Presentation
HE16 - Leveling the Medical Hierarchy: The Right Idea, the Wrong Medicine
SessionPoster Session 2
DescriptionWith around half of healthcare employees seeking to leave their positions by 2025 (Kelly, 2022) – it is clear healthcare has come face to face with the repercussions of running a system where everyone is constantly burned out and incapable of expressing themselves, constantly hindering patient safety. For this reason – among many others – it is clear hospital environments need change. Yet – organizational change is difficult (see Kellogg, 2011), costly, and very, very time consuming. In our quest to aid build a better culture, many researchers have pushed the idea of leveling the hierarchy (e.g. Clapper, 2018; Green et al., 2017). But the premise of this is built on an assumption we have never tested, and leaves employees without the necessary tools for change.
At large, hierarchies can be defined as the rank order of individuals or groups with respect to a valued social dimension (Magee & Galinsky, 2008). Therefore, the essence of “leveling the hierarchy” ties into the idea that differential rank makes it difficult to speak up, so that those with less rank (e.g., nurses, residents) will not call out issues when they see them for fear of punishment. This finding, now widely recognized, is of vast importance given that psychological safety – the ability to speak up without fear of repercussions (Edmonson, 1999) – has been tied to a variety of pivotal outcomes in healthcare, like patient safety (O’Donovan & McAullife, 2020). Notwithstanding, this line of thinking assumes hierarchies equal a lack of psychological safety. No study to date has explicitly drawn that correlation (see Krishnakumar et al., 2021), and in fact, decades of team science research show competing evidence for (e.g., Cantimur et al., 2016; Halevy et al., 2011) and against hierarchies in relation to team performance outcomes (see Greer et al., 2018).
Therefore, the first aim of this presentation is to explore the conditions under which healthcare hierarchies are beneficial to performance (e.g., patient safety) – and largely, to contest that leveling the hierarchy is the appropriate solution to healthcare’s communication issue. Moreover, we discuss how strategies aimed at leveling the hierarchy in a hospital system could potentially exacerbate healthcare’s communication and interpersonal issues, because they threaten those in power, resulting in potential adverse effects (see Mooijman & Graham, 2018; Zhong & Li, 2024). This is based on the fact that hierarchies are not unidimensional – as power and status are “the two most important bases of social hierarchy” (Magee & Galinsky, 2008, p. 358). Power is defined as asymmetric control over valued resources while status can be understood as the extent to which an individual or group is respected by others (Magee & Galinsky, 2008; Magee & Smith, 2013). The parsing out of these two components is vital given that it is well-established that people can have differential power and status. For example, when individuals have high power and low status, this results in destructive effects (Fast et al., 2012). Moreover, all combinations of power and status are possible (see Lovalgia et al., 1995).
At large, there are two main perspectives on hierarchies and their effects on team performance: the functionalist perspective (“pro-hierarchy”) and the conflict perspective (against hierarchies; see Greer et al., 2018). The functionalist perspective holds hierarchy has a coordination-enhancing effect, whilst the conflict perspective argues the segmentation hierarchies result in feeds into the conflicts teams have, mitigating their performance (Greer et al., 2017; 2018). While meta-analytic evidence supports the conflict perspective (Greer et al., 2018) – this picture does not directly translate into the healthcare realm. For example, Greer et al. (2017) state: “Wellman (2013), Mitchell et al. (2015), and Perry (2014) all found that perceived dispersion in referent power, or status, decreased the performance of healthcare teams” (p. 108). Yet, upon examination of these results, it turns out Perry (2014) found differential effects for power and status in nursing teams. While power differentiation led to a reduction in performance errors, status differentiation led to lower psychological safety (Perry, 2014). Moreover, Krishnakumar et al. (2018) explicitly researched the correlation between psychological safety and levels of power distance – and no correlation was found. Therefore, the assumption that leveling the hierarchy leads to an overall better hospital system might be incorrect.
The second aim of this presentation is to parse out the differential effects power and status have on healthcare teams. For example, we know people fundamentally desire status, crucial in determining people’s self-concept and group behavior (Xu et al., 2024). Disputes over status undermine cooperation and encourage conflict in one’s team (Anicich et al., 2016; Xu et al., 2024). On top of this, status differences have been known to mitigate the flow of information among members (Gray et al., 2023). Moreover, healthcare professionals with higher status have reported higher levels of psychological safety, while those lower in status report lower levels (i.e., they are more afraid of asserting themselves; see O’Donovan & McAullife, 2020). Therefore, it is likely that when it comes to hierarchy’s adverse effects, it is status and not power driving negative consequences.
Meta-analytic research has found that task ambiguity positively moderates the relationship between hierarchies and team performance (Greer et al., 2018). Healthcare tasks can be very ambiguous, especially when challenges arise (making team resilience vital for performance). However, research specific to the healthcare field has found that while power centrality is beneficial for difficult tasks (e.g., shared leadership is not beneficial for surgical teams), it does not seem to be beneficial when task ambiguity is encountered (Pasarakonda et al., 2020).
Notwithstanding, in healthcare, tasks tend to be centered around higher power individuals (e.g., surgeons, nurse managers) – and these networks are unlikely to change, as professional mobility is usually limited (e.g., nurses do not usually become doctors; see Nembhard & Edmonson, 2006). Therefore, while it is not necessarily the case in other industries, power hierarchies in healthcare are largely immutable (i.e., a nurse would require years of additional formal training to become a surgeon). For this reason, high power individuals have a disproportionate effect on team outcomes compared to those lower in power (see Avgerinos et al., 2019 for surgical teams) – precisely the situation in which hierarchies have been posited to serve their positive functions (see Greer et al., 2018; Gray et al., 2023). Yet, power hierarchy’s immutability does not guarantee employees will perceive it as legitimate. If power hierarchies are perceived as illegitimate, this can lead to perceptions of unfairness and other adverse effects (e.g., Hornsey et al., 2003). Therefore, for power hierarchies to yield their positive effects, they must display legitimacy, as this represents “buy-in” from followers rather than coercion (see Halvey et al., 2011). If healthcare employees buy into the hierarchical differentiation of resources, and internalize these understandings, then this would enable hierarchy’s functionality aspect.
The third and last aim of this presentation is to provide evidence-based recommendations to make the strategy of “leveling the hierarchy” more scientifically aligned with these differential effects. The presentation will go over ways to flatten the status hierarchy whilst keeping power hierarchies legitimate, and potential training interventions that take these differences into account. Moreover, it will discuss how current training interventions only equip employees with culture toolkits (see Kellogg, 2022), and not the structural changes required to embrace hospital-wide organizational change.
All references are available upon request.
At large, hierarchies can be defined as the rank order of individuals or groups with respect to a valued social dimension (Magee & Galinsky, 2008). Therefore, the essence of “leveling the hierarchy” ties into the idea that differential rank makes it difficult to speak up, so that those with less rank (e.g., nurses, residents) will not call out issues when they see them for fear of punishment. This finding, now widely recognized, is of vast importance given that psychological safety – the ability to speak up without fear of repercussions (Edmonson, 1999) – has been tied to a variety of pivotal outcomes in healthcare, like patient safety (O’Donovan & McAullife, 2020). Notwithstanding, this line of thinking assumes hierarchies equal a lack of psychological safety. No study to date has explicitly drawn that correlation (see Krishnakumar et al., 2021), and in fact, decades of team science research show competing evidence for (e.g., Cantimur et al., 2016; Halevy et al., 2011) and against hierarchies in relation to team performance outcomes (see Greer et al., 2018).
Therefore, the first aim of this presentation is to explore the conditions under which healthcare hierarchies are beneficial to performance (e.g., patient safety) – and largely, to contest that leveling the hierarchy is the appropriate solution to healthcare’s communication issue. Moreover, we discuss how strategies aimed at leveling the hierarchy in a hospital system could potentially exacerbate healthcare’s communication and interpersonal issues, because they threaten those in power, resulting in potential adverse effects (see Mooijman & Graham, 2018; Zhong & Li, 2024). This is based on the fact that hierarchies are not unidimensional – as power and status are “the two most important bases of social hierarchy” (Magee & Galinsky, 2008, p. 358). Power is defined as asymmetric control over valued resources while status can be understood as the extent to which an individual or group is respected by others (Magee & Galinsky, 2008; Magee & Smith, 2013). The parsing out of these two components is vital given that it is well-established that people can have differential power and status. For example, when individuals have high power and low status, this results in destructive effects (Fast et al., 2012). Moreover, all combinations of power and status are possible (see Lovalgia et al., 1995).
At large, there are two main perspectives on hierarchies and their effects on team performance: the functionalist perspective (“pro-hierarchy”) and the conflict perspective (against hierarchies; see Greer et al., 2018). The functionalist perspective holds hierarchy has a coordination-enhancing effect, whilst the conflict perspective argues the segmentation hierarchies result in feeds into the conflicts teams have, mitigating their performance (Greer et al., 2017; 2018). While meta-analytic evidence supports the conflict perspective (Greer et al., 2018) – this picture does not directly translate into the healthcare realm. For example, Greer et al. (2017) state: “Wellman (2013), Mitchell et al. (2015), and Perry (2014) all found that perceived dispersion in referent power, or status, decreased the performance of healthcare teams” (p. 108). Yet, upon examination of these results, it turns out Perry (2014) found differential effects for power and status in nursing teams. While power differentiation led to a reduction in performance errors, status differentiation led to lower psychological safety (Perry, 2014). Moreover, Krishnakumar et al. (2018) explicitly researched the correlation between psychological safety and levels of power distance – and no correlation was found. Therefore, the assumption that leveling the hierarchy leads to an overall better hospital system might be incorrect.
The second aim of this presentation is to parse out the differential effects power and status have on healthcare teams. For example, we know people fundamentally desire status, crucial in determining people’s self-concept and group behavior (Xu et al., 2024). Disputes over status undermine cooperation and encourage conflict in one’s team (Anicich et al., 2016; Xu et al., 2024). On top of this, status differences have been known to mitigate the flow of information among members (Gray et al., 2023). Moreover, healthcare professionals with higher status have reported higher levels of psychological safety, while those lower in status report lower levels (i.e., they are more afraid of asserting themselves; see O’Donovan & McAullife, 2020). Therefore, it is likely that when it comes to hierarchy’s adverse effects, it is status and not power driving negative consequences.
Meta-analytic research has found that task ambiguity positively moderates the relationship between hierarchies and team performance (Greer et al., 2018). Healthcare tasks can be very ambiguous, especially when challenges arise (making team resilience vital for performance). However, research specific to the healthcare field has found that while power centrality is beneficial for difficult tasks (e.g., shared leadership is not beneficial for surgical teams), it does not seem to be beneficial when task ambiguity is encountered (Pasarakonda et al., 2020).
Notwithstanding, in healthcare, tasks tend to be centered around higher power individuals (e.g., surgeons, nurse managers) – and these networks are unlikely to change, as professional mobility is usually limited (e.g., nurses do not usually become doctors; see Nembhard & Edmonson, 2006). Therefore, while it is not necessarily the case in other industries, power hierarchies in healthcare are largely immutable (i.e., a nurse would require years of additional formal training to become a surgeon). For this reason, high power individuals have a disproportionate effect on team outcomes compared to those lower in power (see Avgerinos et al., 2019 for surgical teams) – precisely the situation in which hierarchies have been posited to serve their positive functions (see Greer et al., 2018; Gray et al., 2023). Yet, power hierarchy’s immutability does not guarantee employees will perceive it as legitimate. If power hierarchies are perceived as illegitimate, this can lead to perceptions of unfairness and other adverse effects (e.g., Hornsey et al., 2003). Therefore, for power hierarchies to yield their positive effects, they must display legitimacy, as this represents “buy-in” from followers rather than coercion (see Halvey et al., 2011). If healthcare employees buy into the hierarchical differentiation of resources, and internalize these understandings, then this would enable hierarchy’s functionality aspect.
The third and last aim of this presentation is to provide evidence-based recommendations to make the strategy of “leveling the hierarchy” more scientifically aligned with these differential effects. The presentation will go over ways to flatten the status hierarchy whilst keeping power hierarchies legitimate, and potential training interventions that take these differences into account. Moreover, it will discuss how current training interventions only equip employees with culture toolkits (see Kellogg, 2022), and not the structural changes required to embrace hospital-wide organizational change.
All references are available upon request.
Event Type
Poster Presentation
TimeTuesday, April 14:45pm - 6:15pm EDT
LocationFrontenac Foyer