Maintained and Challenged by some Hospital Staff Members
The Ways that Prestige or Hierarchy is Produced,
Maintained and Challenged by some Hospital Staff Members
A hospital’s main goal is to ensure the well-being of the patients. The doctor is most often perceived as the authority at the top of the hierarchy of hospital organization. After the doctors in perceived importance are the nurses and then lab technicians. Hierarchy is based on more than the professional titles of people in the organisation because the culture outside the hospital has an effect on the hospital organisation. There are other hierarchical patterns in the chain of power based on race, class, ethnicity, religion, gender and religion. (Baer et al., 1997, p. 10) Tensions may be high such as when the dominance of the biomedical system causes “numerous instances of state hostility to indigenous or traditional healers” (Baer et al., 1997, p. 219).
Research studies have applied different measurements in order to evaluate medical systems. For example job satisfaction, hospital performance, and payment system have been used as measurements. Another important variable to measure are the behaviours between personnel, especially between doctors and nurses. New opportunities may now enable a collaborative atmosphere instead of a hierarchy, after all now women become doctors and men become nurses in greater numbers. Perhaps contemporary medical systems have been changing and developing in parallel to the society. A hypothesis has been made that today’s hospital organisations are on the edge of a radical change away from hierarchy in favour of team work.
History, Contemporary Research and Discussion
Not only does the external societal culture influence a hospital’s hierarchy, also the society evaluates the medical system compared to cultural norms. The history of the development of organisational theory as it applies to health care in the UK is discussed. Observations of the relationship between doctors and nurses are discussed by referencing three contemporary research case studies from three different countries. The three countries are Slovenia, Korea and Brazil. The effects of external culture in designing research case studies are observed in detail for Korea. The results between the three cultures are then evaluated for similarities and differences. Finally, the limitations of the studies reviewed and the suggested research will be noted in this section.
Max Weber (1864 - 1920) theorized about the types of social actions that produce the most impact for managing organisations. His theory has been called the “managing of rationalization” (Fry, 1999, p. 15) because he advocated for the need of fair and impersonal public organisational structures. In fact he explained that bureaucratic organizations have a moral responsibility to meet their goals in order to give meaning to their social actions. Fry (1989) explained that Weber’s definition for an “evaluative social action” is one that calls for “purposive, rational conduct” which has been “determined rationally and is oriented toward discrete individual needs (p. 19). In other words, the social action of providing health care is an obligation of the medical system (acting for society).
Talcott Parsons (1902 – 1979) took Weber’s theory further and applied it to ‘sick role behaviour’ and the ‘sick role position’ when he developed the structural functionalist theory. Parsons was very influential in the development of the United Kingdom’s social insurance. He analyzed the function of poor health on the whole society; when workers are sick it is a drain on the society. Parsons helped policy makers understand “the importance of the moral economy surrounding health and illness” (Varul, 2010, p. 72). Parsons also made the important observation that a sick person needs to take on a responsibility to the society by going to the doctor, following the medical instructions, and getting well as soon as possible.
For Parsons, medical authority is first and foremost based on, and justified by, the doctor’s exclusive access to expert knowledge. Consequently, Young (2004: 6f.) observes, as ‘the patient’s knowledge of medicine increases, the power differential between patient and doctor decreases, as does the dominance of physicians in the sick role relationship’ (Varul, 2010, p. 83).
This power differential change can be between nurses and the doctors, too.
Relationship between Nurses and Doctors
Savić and Pagon (2008) specifically looked at the phenomena of the subordination of nurses in order to evaluate the reasons it occurs in a Slovenia hospital. The researchers used surveys and ANOVA for statistical analysis. The results they received from nurses and doctors concerning organizational culture had many similarities but the differences are also interesting. According to Savić and Pagon (2008) organizational culture is “a factor leading to a successful implementation of changes in health care organizations and fostering learning through the work process” (p. 335). The main concepts within an organization culture are that change is welcomed and high quality work is valued. The obstacles to reaching these goals are caused because of the different layers of power and goals which can be found within a hospital’s subcultures: “physicians and managers, physicians and nurses, employees and leaders, unit cultures, team cultures and professional group cultures” (Savić and Pagon, 2008, p. 335).
Organization culture consists of four different types. The clan places the focus on the welfare of the patient. A hierarchy uses a rigid top down power structure. An adhocracy allows individual employees to make decisions. The market focuses on making profits. Vaghetti (et al., 2011) added that “hierarchal structures of authority, rules and lines of specialization are used to organise people” (p. 89). The clan and the hierarchy are both internal mechanisms but the clan allows flexible actions whereas hierarchy controls others in order to ensure stability. The external maintenance types are adhocracy and market. Adhocracy encourages “flexibility and individuality” but market focus on the need for “stability and control” (Savić and Pagon, 2008, p. 336). Physicians and nurses rated hierarchy as the type of organizational culture they had most often experience.
There were no significant differences between physicians’ and nurses’ scores on preferred culture type. Both physicians and nurses preferred clan culture and least preferred hierarchy and market culture. (Savić & Pagon, 2008, p. 337)
In general the participants all agreed that they were satisfied with their job involvement although the amount of satisfaction was not high. The amount of education is the critical variable that causes doctors to treat nurses as subordinates. Interestingly Savić and Pagon (2008) reported that males observed less subordination of nurses than the females observed. (p. 338) The research suggested that “the only domain of work that significantly predicts high job satisfaction as important for all groups is a positive evaluation of local leadership” (Savić & Pagon, 2008, p. 341).
Kim (1994) focused on “human relational aspects (such) as motivation, leadership, and communication among the various groups of personnel” (p. 19). Familism is the attribute which takes into account “traditional norms and patterns of behaviour” between employees. (Kim, 1994, p. 19) Therefore Kim (1994) interpreted familism according to “behavioural patterns of Korean people, which include (a) strict role division, (b) hierarchy by sex and age, (c) patriarchy, (d) authoritarianism, and (e) group orientation” (p. 23). His research was designed to compare “informal structure in relation to corporate culture” (Kim, 1994, p. 33).
The overall findings demonstrate that flaws in hierarchical hospital organisation are observed. Consistently it has been found that “shared learning” is very important to implementing cooperation and collaboration in the hospital’s workforce (Savić & Pagon, 2008, p. 335). Secondly doctors must learn that a whole team works for the patients’ well being, it is not only the doctor who claim responsibility. Thirdly nurses perceive that they are being treated as subordinates of doctors. (Savić & Pagon, 2008; Kim, 1994; Vaghetti, et al., 2011) Steeper hierarchies enabled decreases in motivation and caused unhappy attitudes of subordinate.
Kim (1994) found that communication, work motives, and leadership have contemporary and traditional elements. Familism in Korea affected “patterns of organizational behaviour and job satisfaction” and is key to understanding the comfort employees have within a hierarchical system (Kim, 1994, p. 33). The only reason that employees worked as teams in a rigidly organised environment was because their tasks were not well defined so negotiation was essential.
Vaghetti (et al., 2011) studied conflict in a hierarchal organisational design at two Brazilian hospitals. Organisational Symbolism theory was applied to evaluate the data. Also knowledge from the areas of “health, management, (anthropology), sociology, psychology and the professional experiences of the authors” was incorporated in understanding the data (Vaghetti, et al., 2011, p. 88). They discovered two bureaucracies; a professional and a mechanistic. These parallel hierarchies’ give different meanings to the conflicts between employees at different levels in a hierarchy. Vaghetti (et al., 2011) evaluated two key negative impacts of conflict “Hospital hierarchies and professional disputes” and “Hospital hierarchy and work subversion” (p. 89). Each was found to have different boundaries. They are similar, though, in the way they cause negative attitudes, lower the work quality, and slow down the processes of health care. Interestingly Vaghetti (et al., 2011) could find “no hierarchal lines of power and authority” delineated between doctors and nurses but “the historical submission of nursing to medicine is still present in some hospitals” leading to conflicts (p. 91). This is a serious problem because they understood from anecdotal information that
The lines of authority which are part of the hospital hierarchal structures, especially in the organisation of nursing work, are possible sources of detachment and conflicts between workers, which may lead to subversion in the work in hospitals. (Vaghetti et al., 2011, p. 88)
Hierarchies are not unusual in bureaucratically organised social systems because they are characterised “by more or less hierarchical structures of authority, rules, and lines of specialisation” that organise people (Vaghetti et al., 2011, p. 89). On the one hand the mechanistic bureaucratic structure refers to work processes that are unchanging, standardised, and repetitive. These work processes are determined and controlled by higher levels on the hierarchical ladder. Professional bureaucracy, especially identifiable in hospital organisational structures, is highly dependent on degree of education, specialisation, expertise, and competence at accomplishing tasks. Unlike in other bureaucracies the care givers are not concerned about profit but instead, the focus is on promoting the well being of their patients. The hospitals studied by Vaghetti (et al., 2011) were public hospitals located in Brazil.
In professional bureaucracies, including hospitals, there are two parallel hierarchical lines, one for professionals, in an ascending and democratic order, and another for support positions, in a descending order, with a mechanistic bureaucracy nature. These two lines are in opposite fields and can lead to conflicts in the organisations. (Vaghetti et al., 2011, p. 90)
Goals of employees are dependent on their personal expertise, goals and tasks. Ill-defined task boundaries caused conflict between (a) the administrative personnel and technicians, (b) nurses and doctors, and (c) higher level nurses and lower level nurses. Power struggles and misunderstandings are detrimental on the well being of the patient therefore the hospital’s goal does not have the focus and place of priority it should have. Conflict is a very unfortunate situation for the nurses, the patients, and for the hospital. Vaghetti (et al., 2011) noted that when nurses are no longer regarded as individuals with specific talents and skills but instead as
. . . ‘Positions of power,’ establishing a disciplinary order of the spaces/limits that are allowed, (these are) making the representation of power cause discomfort, both in those that are exercising it and those who are subjected to it. (p. 92)
Anderson and Brown (2010) describe how steep hierarchies are likely to lead to failure. Anderson and Brown (2010) point out that it is essential to make good choices when choosing leaders in order to maintain consistent successes. “Steeper hierarchies will harm collective success when groups select leaders who are selfish, use biased decision-making processes, or use an autocratic leadership style” (p. 57). A leader’s abilities to understand the other perspectives help develop the employees’ trust which is imperative to success. Problems arise with communication processes, trust issues, and defining the boundaries of tasks for smooth work activities; Anderson and Brown call this problem “the hierarchy impeding the intra-group coordination” (Anderson & Brown, 2010, p. 57). Good leaders encourage work motivation and help workers accomplish their work well and efficiently.
Savić and Pagon (2008) received less participation from doctors than from nurses. (p. 341) Kim (1994) was conducted in a Korean hospital so the results cannot be generalized. Vaghetti (et al. 2011) also used the empirical evidence in other studies to reach their conclusions and the observations were in Brazilian hospital so any generalisations should be carefully made.
Kim (1994) used a very interesting methodology, both quantitative and qualitative to breakdown the important elements of familism within Korean organisational culture. Kim’s research would be very good to use as a guide for future research. Vaghetti (et al., 2011) pointed out the need to identify the two types of organisational culture, bureaucratic and mechanistic, in order to give meaning to the conflict events observed. (Vaghetti et al., 2011, p. 92) They highly recommended future studies to develop optimal conflict free work atmospheres by directing attention to “reorientation strategies and awareness of the hierarchical boundaries” (Vaghetti et al., 2011, p. 87).
Savić & Pagon (2008), Kim (1994) and Vaghetti (2011) demonstrated the importance of the external culture on hospitals’ internal organisational. The three cultures (Slovenia, Brazil and Korea) demonstrated that doctors have the prestige and nurses hold subordinate positions. Prestige is awarded to the doctors based on the fact that they have more education than others in the hospital. Physicians need to use their power in the organisational culture to empower others and find ways to motivate high quality performance. Unfortunately often doctors take all the credit for healing patients. Vaghetti (et al., 2011) reported on the negative effects poor leadership in a hierarchy can have on a nurse’s performance. In fact, it can change positive, professional behaviour into negative behaviour.
A hierarchical culture with no defined boundaries as described by Vaghetti (et al., 2011) seems to invite arguments and conflict. In hierarchical cultures there is little experience with team work so positive negotiating skills are not well developed. That is why it is critical to have clearly defined task boundaries to reduce conflict. The tasks necessary in health care include a very broad range of multi-disciplinary skills. The hierarchical (especially the steep hierarchical) structure is the worst to rely upon when a variety of ideas, skills and talents would most help a patient. The steep hierarchical structure does not necessarily lend itself to setting positive challenges for employees.
Assigning prestige to doctors in a hierarchical structure has historic roots and is the traditional way that hospital organisations have been designed. Maintaining the hierarchy is becoming more difficult as health care givers are becoming more specialised in their tasks. Challenges to hierarchy based on this research revealed passive behaviour of nurses who were unhappy at their job. No evidence was found to support the hypothesis that today’s hospital organisations are on the edge of a radical change away from hierarchy in favour of team work. An interesting future study would be to compare hospitals that have encouraged team work with those that have a steep hierarchical structure in order to better understand the processes of change.
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