"You're already starting from behind" - Nurses' perspectives on trust, mistrust, and structural constraints in informal caregiver interactions: A qualitative study.

BACKGROUND: Informal caregivers play a growing role in clinical care, yet the relational dynamics between nurses and caregivers remain understudied. In healthcare systems shaped by time scarcity, institutional pressures, and identity-based assumptions, trust-building with informal caregivers is a complex and emotionally demanding process for nurses. PURPOSE: This study explores how nurses perceive and navigate trust-building with informal caregivers, particularly in the context of structural constraints and prior caregiver mistrust. METHODS: Seventeen nurses practicing in inpatient and acute care settings across four U.S. states participated in semi-structured interviews. Interviews were audio-recorded, transcribed, and analyzed using reflexive thematic analysis. Relational Cultural Theory was used to interpret how trust is shaped through systemic and interpersonal dynamics. RESULTS: Three interrelated themes were identified: (1) structural barriers constrain nurses' capacity for relational care, (2) trust is mediated by identity-based perceptions and caregivers' prior negative experiences with healthcare systems, and (3) trust is actively constructed through relational labor, including cultural attunement, consistency, and respectful communication. Nurses described emotional fatigue, scrutiny, and the need to continually establish credibility within constrained hospital settings. CONCLUSIONS: Trust between nurses and informal caregivers develops through ongoing interaction shaped by institutional structures, visible identity, and caregiver history. As informal caregiving becomes more central to healthcare, nurses require organizational support and training that prepare them to build trust through responsive, consistent, and relationally grounded care.