altogether surprising, given the small number of items
in that subscale (3) and the results from the factor
analyses, which show that 2 of the 3 items had only
moderately strong factor loadings (Table 1). The reli-
ability of the technical candor subscale used by the
standardized clients is adequate for research purposes,
although efforts to improve its reliability through the
Table 1—Exploratory factor analysis results of standardized client trust perceptions from the diet his-
tory and physical examination scenario (n = 96) in a study of veterinary students and standardized
clients interacting in a high-fidelity clinical simulation.
Rotated
factor loadings
Items from trust measure 1 2
Professionalism
The veterinary student put me at ease during our interview (benevolence) 0.95
The veterinary student behaved in a professional manner (ability) 0.91
The veterinary student did not talk down to me or above my head (benevolence) 0.87
The veterinary student was kind and accommodating toward me, 0.46
but firm when required (benevolence)
Technical candor
The veterinary student was honest with me if he or she did not know the answer 0.95
to a question or was uncertain about his or her knowledge (integrity)
I believe the veterinary student would readily seek the advice of others if he or she 0.57
had doubts about his or her diagnosis or recommendations for treatment (integrity)
The veterinary student demonstrated his or her knowledge about my animal’s 0.44
condition by describing his or her diagnosis completely and precisely (ability)
Variance explained (%) 40.8 23.2
Words in parentheses indicate the original subscale of the trust measure from which the item was taken.
Percentage variance explained describes the percentage of total variance in the data captured by the rotated
factor (varimax rotation).
Table 2—Means, SDs, and partial correlations among standardized clients’ perceptions of trust, veterinary students’ self-perceptions
of trust, perceived technical competence, and communication skills in the diet history and physical examination scenario (n = 96) in a
study of veterinary students and standardized clients interacting in a high-fidelity clinical simulation.
Item from trust measure Mean SD 1 2 3 4 5 6 7 8
Professionalism 4.49 0.50 (0.85)
(standardized client)
Technical candor 4.25 0.49 0.69* (0.69)
(standardized client)
Overall trust 4.55 0.51 0.66* 0.43* (0.89)
(standardized client)
Professionalism (self-report) 4.40 0.46 –0.03 0.10 0.04 (0.85)
Technical candor (self-report) 4.33 0.53 0.07 0.19 0.02 0.63* (0.55)
Overall trust (self-report) 4.20 0.63 –0.11 0.05 –0.04 0.77* 0.54* (0.96)
Perceived technical 0.94 0.13 0.14 0.03 0.30* 0.11 0.00 0.16 (0.77)
competencea
Communication skillsb 0.98 0.08 0.26* 0.21 0.32* 0.01 0.02 –0.02 0.05 (0.63)
The numbers in the half-matrix represent Pearson correlation coefficients. Cronbach’s α is reported in parentheses on the diagonal.
*Value is significant (P < 0.05).
aDichotomous response scale (0, did not perform; 1, did perform). bDichotomous response scale (0, disagree; 1, agree).

JAVMA, Vol 242, No. 3, February 1, 2013 Vet Med Today: Special Report 329
inclusion of additional items would be desirable. The
lower reliability of the general communication skills
measure is primarily a function of the fact that nearly
every student received the highest possible score on
the measure (mean score, 0.98/1); thus, those few in-
stances in which an individual did not have a particu-
lar communication skill are greatly magnified in this
index. Nevertheless, analyses including this measure
should be interpreted tentatively.
HLM analyses—The full set of equations, param-
eter definitions, and results from the null and predictor
HLM models were summarized (Table 3). Again, the
purpose of these analyses was to pursue a preliminary
examination of the factors predictive of standardized
clients’ overall trust perceptions in the veterinary stu-
dents. In interpreting these findings, it is appropriate
to start with the null model to evaluate the amount
of clustering present in the data and whether there
is enough variance in trust ratings across students to
warrant further examination. On the basis of the esti-
mates of between-rater (τ00) and within-rater (σ2) vari-
ance, the ICC for trust ratings was (0.06/[0.06 + 0.20])
= 0.23. This large value indicates that on average, the
students rated by any single standardized client were
generally more similar to each other than to other stu-
dents in the sample and is indicative of substantial clus-
tering in the data. Furthermore, the value obtained for
the within-rater variance estimate indicates that 20% of
the observed variance in trust perceptions remains to
be explained by possible predictor variables above and
beyond standardized clients’ average level of trust. In
sum, these results suggest that further examination of
variables that may have accounted for perceptions of
standardized client trust is warranted.
The parameter estimates shown for the predic-
tor model (Table 3) relates whether standardized cli-
ents’ perceptions of professionalism, technical candor,
general communication skills, and perceived tech-
nical competence were indicative of trust in veteri-
nary students. In the full model including all predic-
tors, only perceptions of professionalism (γ10 = 0.48)
and perceived technical competence (γ40 = 0.77) were
significantly (P < 0.05) different from zero, indicat-
ing that students who were viewed as generally more
professional and were demonstrably more competent
performers were perceived as more trustworthy across
all standardized clients. Of additional note, this model
yielded a substantially reduced σ2 (0.07) relative to the
null model, indicating that the included predictor vari-
ables accounted for a large proportion of the observed
variance in trust ratings; in all, approximately ([0.20
– 0.07]/0.20) X 100 = 65% of the observed variance
in standardized client trust across all students was ac-
counted for by the level 1 predictor variables. Similarly,
the reduction in π00 indicates that ([0.06 – 0.02]/0.06)
X 100 = 67% of the between-rater differences in trust
was accounted for by variation in students’ observed
professionalism, technical candor, general communica-
tion skills, and perceived technical competence.
On the basis of the pattern of intercorrelations
(Table 2), it seemed likely that technical candor was
also a significant predictor of overall trust, although
multicollinearity issues with the professionalism sub-
scale (ie, 2 strongly correlated independent variables)
may have been suppressing the effect.25 As expect-
ed, when the professionalism measure was removed
from the predictor model (Table 3), technical candor
emerged as a significant (P < 0.05) predictor of overall
trust (γ20 = 0.40), with higher levels of technical can-
dor related to higher levels of reported trust. These
results suggest that professionalism and technical
candor are likely both significant predictors of over-
all trust; however, they appear to compete for mostly
the same underlying variance, with perceptions of
professionalism accounting for a slightly larger total
percentage than technical candor. In short, veterinary
students who had higher degrees of either profession-
alism or technical candor were generally seen as more
trustworthy by standardized clients.
Table 3—Hierarchic linear modeling analyses and parameter estimates predicting the relationship between
professionalism, technical candor, perceived technical competence, and communication skills on standardized
clients ratings of trust toward veterinary students in the diet history and physical examination scenario (n =
96) in a study of veterinary students and standardized clients interacting in a high fidelity clinical simulation.
Parameter estimates
Model γ00 γ 10 γ 20 γ 30 γ 40 τ00 σ2
Null model 4.56* — — — — 0.06* 0.20
Level 1: Trustij = B0j + rij
Level 2: B0j = γ00 + u0j
Predictor model 4.56* 0.48* 0.03 1.11 0.77* 0.02* 0.07
Level 1: Trustij =
B0j + B1j(professionalismij)
+ B2j(technical candorij) +
B3j(communication skillsij)
+ B4j(perceived technical
competence) + rij
Level 2:
B0j = γ00 + u0j
B1j = γ10 + u1j
B2j = γ20 + u2j
B3j = γ30 + u3j
B4j = γ40 + u4j
*Parameter estimate is significant (P < 0.05).

330 Vet Med Today: Special Report JAVMA, Vol 242, No. 3, February 1, 2013
Additional exploratory analyses—The present
data set permitted examination of 2 additional explor-
atory questions of interest. First, although the beliefs of
the client as the trustor are the most important to out-
comes such as compliance and perceptions of the qual-
ity of care delivered, examining the degree to which
the veterinary students’ self-perceived professionalism,
technical candor, and overall trust differed from that of
the standardized clients may offer insight into mean-
ingful differences in the manner by which trustees ver-
sus trustors interpret a given interaction. The results
of paired-sample t tests were used to examine whether
standardized clients and students’ perceptions of trust,
professionalism, and technical candor were significant-
ly different following the simulated interaction. In this
case, only perceptions of overall trust were significantly
different between both groups. The standardized cli-
ents reported significantly (P < 0.01) higher trust in the
students (mean, 4.55) than the students perceived that
the standardized clients felt toward them (mean, 4.29;
t[95] = 4.074). In other words, the students were less
likely to believe that the standardized clients trusted
them than the standardized clients actually reported.
Furthermore, the nonsignificant correlation between
perceived trust of the students and standardized clients
implies that this perception was true regardless of the
level of trust felt by either party.
Discussion
The development of trust has often been noted as
a primary leverage point for the creation of healthy and
productive doctor-patient relationships in the human
health-care industry.9–13 The present study attempted to
expand this notion to the veterinarian-client relation-
ship by developing a measure of trust specific to the
context of veterinary medicine. This effort resulted in an
11-item questionnaire, which was tested in a simulated
clinical visit with veterinary students and standardized
clients. Unlike previous examinations of aggregate trust
perceptions in generic work settings, results across 2
medical scenarios revealed that the measure tapped 2
facets of perceived trustworthiness, which were labeled
professionalism and technical candor. Furthermore, in
the context of the simulated diet history and physical
examination visit, preliminary evidence indicated that
standardized clients were more trusting of students
who appeared technically competent and had greater
professionalism or technical candor. Lastly, exploratory
analyses indicated that the veterinary students tended
to underestimate the degree of overall trust placed in
them by standardized clients following their brief in-
teraction.
Given the central role that the identified profes-
sionalism and technical candor perceptions held in re-
lation to perceptions of trust in this study, it is useful to
more precisely examine and elaborate on the meaning
of these 2 facets in the general context of the veterinar-
ian-client relationship. Perceptions of professionalism
appear to most closely correspond with the quality and
nature of the interpersonal boundaries between a veter-
inarian and his or her client. Characteristics indicative
of a veterinarian’s professionalism describe actions that
establish his or her role as a respected and respectful
practitioner as well as a figure of authority whose pro-
cedures and professional recommendations are clear,
fair, and beneficent to the client. Thus, behaviors and
communication approaches that demonstrate to clients
a neutral stance with regard to prognoses and recom-
mended treatments (eg, having no ulterior agenda for
treatment recommendations), allow clients to voice
their questions and concerns, ease clients through the
diagnoses and results of tests, and establish the veteri-
narian as a knowledgeable, empathetic decision maker
are likely to improve clients’ perceptions of a veterinar-
ian’s professionalism.
Alternatively, perceptions of technical candor de-
pict the situational and task-based dynamic of the vet-
erinarian-client relationship. The relevant characteris-
tics indicative of technical candor describe the extent
to which a veterinarian is perceived as honestly dem-
onstrating their domain-relevant capabilities, knowl-
edge, and expertise in their attempts to problem-solve
and provide their services to a client. Notably, this facet
does not reflect an individual’s actual level of techni-
cal proficiency but rather the manner by which the
veterinarian conveys what and how they know about
the condition of the client’s animal. Providing full dis-
closure about one’s interpretations of diagnostic tests,
results, and personal recommendations as well as per-
mitting admissions of uncertainty backed with reassur-
ances of follow-up and further investigation promotes
a sense of truthfulness and integrity in one’s medical
explanations and conversational dialogue that encour-
ages trust development. Interestingly, technical candor
seems to capture a mutual and nonrecursive aspect of
trust somewhat unique to the veterinarian-client rela-
tionship in that the veterinarian’s willingness to display
his or her own vulnerability (eg, by revealing the limits
of their domain and task knowledge) plays an impor-
tant role in the client’s perceptions of trust. However, as
the significant positive relationship between trust and
perceived technical competence shows, one is not like-
ly to be trusted if completely incompetent or incapable
of performing a task one has been entrusted with com-
pleting.17,18,21 However, recognizing and acknowledging
the boundaries of the veterinarian-client exchange re-
lationship did not appear to be perceived negatively in
this study. This finding adds to previous research that
shows patients and clients are generally most satisfied
and experience better health-care outcomes when the
communication and power dynamic between health-
care provider and receiver is balanced and factors in the
needs and capacity of both parties.28,29 Thus, even in a
professional domain where veterinarians are expected
to be highly knowledgeable and generate immediate so-
lutions to the problems of their clients, a healthy trust
relationship may still emerge if the interaction is open
and honest and the veterinarian expresses a commit-
ment to solving the issue through other means.
The relationships identified between trust and its
facets as well as its relations with perceived technical
competence and communication in the study implicate
a number of directions for future research and the edu-
cation, training, and continued improvement of both
veterinary students and established practitioners. First,

JAVMA, Vol 242, No. 3, February 1, 2013 Vet Med Today: Special Report 331
the nonsignificant correlations between the veterinary
students’ trust-related perceptions and those same per-
ceptions from the perspective of the standardized cli-
ents suggest an intriguing area of focus. Such null re-
sults may be attributable to statistical artifacts (ie, floor
effect in the questionnaire responses in which neither
students nor standardized clients tended to provide
ratings below the scale mid-point); nevertheless, these
findings suggest that examinations of trust perceptions
from the perspective of the veterinarian may also prove
useful in determining whether he or she is effectively
building a trusting relationship with clients. Previous
research14,28–31 has primarily focused on the messages
and specific content of communication delivered by
veterinarians rather than veterinarian’s effectiveness as
socially attuned, reflexive, and participative actors in
exchanges with clients. Adapting the tone, content, and
goals of one’s communications in response to social and
situational cues is critical to influencing the perceptions
and related outcomes held by other individuals,32–34
especially when there are imbalances in the authorita-
tive power of the interacting parties.35–37 Although im-
provement in this area is likely to be a gradual process,
even simple interventions that encourage veterinarians
to seek feedback from clients on the nature and qual-
ity of their professional and interpersonal relationship
building, engage in fully transparent conversations that
balance client wants and goals for their animal’s health
with available treatment options, or reframe clinical vis-
its as a single step rather than one-off encounters in the
trust-building process have the potential to substantially
improve the communicative quality and trust-building
efforts between veterinarian-client interactions.
Second, the present results demonstrated the ef-
fect of trust on short-term, immediate outcomes (ie,
perceptions of the quality of care provided and general
communication skills), but it remains to be seen what
implications the trust of clients toward their veterinar-
ians hold for outcomes beyond a single interaction. The
decrease in the frequency of client visits to pet health-
care providers is a growing concern for many veterinary
professionals.8 Although evidence from the human
health-care industry strongly suggests that the trust
that develops between doctors and patients has a sig-
nificant impact on visitation and compliance behaviors
over the course of extended medical treatments,11–13 a
number of possible intervening factors may cause this
relationship to operate differently within the veterinary
profession. For example, the simple fact that the health
service is being delivered to one’s pet or animal as op-
posed to one’s self suggests that clients’ perceptions of
the necessity of treatment may be an important differ-
ence in the decision to seek out and comply with veteri-
nary services. This implies that the strength of the pet-
owner bond may be an important moderating influence
of the relationship between trust and compliance and
visitation likelihood.38,39 As another example, research-
ers have found that non-Caucasian pet owners are ap-
proximately 7% to 13% less likely to take their pets to
a veterinarian during any given 12-month period than
are Caucasian pet owners, even after controlling for in-
come, education, location, and other factors known to
impact the likelihood of purchasing veterinary care.40
Given that veterinary medicine is among the least di-
verse of any of the health-care professions,41 discrepan-
cies in trust between clients of different versus the same
race or ethnicity as their practitioner may also hold
unique implications on the impact that trust exerts on
outcomes desirable to veterinary care providers.
Lastly, previous research indicates that individu-
als may have very different perceptions of trust when
considering relationships with specific individuals
(eg, a specific veterinarian or a front office reception-
ist), groups of individuals (eg, a specific veterinarian
practice), or larger institutional and social systems (eg,
veterinarian practice in general).9,18 In areas where suc-
cessfully establishing a cooperative and effective work-
ing relationship is paramount to achieving a particular
goal, perceptions of mistrust at higher group and sys-
tem levels can be problematic.11,42,43 However, the be-
haviors and attitudes adopted by a specific veterinarian
toward his or her clients over the course of multiple
interpersonal interactions may be able to counteract
these perceptions and exert a strong influence over the
development of a productive and mutually beneficial
veterinarian-client relationship. Such a calculus-based
model of trust development18 implies that examining
differences between clients’ perceptions of interper-
sonal trust toward a single veterinarian and veterinary
practice in general may be an important distinction for
improving visitation rates and compliance behaviors.
The results from the present study hold practi-
cal implications as well. First, the items from the trust
measure (Appendix) can be easily implemented in vet-
erinary practices as part of a brief exit questionnaire
or customer feedback package to assess clients’ overall
perceptions toward the clinic or veterinarians within
the practice. The calculation of the subscales is easily
performed, and the conceptual definitions provided
make their interpretation straightforward. In addition
to its descriptive and evaluative uses, information on
perceptions of trust and its predictive facets may also
be useful for coaching or training purposes. To the ex-
tent that efforts to promote compliance rates and high-
quality relationships within one’s client base remains an
important directive, the ability to provide guidance to
veterinary students and doctors on the specific types of
relational qualities important to such efforts is critical.
Simply advocating that the development of effective
nontechnical or communication skills are essential to
healthy veterinarian-client relationships does not pro-
vide the prescriptive framework needed to elicit effec-
tive behavioral change. However, by identifying specific
dispositional and communicative practices conducive
to trust building, explicating what is meant by those
constructs, rewarding conscious efforts to improve
those areas of practice, and monitoring progress toward
achieving goals of improved client trust and compli-
ance through continued measurement, considerable
progress can be achieved.
This point is also highlighted by the nonsignificant
relationship between general communication skills and
trust observed in the present study. The communication
skills measured in the present study largely captured
generic behaviors that a person would expect from any
interaction in a service context (eg, pleasant greeting,

332 Vet Med Today: Special Report JAVMA, Vol 242, No. 3, February 1, 2013
did not interrupt, and allowed and invited questions).
However, the willingness for one to make themselves
vulnerable to the decisions of another which accom-
panies perceptions of trust is a complex cognitive and
emotional process that research suggests is influenced
by specific verbal and nonverbal factors.17,18 Although
the purpose of a given clinical appointment may strong-
ly influence the communicative nature of the veterinar-
ian-client interaction,29 a trustee who is knowledgeable
of those factors that underlie a trustor’s perceptions of
trust (eg, professionalism and technical candor) has the
potential to adapt their interactions in a manner that
is more favorable to trust development and, ultimately,
improved client and patient outcomes.
As with any empirical investigation, several limita-
tions relevant to the interpretation of the present study’s
results should be considered. The first is the small sam-
ple size obtained and the fact that it consisted of stu-
dents interacting with trained actors in a high-fidelity
simulation. With respect to sample size, the statistical
results of the measurement validation and HLM analy-
ses were fairly conclusive and it is unlikely that a larger
sample size would have produced substantially different
findings. Nevertheless, a larger sample would have been
desirable to produce more stable parameter estimates in
both analyses; thus, we believe it is justifiable to draw
conclusions on the basis of the observed direction of
the identified relationships (ie, higher professionalism,
technical candor, and perceived technical competence
led to greater perceptions of trust), though interpreta-
tions of the relative magnitude of the effects (eg, wheth-
er performance is more important to perceptions of trust
than professionalism or technical candor) should be
withheld until further data has been accumulated.
Note that on the basis of the present study, we do
not advise use of either the professionalism or technical
candor scales for purposes beyond descriptive feedback
in practical applications. The small sample size upon
which the measurement validation results are based
and the moderate internal consistency reliability coef-
ficients do not offer sufficient support for the use of this
measure in evaluative decision contexts (ie, as part of
performance assessments or other major organizational
decisions). Through the accumulation of additional in-
vestigations with this measurement tool, greater con-
fidence can be placed in the validity and reliability of
the instrument; until that time, the results of this study
offer a preliminary treatment of the conceptualization
and measurement of trust in veterinary contexts.
As concerns the use of veterinary students and
standardized clients across only 2 simulated scenarios,
one could argue that these interactions may not have
been sufficiently realistic to obtain measurements of
trust. Consequently, issues regarding the generaliz-
ability of the present study’s results can be called into
question. We acknowledge this limitation, but this
weakness is partially offset by the experimental control
afforded by the present study’s design. Given that our
stated goal was to develop and examine the function-
ing of a trust measure specifically targeted toward vet-
erinary contexts, the present design offered a number
of desirable advantages, such as the ability to explicitly
standardize situational factors of the student–standard-
ized client interactions (eg, severity of patient condi-
tion and purpose of visit), which may have confounded
validation efforts in a real sample.9,10,17 Additionally, the
ability to gather data on perceived technical compe-
tence and general communication skills from trained
standardized clients, which may have been difficult
or impossible to gather from real clients, permitted a
richer exploration of the factors that relate to percep-
tions of trust. Lastly, the unique opportunity to pursue
cross-validation efforts with the trust measure across
2 controlled scenarios administered at different time
points and with different student–standardized client
combinations lent further strength to the conclusions
drawn from results of the factor analysis. Nevertheless,
we note that there is always a tradeoff between issues
of internal (ie, whether the study adequately examines
what it intends to) and external (ie, whether the results
of the study extend to samples beyond the one used
in the research) validity in any experimental research
that must be justified by the intended purpose and
goals of the research.44 The present effort represented
an initial exposition and preliminary examination of
veterinary trust that was appropriate for examination
in a controlled environment; however, future investi-
gations would benefit from attempting to extend these
findings to clients in a practicing veterinary office. Al-
though the use of simulated settings to study technical
and nontechnical skills is a new advancement in veteri-
nary medicine, we contend, as have other researchers,
that the methodology holds many benefits and offers
considerable potential for informing best practices.45–47
Additional limitations concern aspects of the cor-
relational research design and the use of same-source
perceptual data. Previous theory and empirical evi-
dence17,20,23 provide adequate justification for treating
perceptions of professionalism, technical candor, and
perceived technical competence as causal influences of
trust. However, the fact that all data were collected at a
single time point in a nonexperimental design does not
permit a true test of this presumed causal ordering. This
goal was not a central pursuit of the present study, but
future research could greatly contribute to this area of re-
search by incorporating behavioral data or pretest-post-
test experimental designs and manipulations to examine
the causal ordering of factors that contribute to trust.
The practice of understanding, interpreting, and
improving veterinary communication competencies is
a young but burgeoning area in the veterinary profes-
sion.28–31 In the present study, the case was made for
the centrality of trust as a critical component of veter-
inarian-client interactions and relations that holds im-
plications for improving client compliance, visitation
frequency, and the quality of care that can be provided
by veterinarians.8,15,16 The results of this research offer a
preliminary step in deciphering the unique role of trust
in the veterinary profession. It is our hope that through
the development and application of measures, tools,
and interventions designed to specifically examine the
manner by which trust is manifested in the context of
veterinary care, valuable and meaningful improvements
can continue to be made to the training of future indus-
try professionals and discussions of best practices in the
field of veterinary medicine.

JAVMA, Vol 242, No. 3, February 1, 2013 Vet Med Today: Special Report 333
a. SPSS, version 19.0.0, SPSS Inc, Chicago, Ill.
b. AMOS, version 19.0.0, SPSS Inc, Chicago, Ill.
c. HLM, version 7.0 (student edition), Scientific Software
International Inc, Skokie, Ill.
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334 Vet Med Today: Special Report JAVMA, Vol 242, No. 3, February 1, 2013
Appendix
Veterinarian trust scale instructions: on the 5-point scale (1 = strongly disagree, 2=
disagree, 3 = neither agree nor disagree, 4 = agree, and 5 = strongly agree), please
respond to the following items regarding your perceptions of the veterinary student
you have just interviewed with to the best of your ability.
Professionalism
The veterinary student put me at ease during our interviewB
The veterinary student behaved in a professional mannerA
The veterinary student did not talk down to me or above my headB
The veterinary student was kind and accommodating toward me, but firm
when requiredB
Technical candor
The veterinary student was honest with me if he or she did not know the answer
to a question or was uncertain about his or her knowledgeI
I believe the veterinary student would readily seek the advice of others if he or
she had doubts about his or her diagnosis or recommendations for treatmentI
The veterinary student demonstrated his or her knowledge about my animal’s
condition by describing his or her diagnosis completely and preciselyA
Overall trust
I trust this veterinary student as a veterinarian-in-training
Based on this interview, I would see this veterinary student again for my animal’s care
I trusted that the veterinary student had carefully considered my and his or her
concerns regarding my animal
I would recommend this veterinary student to others for their veterinary needs
A,B,IAbility, benevolence, and integrity subscales, respectively, from the original 3-facet
measure.