The healthcare hierarchy is a complex landscape that is built upon professional credentials, status, biases of social construct and gender norms. What does all that mean? It means that not only do the initials by your name matter, but also what society and your work cultural norms view as more or less powerful in the workplace. To better understand health care hierarchy, we must first talk about the types of power in the workplace. The presence of two or more overlapping and entangled power hierarchies exists in many healthcare practices and their administration. I'm talking about that subtle or not so subtle war between executives and providers. I’m sure you have seen it, if not experienced in your workplace -often framed as” the moral and righteous white coats vs the bottom-line policy making suits”. Every practice is different and has their specific nuisances, but the basic principles of power in the workplace still exist and contribute to the internal battles regardless of geography or specialty.
To give context to the discussion, I will begin by briefly reviewing French and Raven’s model for the six bases of power that informs the content of this article.
In 1959, two social psychologists, French and Raven, studied power in the workplace developed five initial types of power. They later added a sixth base. (French, J. R. P., Jr., & Raven, B. H. (1959). The bases of social power. In D. Cartwright (Ed.), Studies in social power (pp. 150–167). Ann Arbor, MI: Institute for Social Research.)
1. Legitimate – This comes from the belief that a person has the formal right to make
demands, and to expect others to be compliant and obedient.
2. Reward – This results from one person's ability to compensate another for
compliance.
3. Expert – This is based on a person's high levels of skill and knowledge.
4. Referent – This is the result of a person's perceived attractiveness, worthiness and
right to others' respect.
5. Coercive – This comes from the belief that a person can punish others for
noncompliance.
6. Informational -This results from a person's ability to control the information that
others need to accomplish something.
Understanding these bases of power can help leaders recognize the positive and most effective ways that power can move others toward change, action or collaboration. The six bases of power can be further categorized into Personal and Positional types of power.
Positional power is one form that means power is given to the individual. For example, someone is hired as a manager and charged with the ability to reward or punish team members for actions. Of the six bases of power, four fall under the category of positional power. I make this distinction between positional and personal power because they help us understand how power is obtained and lost in the workplace.
In this article, we will explore broadly the two categories of power.
Personal Power: These powers are earned from others. Meaning that those perceived as having these qualities or traits will garner admiration, trust and acknowledgement of given power. These qualities allow for greater influence and motivation of teams and Individuals. Personal power alone is not always a positive. Someone with poor integrity but strong interpersonal skills can obtain referent power within a group and have negative impact. Good leadership means understanding and utilizing different bases of power to motivate and lead.
Positional Personal Power
Legitimate Expert
Reward Referent
Coercive
Informational
Now that you understand the basic principles, you can better visualize the interplay and metaphoric climb for both healthcare providers and administrators up and down the power hierarchy ladder. Mentally, picture a tower (the organization) with two ladders ascending toward the top. These two ladders represent the two parties : providers and administration. How each person moves up each rung of the ladder looks different. The need for collaboration between these two groups is vital in this economy for the organization to succeed, therefore a scaffolding must be created to connect both parties and will ultimately strengthen and protect the tower (organization).
Positional Power: One of the easiest forms of power to recognize is positional power. ln the typical healthcare power ladder, physicians (MDs) typically wear a white coat with embroidered script declaring their title and represents the symbol of their power and status. This symbol has a cultural meaning that is easily recognized. Seeing the white coat not only infers that this individual is a physician, it generates a physiologic response in some known as “White coat hypertension” .Many people may be familiar with this as they experience heightened blood pressure when they see and experience the intimidation or anxiety from seeing their doctor. Even within the physician subculture, the white coat length is a symbol for graduated levels of medical training. Society and the health care culture gives physicians the positional power and the white coat acts as a supporting visual symbol to reinforce that position. The physician’s positional power allows them to give orders to lesser status individuals and in turn assurance that the orders to be followed as the physician has the expertise to make the decisions and orders.
This expertise as a physician, provides the supporting expert power, a form of personal power, granted by their lengthy education training that prepares them to treat patients. Similarly, the credentials of a nurse-RN in our health care systems signals to patients to bestow expert power allowing for implicit trust to form quickly. Slowly evolving over the years, physician assistants have been given expert power by patients as they now become more familiar with the role of the PA in their care. Even with these formal titles, symbols and cultural norms in place, power can easily be disrupted and taken away depending on the playing fielding.
HOW POWER IS GIVEN, EARNED AND TAKEN AWAY.
In day to day hospital interactions, it is also not uncommon to witness a different type of power usurp traditional positional power. This more hidden type of influencer if called referent power. We will often see nurses disrupt the health care power hierarchy by utilizing this type of power. For example, senior OR nurses using their influence to ensure a new resident surgeon adapts their behavior to that of the group norms of the environment. A proverbial flex of muscle by nurse to the doctor to show that referent power a subtype of personal power can trump position, even by those who carry the highest status.
Referent power is an important type of power to understand because successful organizational leadership and management depends more and more on collaborative efforts and influence. Referent power is a type of personal power that is characterized by reverence gained from strong interpersonal skills and ability to be respected, trusted and admired. Literature supports the use of referent power as more effective for team motivation than use of pure positional power. Recognition that physicians and providers who see themselves as all powerful because of their position, knowledge and status in societal norms aren’t going to be successful navigators of this complex intersection of healthcare and business. Similarly, administrators must also be watchful of the dangerous mindset that their positional power in the C suite as it does not always carry the same status in the world of healthcare.
Knowledge will give you power, but character respect. -Bruce Lee
Removing titles and engaging in collaborative team interaction should allow for the most effective forms of power, referent and expert, to show up. Awareness that the two titans of power, suits and white coats, are going to need to depend upon the use of several bases of power to be successful. The use of referent power is much more effective in this complex system and relies on your ability to build strong relationships with others, gain the respect of your teams, peers and administrators. Recognizing that the energy to influence must not rely on your positional or expert power, but rather your ability to communicate and develop relationships to influence others.
" A title is the most fragile form of power"
Power is a complex and dynamic interplay in our social experience. Increasing your awareness of this cycle of power, helps you to pause and recognize more effective interpersonal communications even if you don’t have a true position or title of power. Decisions and collaboration don’t occur when win-lose, right or wrong strategies enter the power play game. Taking sides only weakens the organizations immune system and reduces your ability to create the strong scaffolding between these two hierarchal systems. Mobilizing everyone’s power and talents is what it takes to lead in medicine.
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