ARTICLE
Rethinking power in a hospital setting
Peter Dickens, PhD
Although hospitals are among the most complex human systems ever devised, they continue to deliver quality patient care. A brief examination of the literature related to power and hospitals reveals some interesting patterns that I then frame through a case study in a Toronto hospital that has demonstrated a commitment to interprofessional collaboration and distributed leadership. The case study involved a series of interviews with participants in a Process Improvement Program that dramatically reduced wait times in the emergency department. Rather than leaving the development of strategy with those who typically hold “power,” the challenge was given to two teams of nurses, porters, physicians, and housekeepers: those closest to the problem and those with a personal stake in finding an effective resolution. The case study suggests that there are significant opportunities to improve care processes when power is redistributed.
The health care system in Canada is going through what Alvin Toffler1 once referred to as a “power shift”: a deep-level change in the very nature of power. It can be argued that this power dynamic was not merely accidental or a result of the mores of the time, but rather it had its origins in medical and nursing school training. Top
While medical school training can be seen as a “toughening up” process preparing students for the rigours of a doctor’s life, nursing training is an object lesson in submission. In nursing training others get tough. The nurse is taught to follow rules, to be deferential to doctors, and the importance of routine is emphasized.2
As Mintzberg3 points out, traditional assumptions about power are deeply rooted in the dominant modernist metaphor of the organization as a machine: all the parts running smoothly, but with all the power vested in the hands of a few individuals. Top
When we hear the word “power,” our minds often gravitate to the rampant abuses of power that litter the pages of history — and today’s headlines. We can become obsessed and appalled by these excessive displays of brute force. Northouse4 suggests that, “in discussions of leadership, it is not unusual for leaders to be described as wielders of power, as individuals who dominate others. In these instances, power is conceptualized as a tool that leaders use to achieve their own ends” (p. 9).
We get a little closer to a more engaging construct of power when we consider it simply as the capacity to get things done. Northouse would simply say that, “power is the capacity to influence. People have power when they have the ability to affect others’ beliefs, attitudes and courses of action”4 (p. 7).
Power in a health care setting
As early as 1962, Georgopoulos and Mann5 noticed that, “the hospital is dependent very greatly upon motivations and voluntary, informal adjustments of its members.” Despite its complexity and this need for such adjustments, descriptions of the construct of power in a health care setting are lacking. Top
That said, Fried6 did explore the concept of power acquisition in a health care setting through the lens of strategic contingency theory, suggesting that, “power acquisition is a function of one’s centrality to organizational functions, substitutability, and ability to cope with uncertainty.” He notes the limitations of applying organizational theories to health care organizations because of the unique nature of physician roles and attributes and demonstrates the distinction between doctors and nurses when it comes to the acquisition of power. Doctors achieve their power because they are perceived to be irreplaceable, while nurses “must be central and cope with organizational uncertainty in order to achieve power.”
This distinction is exacerbated in Ontario where physicians are recruited by hospitals because they have a required skill in a medical subspecialty, but they are not employees of the hospital in the formal sense. They are given privileges, but have no formal accountability to the hospital and are not paid by the hospital. This gives them the potential for enormous power. Nurses, on the other hand, are hired and can be fired as normal employees. Thus, nurses have historically tended to focus career development on one of two distinct tracks: some pursue management roles while others move into the advanced practice roles that are beginning to fill the gap between physicians and nurses. This enhances their centrality and increases the difficulty of replacing them. Ironically, their perceived easy replaceability may be more myth than fact as Ontario, like many other jurisdictions, is facing a “pandemic” nursing shortage7 brought on by an aging work force. Top
The power dynamics that exist between physicians and nurses can have a trickle-down effect on the power dynamics between nurses and patients. In this case, “power has been viewed as the right of professionals that they exercise to inform (informational power) clients on the basis of their knowledge (expert power), even to persuade them to change their behavior.”8 Health care providers also indicate their power by using jargon, dictating the topics, disregarding the patient’s initiative, interrupting, questioning, and controlling the time.8
Fortunately, these power dynamics are beginning to change. Today, virtually every hospital has begun to think in terms of patient-centred care, which ensures that patients are viewed as central to, not excluded from, any discussion about their care. The following case study affirms the importance of taking a patient-centred perspective, even when trying to solve a complex, hospital-wide challenge. Top
A case study: the Process Improvement Program initiative
The PIP initiative, in a Toronto hospital, brought together two teams of front-line staff who were to look for process improvements that would reduce wait times in the Emergency Department (ED) and improve the flow of admitted patients from the ED to the medicine floor. A key measure in the ED is the number of patients who have been admitted for observation and care, but for whom there is no available bed in a medical unit. They end up waiting, sometimes for several hours, in the ED on a gurney, thus limiting the capacity of the ED to care for new, incoming patients. Both departments were involved in the initiative, because it became clear that the challenges in the ED could not be resolved without a concurrent effort to improve bed capacity in medical units.
The province’s Ministry of Health and Long Term Care provided two “coaches” who had experience in Lean process-improvement methods. The PIP initiative was limited to an 8-month time frame and the ministry set out clear guidelines: a maximum 4-hour time limit for treatment in the ED of patients not being admitted and 8 hours to an inpatient bed for those requiring admission.
Over the course of 2 days, I interviewed 11 people in connection with the initiative: physician leads, nurses, porters, and members of the executive team. Top
A new perspective
This initiative was an intentional attempt to look at the process from the patient’s perspective, not the provider’s. Although this may seem obvious to outsiders, hospitals can be so complex that it is common for providers to feel that they are the only ones who fully understand what is going on. This change in perspective created a powerful common point of focus.
A second novelty was that the people who were most directly involved in the processes related to patient flow were identified as the ones to drive the initiative. This was part of the framework provided by the ministry, to which the hospital had to adhere. A third key element that became clear from the interviews was that any proposed changes must be driven by careful analysis of available data. Hospitals, like many other institutions, build up layers of myths and assumptions that then guide decisions. Given the “bottom-up” nature of this initiative, it was critical to combat these myths with unassailable data. The end result was that the metrics established at the beginning were met or exceeded — and expectations continue to be exceeded 2½ years later! Top
Power dynamics
One of the central questions that I was curious about was how participants perceived power in a general sense and what power dynamics were in evidence in the initiative.
As one participant noted, “Traditional, positional power in which the physician assumes he is in charge and that he has all the right answers was not going to solve this problem. The Lean process put the power in the data. Clear, accurate data dissolve power relations and politics. Lean ensures that we bring data, structure and the appropriate tools to deliver validated improvements. That’s where the power is. Interestingly, it allowed us to be comfortable giving people who might resist change a legitimate voice because we always had the data to challenge them.”
The power of data was contrasted with the potentially destructive power of myths and assumptions. One person noted that, “For years, hospitals have lived on the basis of urban myths, assumptions and distorted mental models. Key decisions were made based on someone’s ‘gut feeling’ or well-worn assumptions that were taken as truth. The data challenged and changed all that.” Top
Another participant described this as creating a level playing field, which was seen as important in a setting where clinical expertise is generally held in very high regard. In the same way, physicians and others were willing to engage in process change when the data were clear and when they had a clear indication of what one interviewee called “off ramps.” They needed to know what data were required to indicate that a change was not working as anticipated and people would be willing to rethink the approach.
This initiative challenged the hospital executives to think about their power in a very different way. The CEO told me that, in the past, if he saw negative data related to patient flow, he would immediately assume the lead, convene a meeting, and try to solve the problem. “This process has really affirmed that that approach not only doesn’t work but it is completely counter to any rhetoric about empowering people. I had to learn a whole new level of patience.” Top
I received some interesting feedback on the nature of physician power. As one doctor commented, “A physician’s power comes from their ‘separateness’ from the hospital [in terms of their employment relationship]. Doctors can appear to others to be behaving irrationally or using their power inappropriately, but it is because they have a very different agenda. They have different incentives and not all of them are savory.”
Key lessons
I ended most of the interviews by asking participants to reflect on the key lessons learned from the PIP initiative in terms of power. Four themes immediately emerged.
The first was clearly the power of data. The director of the ED commented, “Today, data and the transparency of that data drive power. The CEO is very much driven by real time data, especially when it comes to the ED. I know that, good or bad, I will get a call between 7:15 a.m. and 7:30 a.m. every day, so I need to be prepared to explain the data and think about who the people are that need to be engaged in driving any change.” Top
The second theme was the importance of clarity of focus and roles. One executive suggested, “You need every one to be very clear about what it is you want to achieve. We [the executives] needed to be clear and consistent in defining what needed to be done, why it needed to be done now, and who needed to be involved. What we didn’t do — and can’t do — is define how something was to get done.”
In a new setting, being clear about the various roles can be challenging. As one executive put it, “When you’re new to something, it’s easy for people to trip over each other. You need to have patience and discipline to let people get on with it and not feel like you have to interfere.” Top
Another executive suggested, “Distributed power is great, but it does require very clear parameters. I believe that the majority of changes are distributable, but only if you provide clarity.”
The third theme was that Lean methodology works. As one interviewee commented, “While it was first developed for the automotive industry, the same approach to looking at simplifying processes can work in a health care setting.” However, it requires a fundamental change in the culture of an organization. This begins with getting people to work together in a highly collaborative way across departments. Top
As one team member put it, “Lean demands a blame-free environment in which people feel safe to try new approaches. However, the media immediately want to attach blame if anything goes wrong. Freedom of information is an important concept, but it leads to headlines and knee-jerk responses. It’s vital that we find the right balance.”
The final theme related to the power of collaborative learning. It started right at the beginning with a significant investment in the time required to train the two PIP teams so that they were confident and comfortable with the tools and processes. This initial learning was clearly well supported by the external coaches. Then, as the initiative unfolded and began to achieve some successes, the teams became more and more comfortable sharing their learning, experimenting, and developing novel solutions. Top
As one interviewee said, “New knowledge was being created at the front end of the process, with the PIP teams. Learning by doing can exclude some in the hierarchy and they may not have the knowledge that front-line staff are developing, but then the question is, do they need it or is this an example of wanting knowledge for the power it may provide? When you invert the knowledge pyramid, really interesting things happen. There can be comfort in the bubble, thinking that you know what is going on and that things are getting done your way, but the inversion process forces formal leaders to go out and see what’s actually happening.”
“We have learned the collective power of working and learning across systems,” commented one interviewee. “We have taken huge steps forward in the relationship between ED and medicine. We have a better understanding of each other’s challenges, people are much more respectful, and people have clear accountabilities for their piece of the process. The results tell the tale.” Top
“I think that one of the things we have all learned about power,” said an interviewee, “is that any one person has actually very little power — even the CEO. What you need is for a couple of things to converge and then recognize the power that you have to take advantage of the convergence. The wins at the end of the day were not based on one thing, but on a whole bunch of smaller changes converging to produce a transformational change. That has been significant learning for all of us: don’t look for the one magic bullet.”
Conclusion: creating the structural conditions for empowerment
The case study demonstrates the efficacy of intentionally designing the structural conditions through which people have the opportunity to empower themselves, thus allowing sustained change. What is particularly significant is that, in the 4 years since the PIP initiative, new structures have evolved into disciplined strategies. The organization continues to review data and performance. They bring content experts together to create “tests of change.” Together, they set targets for improvement based on current evidence; they have developed lead and lag measures that are monitored over time and then re-evaluated to set new goals. As a result, cycles of improvement continue. Top
References
1.Toffler A. Powershift: knowledge, wealth, and violence at the edge of the 21st century. New York: Bantam Books; 1990: 19.
2.Mackay L. Conflict in care: medicine and nursing. London: Chapman & Hall; 1993:43.
3.Mintzberg H. Mintzberg on management: inside our strange world of organizations. New York: Free Press; 1989:365-6.
4.Northouse PG. Leadership: theory and practice (4th ed.). Thousand Oaks: Sage Publications; 2007:9.
5.Georgopoulos BS, Mann FC. The community general hospital. New York: Macmillan; 1962. 693 pp.
6.Fried BJ. Power acquisition in a health care setting: an application of strategic contingencies theory. Human Relations 1988;41(12):915-27.
7.Faulkner J, Laschinger H. The effects of structural and psychological empowerment on perceived respect in acute care nurses. Journal of Nursing Management 2008;16(2):214-21.
8.Kettunen T, Poskiparta M, Gerlander M. Nurse-patient power relationship: preliminary evidence of patients’ power messages. Patient Education and Counseling 2002; 47(2):101-13.
Author
Peter Dickens, PhD, is a principal in the Iris Group, providing leadership and organizational change consulting to hospitals. He is also a member of the faculty of the Canadian Medical Association/Ontario Medical Association Physician Leadership Development Program, offered through the Schulich Executive Education Centre.
Correspondence to: peter@irisgroup.ca