One of the nurses in tertiary care hospital; when he encountered the unexpected incident, while caring a 70 year old male patient in the morning shift, admitted with below Knee amputation due to diabetic foot. While he was performing the nursing task, physician came on round and asked the patient what he had in the breakfast patient replies; milk with vermicelli’s and tea with white bread, on that physician got upset and started shouting at nurse that why you have not stopped this patient eating white bread . Nurse said this is what dietician has recommended him. He started misbehaving with the nurse. Nurse came to my office to share the incidence, I was working there as a Clinical Nursing Instructor (CNI); all the nurses come under the umbrella of medical administration. Physician and his team also followed the nurse to office where he called nurse in a harsh way that you are ”stupid” and “idiot” and punched him on his hand twice and said you shut up and I don’t want to see you again.
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I told the physician to wait and let me check your orders and find out, in the mean time me and my colleague went to the patient to ask was there sugar present in the milk or tea. He said no then we checked the order, it was written clearly diabetic regular diet. I called Diet office and talk to dieticians she said each and every patient get white bread because most of the time people add brown color in the bread and call it a brown bread, so we avoid using brown bread in the hospital with permission of Hospital Director. I called dietician and arranged a meeting with physician and a nurse. Physician did not speak a single word because it was not nurse mistake. This incident upset the nurse emotionally, and eventually the nurse had a fear to lose the job.
Same day I reported to my manager and director; they replied to take an immediate action. There were no existing policies made by human resource department as this hospital is newly emerging organization so there is no well-defined and properly documented policies to take action. Whenever such situation arise they call the inquiry committee, this time they call director of infection control department, director of finance department and director of human resource department but no one from nursing division. I asked my director why finance director was called in the meeting because he has no idea about nursing department how he is going to make a decision. He said I want a neutral person so no one feel bias. Then the nurse was called in front of the inquiry committee, and simultaneously, one of the physician colleague came to me and said “you better withdraw your case otherwise you can never imagine what will happen after that”. I was threatened multiple times and was under pressure. But I asked physician, if the same scenario happened where nurse hit the doctor still your attitude towards nurse be the same. He didn’t reply to me. However, he said I want you to take your case back. Thereafter, I immediately ran to my director’s office and shared the whole story. He said I think you withdraw your case because our goal was to make these physicians realized that now nurses can raise their voices and on that action can be taken. Ultimately at the end you people have to work together. The reason I found later that the whole surgery department was ready to resign and if they resign, the patient will suffer and funds will also be affected. I was very upset and feeling helpless, therefore I suggested him to design a sustainable policy which is applicable to health care professional and next time no one can use their unnecessary power on each other. After that we developed code of conduct, Zero tolerance policy. This enhances empowerment in nurses by increasing job satisfaction amongst the staff, increasing retention and recognizing the nursing profession.
Disruptive physician-nurse relationship is very common in every healthcare organization. However, it is underreported in some healthcare settings. Most of the nurses think that it is the part of their job, fear of not getting support from their superior; Physicians are more educated than nurses. In this position paper I will discuss how Power Game influences nurses, as a major issue in healthcare setting in Pakistan. I will also highlight the Organization power dynamics, line of report to hierarchy management, what power are given to nursing supervisors, Clinical Nursing Instructor (CNI) and Nurse Coordinator (NC) by the organization through literature support and theories. Finally, actions could be taken to overcome similar situation in the future by designing policies and how to empower nurses in the organization.
The Nurse and Physician Power Game discussed by Leonard Stein in 1967. The implicit and explicit relationship of power dominance between doctors and nurses plays the key role in maintaining the balance. By tradition doctor nurse hierarchy is very simple. Doctors are superior to nurses. Doctors are there to cure the patient, and nurses are in charge of folding pillows and mopping brows. Nurses and doctors interaction was very well managed at that time, so no one could disturb each other’s hierarchy.
After 1970, there was a change in the nursing profession through professionalization, moved to university for qualifications, role, and status of nursing began to change. Nursing changed from nurturing to profession that valued its education, responsibilities and skills. Nurses were not necessarily women any more. However, in actual fact nurses yet subordinate to medicine but the status of profession has changed. Opportunities do exist for nurses to exercise their autonomy, beyond the passive role implied by doctor/nurse game. Amongst the health workers, nurses are the front line staffs who come in the close interaction with patient, physicians, families and other paramedical staffs. Nurses are observed as marginalized in the society due to the type of work they are doing for the patient in the hospital. For example, giving bed bath and changing bed sheets. This gives the oppressed image in the eye of the physician. Hence they are easily prone to trap in the power game. For the physician, it is easier to exhibit aggression behavior towards Nurses. My position is when nurse display disruptive behavior she is terminated immediately with disciplinary action whereas physicians have more leniency when it comes to disciplinary action. Therefore it seems organization is more willing to accept their negative behavior, this sends message not only to physicians but nurses also, who are dealing it on continue basis.
Significance of the Problem:
Disruptive relationship between doctors and nurses is common issue in Pakistan. According to my experience some of the hospitals that have developed policies, number of incidences are lower than the hospitals that have not made any policy against such a devastating issue. Nurse Doctor Behavior Survey (2009) shows that nearly 98 percent of the respondent reported disruptive behavior between doctors and nurses in the past year. Furthermore, it is divided into number of times happen in the health care settings, about 30 percent of the participants said bad behavior occurred several times in year , while another 30 percent said it happened weekly, and about 25 percent said monthly. Surprisingly, 10 percent said they witnessed problem every single day. Common complaints were shared by the respondents is 85 percent experience degrading comments and insult at their organizations. Yelling was the second problem with 73 percent. In Pakistan no survey has taken place so far, but there are some reasons that are under reported. Nurses take this as a part of their job, they think doctors are more educated than nurses, most of the time nurses blame themselves not the doctors and some think that our nurse manager will not support. Some of the nurses are the only earning member of the family and therefore fear of losing job let them to be passive in raising voices against physicians. There is considerable impact of cost on the individual and the organization estimated cost could be up to 4.2 million (Marquis & Huston, 2012). According to the scenario, the nurse told that I think this is a part of my job and I am the only earning member of the family, so we assured him our full support and discussed our plan of raising incident report within the power given to us by the organization. A very important point to ponder; why power is important for individual? Who is working in the health care settings? Physician administrator are considered the dominant group in the healthcare settings that often shows disruptive behavior towards nurses and ultimately hinders the nurse autonomous decision making power which makes it difficult for the nurses to work for the patient benefits under such circumstances. In this scenario, it was a dietician who was responsible for patient’s food whereas nurse responsibility was to check whether patient has received the appropriate meal according to his diagnosis. I believe doctor insulted the nurse for no reason. We asked the nurse to raised incident report and send to Nurse Coordinator, Manager Administration and chief director operation (a Physician) and Human Resource Department.
Power Dynamics in the Organization:
Power is a capacity to act or strength and potency to accomplish something. It is impossible to achieve organizational power or personal without adequate power. (Sullivan &Decker, 2008, .p.58). Power is an important concern in nursing practices. In the past, power use by the formal organization structure is changing significantly. According to Thompson (1960) formal organization is planned system where each participant has a defined role to perform. These roles are assigned to individuals in order to achieve organizational goals.Due to global competition and deregulations of the organizations are searching to bring new change to manage employers. New forms of role and responsibilities of the employment are being developed political system in the organization plays a very vital role in this regard. When organization are changed primarily the existing balance of power is also change, people in and around the organization will either support or create hindrance to these processes.( Argyris, 1990; Beer, 1988; Kanter, 1993). Organizations power is used by Board of directors, Chief Executive officer (CEO), Administrative Manager (Physician), employees and the interest group. The function of this group is to use their power to manage and bring effective change. Long-established management viewed changed process as a challenged whereas the management takes their view as a resistance. Since these actions are fall outside the legitimate activities of the change process. Legitimate power is a position power gained by a title or position given by the organization (Hardy &Clegg, 1996). Power, change process and resistance are closely related concepts. In change process many people play their role. As a result, power concept means power over another person and this can easily lead to resistance (Clegg, 1994). However, not all the power efforts results in resistance. In change process and power can be equally leads to compliances or even commitment to change (Falbe & Yulk, 1996). Therefore, I see a close association between power and individuals resistance to change.
In organizational change, sometimes part of power dynamics may not be visible, occasionally issues decision making may excluded in the change process which constraint the equal or full participation (Bachrach & Baratz, 1962). Whereas, constructive management used power to create legitimate outcomes, decisions, values, and demands (Pettigrew, 1977). There are five perspectives of power dynamic which relate to organizational change process. These cannot be isolated but it can be used in combinations. First perspective is legitimate power. This power is used by top managers in order to bring effective change in the organization. This power requires control to possess pertinent power sources in order to get things done by others what you want them to do. Bass (1960) has distinguished two power sources: position power and personal power. Position power is person’s formal position which applies to legitimate authority positive or negative such as reward or coercion. Hence, position power helps management to control the behaviors of others. This power is important to know to what extent employees are performing their task. Therefore, management uses control system. A leader has the authoritative figure to impose and declares effective organizational change. The criteria for effectiveness are quick financial and technical result. Decision based on one sided interest of share holders and exclusion of employers. Change is forced by reward and coercive strategies (Chinn& Benn, 1976; Dunphy & Staces, 1988). This approach is common at time of crisis and rapid action is required. Resulting, in compliances when organization depends on each other, take immediate action when there is no other alternative available. As in the scenario, physician used this power very effectively; organization as a whole views physician as powerful. As all nurses are reporting to director operation who himself is a doctor. Second perspective is a personal power. Personal power is required to make changed happened in the organization. According to Bass (1960) personal power is a referent power, expertise, and charisma. This power can be viewed as a capacity to influence another person, so your ideas or plans accepted in the organization. In order to act as a change agent in the organization, one has to have six power bases (Beer, 1980). That is competency, professional capability, and effectivity. Second and third power base is coalition, this will help the nurse to develop relationship with multiple key power figures in the organization. These relationship give access to the nurse to those key individuals who knows what is going on in the organization, which will help her in the implementation process in the organizational change. By developing staff support as a power base a manager can increase the resources influence strategies as these key figures gives power in the organization. By showing the improvement in the organization gives positive reputation and credibility. Reputation is the fourth power base. Fifth base is a group support, when there is strong group cohesiveness and agree on the same goal and support each other makes it group much more powerful. Sixth power base is a resource and knowledge, when a manger offer help in solving the problem when it is required. This will enhance the influence as they have important resource which manager has it. To my understanding, uses of power where people are not getting equal rights, where their emotions and behavior are attached to self-respect of the individuals are not taking seriously. Rights of the nurses are compromised and ignored. CNI’s power was to designing policies, recruiting and selecting new nurses, working in collaboration with stake holders, inter -multidisciplinary team in the development, implementing and evaluating staff development programs, sharing and reporting staffs concerns and discussing issues directly to administrative manager.
Third perspective is that many organization uses power distribution to the individual in the organization to control the process of organizational change. All individual play their own role, based on their power in the organization, department power and their own interest. Management uses this power to win the conflicts and strengthen their position in the negotiation process. Here CNI has power to report if any incidence takes place to director. If the nurse will not report complain it would remain under reported and directors and CEO would not be able to take any action. Moreover, this will not give chance to develop or generate the policy. Organization rule and regulation, decision making, and negotiation reflect the management struggle to control such incidences should not take place is the great achievement of the management (Edwards, 1979; Giddens, 1979; Hardy & Clegg, 1996). For example, CNI raised voice for their sub-ordinates at higher decision- making levels in health care and make them realized the importance of nurses.
Fourth perspective is cultural power; every organization has its own values and norms as I mentioned earlier there were no proper policies documented but they use to take action on misconduct like misbehaving with patient. In the organization previous ideas and culture regarding medical dominance were taken for granted because nurses didn’t have emergent role, like today in well-established institution where nurses’ role is very emergent and doctor nurse relationship are not disruptive. Management fulfills a special role in cultural power which gives opportunity to develop norms and values in the organization. As I state in the scenario, management developed a policy which is applicable for healthcare professionals. This supports the organizational sociocultural norms, which brings behavioral change in attitude, values and significant relationship.
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Fifth perspective is open discussions and communication is critical component in the improvement of the working environment. Open discussions based on good will, arguments, and exchange of questions and rational bring consensus about the present and future states of the organization. Where everyone gets opportunity and learn from each other’s experience. As in the case scenario, doctors were not willing to negotiate because they threat the nurse and CNI to withdraw the case. CNI was resistant because there was no proper policy or code of conduct exists. This time CNI’s fight for the nurse’s right. Right is defined as a claim to anything which a person is allowed, such as power or opportunity. It is organization responsibility to give respect to nurses and their profession to encourage safe working environment.As I discussed, earlier nurse felt very anxious and helpless. The role of doctor as a leader was not supportive to nurse. However, he was in a win lose situation. Filly (1975) Win lose situation is in which one party win usually by power of authority and ultimately other party loses; by forcing, competing and negotiation. Here Director asked CNI to withdraw the case because if she would not withdraw the case then the physician and his department would resign. As he bring lot of funding to an organization. Hence, for saving nurse job we transferred to him other unit, where he cannot come across to the same doctor.
Policy in the Organization
Policy is a key element in healthcare organization to function on set standards. According to Sullivan and Decker (1997) that “Policy is a principle that govern action directed towards given ends” (p. 440). Development of the policy is the current requirement of the administration. Leader-managers in power positions in today’s health settings need to understand the politics within the context of their employing organization. In order to make the policy it has to meet certain requirements, that is identifying the problem, use legitimate power and raise action. According to Kingdon (2000) Policy can also be characterized as policy window. It is open when three stream – Problem, proposal, and politics comes together .In other words policy decisions are taking place when problem are recognized , solutions are available and political conditions are right. According to Tremain (2009) once policies are in placed, leaders begin to expect good behavior and self- policing takes place. Many organizations do have the policy but for the documentation purpose practical implication is lack. Same happened in the scenarios, in doctor nurse power game use to happen in the past but went under reported like in this case nurse would not have reported, policy action would not have taken place. Having the right policy and procedure supports the organization by educating the health care professional, addressing this disruptive issue as prevention. Such as, code of conduct like misbehaving with staff or patient, misuse of absent policy and so forth,and zero tolerance policy in the context of individual organization. This policy states that hospital will not tolerate any unhealthy behavior from patient, family, and health care professional. Such policy helps the organization to provide safe environment.
Conceptual Frame Work
The concept of empowerment in nursing is very primitive and essential ingredient to work effectively in the organization. According to Malin and Teasdale (1991) empowerment is a freedom to choose and retain autonomy and responsibility for decision making. Nurses often experience disruptive behavior from physicians like over dominating behavior example hitting and using inappropriate words over nurses. Moreover, in Pakistan nurses are viewed as a very oppressed.According to Freire’s (2007), oppression is characterized by assimilation, marginalization, selfâ€hatred, low selfâ€esteem, submissive behaviors inappropriate words. Due to which imbalances of power in the institution takes place, resulting in low self- esteem, low autonomy and limited access to resources. In case of nurses, dominating group are physicians and hospital under administration, they view nurses as inferior morally and intellectually; despite of advance education and scope of practice of nurses. The result of this lack of autonomy nurses are not supported by the institution which is a discriminatory attitude towards nurses. As we know, nurse without power is ineffective because she would be unable to influence physicians, patient and other health team member. In order to survive in the organization, organization needs to provide power to bring effective change. Employees who are empowered by the organization they are committed, accountable and able to fulfill job demands in an effective manner.
Empowerment is a positive concept which focuses on strength instead of weakness this would help nurses to think critically. Kantar’s theory will help us to promote empowerment in nurses, provides nurses with access to information, resources, support, and the opportunity to learn and develop. I would like to share a background of the organization where I use to work; initially there were no concept of CNI’s and nursing education services exist. There were only head nurses who are directly reporting to the hospital administrator who is a doctor. When I joined, I had to face a lot of challenges in struggling for nursing power, we had a group of nursing coordinator and two CNI’s, our goal was to bring change in nurses attitude and behavior and the cultural norms that nurses are inferior. Looking at this, physicians were very reluctant and resistant to accept change in the system. Although, organization given us power, support and environment to bring effective change where nurses can take their ownership.
According to Kantar (1977/1993) workers are empowered when they perceived that the environment providing them opportunity to grow and access to power required to carry out their job demand. When the employees feel powerlessness, this leads individual to reduce job satisfaction. Kantars state that power enables to mobilize resources in order to accomplish the task. In the organization one should have the power to access the resources, support and information for job related empowerment and challenge to growth and development of the organization for that one need to have formal and informal power. Formal power is learned by extra ordinary performance at the organizational level, which attracts others (Brown &Kantars, 1982). Informal power results from political and social influential relationship like sponsors, peers and subordinate. Sponsors are mentors, coaches, in my organization sponsors were directors and manager administrator who provide approval, supports, and guidance to function effectively in a given position. As a nurse, we had formal power where we formed a nursing committee comprises of head nurses from different department, meeting use to held every week, where we discuss their issues and make a report and take necessary actions. There was another committee comprises of physicians from multidisciplinary teams and CNI’s where we discussed nurses and physicians, and patients related concern and then plan of action decides handling complaints and patient satisfaction outcome. As a Nursing Education Services (NES), quarterly employee recognition on the basis of assessment criteria developed by our team with administrator support, annual performance appraisal, funding support to bring manikins and equipments to teach different skills to nurses was a great source of support. If there were no support and resources provided by the organization we would have experienced increase frustration and burn out. This empowerment develops trust and supports from subordinate which is very important for the organization. If we would not have that power, then we were unable to fight for the nurse rights, would not have fostered the nurse morale. Before they were not reported the incidence taking place as they had a fear of not getting support from the superiors. As a result, in this scenario nurse viewed CNI’s are there to fight for them. In order to empower your subordinate, it is very necessary to empower yourself with experience, knowledge, and expertise that gives the power. As a result this gives great impact on the subordinate. Although I had a formal power but I didn’t have informal power that is external political power whereas the physician had both the power (internal and external) to exercise his autonomy in the organization. This made me realized that positional power is not sufficient only when you have to have political power in order to survive in the organization. Therefore, I was threatened and withdrew my case as I have to see my personal safety and security also. Although I was in the ambiguity at that time and wanted to support nurses but I felt helpless.
The structure of opportunity is defines when individual’s prospects of growth and movement within the organization includes sense of challenge, chance to learn, and developed. Those who get chance to access to opportunity they seek to learn and develop whereas people who do not get access to these opportunity face low self- esteem. Likewise, I felt inferior when I was threatened and due to political pressure I had to withdraw the case. Political situation is not controllable in this current situation of our country. As director was a doctor he had win lose situation where he supported the physician, if he didn’t support him then patient would suffer and great impact on funds may occur and organization cost would also be affected. Whereas, in nurse case we shifted him to another unit as we wanted to save his job and to avoid further disruptive relationship between physician and the nurse. Kantar (1993) stated that individuals who maintained access to power and opportunity structure can achieve the goal because they are highly motivated and able to motivate and empower others. The personal impact on the employee’s gives respect and cooperation and better patient outcome.
Historically, nurses have had a limited power in the health care system. Change may not occur rapidly as desired, and nurses may get frustrated because of inability to influence in the organization. Nursing organization are providing with voice at higher decision making levels. Nurses need to remain knowledgeable through education and skills to increase the power as an essential part of management also for nursing practice.French and Raven argue nurses gain power, when they have unique knowledge, skills, and expert ability. Provide certified courses so they can integrate theory into practice. Provide opportunities for career ladder where they can enhance themselves professionally for example, Baccalaureate in Nursing and Masters in Nursing. Arrange awareness and development sessions for nurses, on how to catch verbal and physical abuse signs and how to response when the situation occur like incidence reporting, unblocking channels of communication e.g., timely reporting of incidence, strengthens the reporting system. Finally, informed superior person, at least they can remove the person from the unhealthy environment and help to save their job. Organization must provide alternative like transfer the nurse to a different department according to his or her competence and expertise. Kanter (1993) stresses that, positive feedback from higher management and opportunity to make own decision is an important source of power. As these components link employees to organization mission or goals. Nurses should be conveyed the approved Policy of the organization, so that they can work on the standard of practice and know their rights, roles, and responsibility.
Nursing had changed from a nurturing role to being a professional that valued for its education, skills, and responsibilities. More recently, emergent of Nurse Practitioner role brought further evolution in the nursing professional status and influence over health care system. Nurses’ remain subordinate to medicine, but status has been changed professionally, although now a days nurses are exercising their autonomy in a limited manner and not accepting the passive role of the physician. In Pakistani context the boundary between care and cure lead to empowerment of the nursing profession and encourage nurse and doctors to work with mutual and respectful relationship.
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