A scoping review exploring the impact and negotiation of hierarchy in healthcare organisations

Abstract

Healthcare organisations are hierarchical; almost all are organised around the ranking of individuals by authority or status, whether this be based on profession, expertise, gender or ethnicity. Hierarchy is important for several reasons; it shapes the delivery of care, what is prioritised and who receives care. It also has an impact on healthcare workers and how they work and communicate together in organisations. The purpose of this scoping review is to explore the qualitative evidence related to hierarchy in healthcare organisations defined broadly, to address gaps in macro‐level healthcare organisational research, specifically focusing on the (1) impact of hierarchy for healthcare workers and (2) how hierarchy is negotiated, sustained and challenged in healthcare organisations. After a search and screening, 32 papers were included in this review. The findings of this review detail the wide‐reaching impacts that hierarchy has on healthcare delivery and health workers. The majority of studies spoke to hierarchy's impact on speaking up, that is, how it shaped communication between staff with differential status: not only what was said, but how it had an impact on what was acceptable to say, by whom and at what time. Hierarchy was also noted to have substantial personal costs, impacting on the well‐being of those in less powerful positions. These findings also provide insight into the complex ways in which hierarchy was negotiated, challenged and reproduced. Studies not only detailed the way in which hierarchy was navigated day to day but also spoke to the reasons as to why hierarchy is often entrenched and difficult to shift. A number of studies spoke to the impact that hierarchy had in sustaining gender and ethnic inequalities, maintaining historically discriminatory practices. Importantly, hierarchy should not be reduced to differences between or within the professions in localised contexts but should be considered at a broad organisational level.

Factors influencing the joint practice of evidence-based medicine and shared decision-making: A qualitative study of junior doctors and consultants

“…Thus, they did not prioritise decision-making linked to EBM and SDM and consequently educational opportunities for junior doctors under their supervision were reduced. These ndings support those of other studies concerning the impact of medical hierarchies on junior medical staff, where power is recognised among senior medical staff positioned at the top of the hierarchy, thereby reducing the autonomy of those positioned lower in the hierarchy, such as junior doctors (Essex et al, 2023) ). However, there is now a framework providing core competencies that can underpin an EBM curriculum that incorporates SDM .…”

Board talk: How members of executive hospital boards influence the positioning of nursing in crisis through talk

“…This aligns with extant literature on talk and its influence on positioning (Greenhalgh et al, 2023;Oldenhof et al, 2016). However, this literature states that the influence of talk is dependent on hierarchical positioning (Essex et al, 2023). However, this is too limited as organizational interaction is more complex than just organizational hierarchy.…”

“…Nevertheless, we cannot deny the asymmetric power relations (Aspinall et al, 2022;Kee et al, 2021) and the gendered images (Essex et al, 2023;Langley et al, 2019) that exist of and between board members and nurses in crises. As Lopez-Deflory et al (2023a) recently stated; "Nurses play an active role not, only in the reproduction of the institutional status quo which maintains their subordination, but also in the challenge of the complex network of power that constitutes its subordination (…).…”

Patient care in complex Sociotechnological ecosystems and learning health systems

“…Furthermore, hierarchical leadership structures limit the ability of “lower ranking” team members to voice opinions, make implementing change and innovation difficult, and contribute to gender and ethnic inequalities and discriminatory practices. 99 Diverse team leadership groups have demonstrated to be a characteristic of high‐performing teams, 100 with greater success in innovation and outcomes. 101 To facilitate team leadership, the conceptual framework of boundary‐spanning leadership (BSL), 102 defined as “leadership that bridges boundaries between groups in service of a larger organizational vision, mission, or goal,” 103 offers three strategies to align team members across multiple groups, including managing boundaries, forging common ground, and discovering new frontiers.…”