Scott T. Paynton, PhD
There is a large body of literature devoted to physicians' abilities to communicate effectively regarding medical interventions. However, nurses’ use of a variety of communicative techniques to advocate appropriate patient care effectively has gone largely unexamined. Although a great deal of formal power in the distribution of healthcare resides with organized healthcare systems, clinical administration, and physicians, nurse participants in this study demonstrated they communicatively exercised informal power strategies in the performance of their role as patient advocates. This study is a qualitative analysis of the narratives of six registered nurses, gathered over a six month period of time, which reveals the ways nurses influenced the outcomes of patient care through their use of the informal power available to them. The narratives of these nurses revealed how they were able to draw on informal power to manage both organizational and also hierarchical constraints in order to advocate for proper patient care.
Citation: Paynton, T., (October 27, 2008) "The Informal Power of Nurses for Promoting Patient Care", OJIN: The Online Journal of Issues in Nursing; Vol. 14, No. 1
communication, formal power, hierarchical constraints, informal power, narrative discourse, organizational constraints, patient advocate, patient care, patient health outcomes, power
In the mid-nineties a series of articles and responses in the Journal of Medical Ethics highlighted the functions of power and authority as practiced in health organizations. May (1993) initiated debate when he argued that nurses maintain significantly little authority and autonomy within healthcare. He further argued that there remains an organizational mandate for nurses to follow physicians’ directives based on institutionally recognized power and hierarchical structures. May asserted that logical and essential reasons, such as education, validate the notion that physicians should hold the greatest formal power within healthcare organizations by writing, “The basis for the nurse’s obligation to carry out a physician’s order lies in the credentials of the physician” (May, p. 224). Thus, May concluded that nurses are professionally bound to follow physicians’ directives, essentially without question.
...nursing is a fundamentally different profession than medicine. Not surprisingly, many believed May’s reasoning was flawed. Critics of May have pointed to the inconsistent ways he delineated institutionalized power differences between physicians and nurses. De Raeve (1993) stressed that May’s assessment of institutionalized power in health organizations is dependent on an outdated, bio-medical model that places physicians as the ultimate authority concerning medical decisions. De Raeve conceded that physician authority rests largely in the context of her or his training. However, he argued that nursing education is not inferior, but necessarily different than that of physicians, in that nursing is a fundamentally different profession than medicine.
Nash (1995) countered both May and De Raeve when he suggested that neither physicians or nurses maintain ultimate authority in the provision of patient care, a sentiment that is largely held and experienced in today’s world of healthcare managed by a variety of organizational constraints. Nash stated that both physicians and nurses work under the restrictions of organized healthcare that continually redefine how healthcare professionals exercise their roles. May (1995) responded that, despite changes that have occurred in healthcare operations, physicians are still ultimately responsible for patient care.
Healthcare organizations continue to increase the professional responsibilities of nurses, yet remain slow in recognizing nurses as autonomous professionals. Fast forward a decade, and debates about power, authority, and autonomy continue to emerge regarding the definition of nursing and the execution of nursing interventions. In a study by Kihlgren, Forslund, and Fagerburg (2006) nurses reported that physicians, and those with organizational control, did not understand nurses’ professional place in the implementation of patient care. Physicians have traditionally been trained to expect other healthcare providers to be submissive to their directives (Campbell-Heider & Pollock, 1987; Cassell, 2005; McCullough, 1999; Tauber, 2003). In contrast, nurses, whose view of patient care is often conceptually different than that of physicians (Paynton, 1997), often seek mutual respect and collegiality in order to successfully form collaborative healthcare teams that facilitate quality patient care. Healthcare organizations continue to increase the professional responsibilities of nurses, yet remain slow in recognizing nurses as autonomous professionals. Even with increased work responsibilities, nurses are often treated in ways that discourage any enhancement of their formal power and authority to provide patient care (Ruston, 2006). Coombs and Ersser (2004) found that while nurses are important in implementing patient care, their role too often remains devalued and unacknowledged. They argued that formal power structures make it difficult for nurses to have substantial formal influence in decisions regarding patient care. Burns (1978) noted that power is often dependent on relational contexts and is used to meet the collective goals of the relationally involved.
Northouse (2001) defined power as “the capacity or potential to influence” and proposed that organizational members exercise “position power” and “personal power” within the context of their professional roles (p. 6). Too often, the position (formal) power of nurses is understood as being beneath that of healthcare organizations and physicians. Although nurses are often perceived as not having significant amounts of formal power, they are able to use their personal (informal) power to implement patient care.
Ironically, within healthcare organizations, formal power is often proportional to time spent separated from patients. Ironically, within healthcare organizations, formal power is often proportional to time spent separated from patients. Nurses spend considerable time assessing and caring for patients. Mumford (1983) wrote, “contradictions in formal authority and rights compared with daily responsibility and information characterize the work of many nurses in hospitals” (p. 287). He insisted that nurses exercise a great deal of power regarding health outcomes for patients because they spend the greatest time in direct contact with them. Nevertheless, the greatest formal power remains with healthcare organizations, as well as physicians; the people who spend the least time with patients. Continual and direct access to patients provides nurses with considerable informal (personal) power; in contrast physicians, who maintain far less personal contact with patients, must rely on information they receive from nurses to make informed medical decisions. Nurses understand that access to, and distribution of, information are increasingly equated with power. Thus, nurses recognize the importance of the information about patients that they have at their disposal as a tool for implementing patient care, regardless of the degree of formal recognition of their professional role. Nurses take on significant decision-making responsibilities due to the information they have about patients, even when that decision making is not necessarily sanctioned by healthcare managers or physicians. In this way, nurses exercise noteworthy informal power for influencing patient care (Hughes, 1988; Lipley, 2006). Despite their ability to utilize informal power, nurses have continued to express dissatisfaction in their professional roles due to a perceived lack of control and formal decision-making involvement in patient care (Attree, 2005).
Nurses take on significant decision-making responsibilities due to the information they have about patients, even when that decision making is not necessarily sanctioned by healthcare managers or physicians. In an attempt to recognize and validate the power that nurses have to influence patient care, many medical schools have developed programs to teach medical students the importance of listening to nurses. Johnson, Norton and Wilson (1992) wrote of an early program at the University of Kentucky Medical Center that encouraged residents to foster collaborative partnerships with nurses. Residents in this program followed nurses through an eight-hour shift, assisting them without maintaining the formal status differential in roles. Residents stated they gained a greater appreciation of the level of informal power nurses maintained regarding patients’ health status and care through this experience. Studies are clear that increased collaboration, and recognition of the value of professional roles, positively impacts the outcomes of patient care (Raymond, 2005; Taylor, Oberle, Crutcher & Norton, 2005; Tschannen, 2004). Despite organizational constraints, a trend continues to promote greater collaboration among healthcare professionals to improve patient care. Additionally, as Jervis (2002) has noted, nurses continue to seek formal recognition of their professional status as they work in the context of medicine’s hegemony over healthcare.
This article will describe a study designed to determine how nurses used the informal power available to them to promote patient care. This study utilized the guidelines of narrative analysis and grounded theory to analyze how nurses constructed and represented their use of informal power in hospital settings in their narrative discourse. The research question for this inquiry was:
RQ: How do nurses narratively create and communicate their use of informal power in the implementation of patient care within healthcare organizations?
Registered nurses were chosen for the focus of this study as they are the largest population of nurses and work with a variety of healthcare populations (Cockerham, 1989). Participants were limited to baccalaureate-prepared nurses because these nurses have more extensive education than many other levels of nurses, and also to nurses who work in hospitals, so as to gain a greater understanding of what it means to exercise informal power within an organizational context. Instead of focusing on a specific nursing group, e.g. nurses working in a particular clinical area or on a particular shift, the decision was made to study the narratives of registered nurses who worked differing shifts with different clinical populations in a variety of hospitals. After receiving approval from the Southern Illinois University Human Subjects Review Board to conduct the study, an announcement of the study was placed in newspapers and hospitals to seek volunteers meeting the above criteria to participate in the study. Ten nurses responded to the call to participate in the study. Of the ten, six met all of the requirements above and were able to participate over the course of several months of interviews. Given the breadth and depth of the work experience of these six responders, it was determined that they would provide sufficient data to answer the research question. Three of these nurses were from rural areas and three from urban areas.
The average age of the participants was 43 years old. At the time of the interviews, participants had worked as nurses for a total of 117.5 years, with an average of 19.5 years of experience per participant. Although all of the participants worked in some capacity within a hospital, they represented a wide range of nursing responsibilities, and a depth of professional nursing experience. All nurses signed a statement of confidentiality and willingness to participate in the study. For purposes of confidentiality each of the six participants is identified as N1, N2, N3, N4, N5, and N6.
Data Collection and Analysis
To answer the research question, the author followed the data collection and evaluative steps of narrative analysis outlined by Riessman (1993, 2003). Narrative analysis values the stories people tell as the focus of data. As Riessman (1993) wrote, “Narrative analysis takes as its object of investigation the story itself” (p. 1). Narrative analysis is interested in what stories tell about those under investigation, and follows four primary steps. Riessman has stated that researchers must: (a) orient to the telling of narratives, (b) transcribe the collected narratives, (c) analyze the transcribed narratives, and (d) report them in an appropriate manner.
For the purpose of this study, orientation to the telling of the nurses’ narratives occurred by first forming the research question and establishing interview questions. The research and interview questions served as the means of obtaining narratives from the nurses who participated, and framed the eventual analysis of the narrative data they provided. The author of this project, an organizational communication ethnographer from Humboldt State University, worked as the sole researcher in the process of interviewing, transcribing, and analyzing the narratives. After completion of the initial interviews with each participant, three follow-up interviews were conducted with each nurse who participated. Follow-up interviews occurred from nine to thirty-five days after the previous interview for a total of twenty-four interviews over the course of six months. Interviews occurred away from the nurses’ work environments to maintain greater confidentiality for the nurses. After six months, analysis indicated repetition of themes in the collected narratives, and the decision was made to cease interviewing, as the author determined that the narratives provided sufficient data to answer the research question.
All interviews were audio-recorded and transcribed to accomplish the second step of narrative analysis. Interview transcription yielded a total of 183 single-spaced pages of narrative data. Because there are few established standards for transcribing narrative data, the choice was made to transcribe the interviews in accordance with techniques common in Conversation Analysis research. All words and utterances of the participants were transcribed as stated by them in response to the interview questions.
After transcription was complete, the author analyzed the transcribed narrative data. Only data from the transcribed narratives was used to identify commonalities among (and within) the collected accounts that best described/explained how nurses used informal power to promote patient care (Patton, 1990; Polkinghorne, 1988; Riessman, 2003; 1993). Because there are multiple qualitative approaches for analyzing narrative data, the author followed general guidelines of grounded theory to perform the actual analysis of the participants’ narratives. Charmez (2003) has stated, “Grounded theory methods consist of flexible strategies for focusing and expediting qualitative data collection and analysis” (p. 311). The author examined ways nurses narratively characterized themselves in respect to the other healthcare professionals with whom they worked so as to identify how they used informal power in their professional interactions with others to promote patient care (Kerby, 1991; Lanser, 1981; MacIntyre, 1981).
Narratives were categorized and organized according to their relevancy to the research question. Commonalities were identified that represented how nurses illustrated their use of informal power in their job performance through the narratives they told (Clandinin & Connelly, 1994; Manning & Cullum-Swan, 1994). Common themes from one source (narrative data of one participant) were compared with those of other sources (narrative data of the other participants). The author used open coding, reading through all of the transcripts of the participants’ narratives, to first identify instances in which participants expressed their use of informal power to promote patient care. Once open coding was completed, and instances of informal power use by the participants were extracted from the data, selective coding was conducted by the author to identify specific categories and ways nurses used informal power as highlighted in their narratives (Polit & Beck, 2004). The categories of “Managing Organizational Constraints” and “Managing Hierarchical Constraints,” as well as four specific informal power strategies used by the participants, were identified by the author through the selective coding process. The narrative examples provided in the “Findings” serve to demonstrate the specific ways participants used informal power to promote patient care. As Riessman (2003) put forward, the end result of narrative analysis is not “Truth” but trustworthiness. In this study the end goal was trustworthiness regarding the manner in which nurses carried out informal power within their professional role.
The findings are presented below in a style labeled by Van Maanen (1990) as “realist tales.” Realist tales “push the most firmly for the authenticity of the cultural representations conveyed by the text” (p. 45) by writing research reports from a third person perspective that conforms to notions of objective social scientific forms of writing. Every attempt was made to present the findings here as the nurses expressed them in their narratives. To validate the findings, participants of this study were asked to read through the findings and comment on their authenticity. Participants expressed that the findings appropriately represented their use of informal power to promote patient care as stated in their narratives, thus increasing the trustworthiness of the findings presented in this study.
Participants in this study stated that organizational and hierarchical constraints both facilitated and hindered their ability to act as patient advocates. Narratives demonstrated how nurses were able to use informal power to achieve intended outcomes. When they perceived constraints as detrimental to using their formal power to advocate for patients, they demonstrated efficiency in utilizing informal power to overcome formal organizational and hierarchical power structures and constraints to implement patient care. The strategy nurses used to manage organizational constraints, namely circumnavigation - the organizational work-around, and the strategies used to overcome hierarchical constraints, namely the doctor-nurse game-continued, direct confrontation, and circumnavigation of directives - the hierarchical work-around, will be described below.
Managing Organizational Constraints
Participants consistently expressed their frustration at...powerlessness they sometimes experienced...when formal organizational constraints worked against quality patient care. Participants consistently expressed their frustration at the formal powerlessness they sometimes experienced in their positions when formal organizational constraints worked against quality patient care. Nurses stated a succinct willingness to act as patient advocates by implementing informal power available to them to facilitate necessary patient care. When patients were not knowledgeable about the workings of healthcare, nurses often acted as their advocates in ways that helped to overcome organizational constraints.
Circumnavigation–the organizational work-around.
The primary informal (personal) power strategy identified by participants’ narratives as being used to advocate for patients was the circumnavigation of restrictive organizational constraints to ensure that patients received needed care--also known as “work-around” strategies. Participants stated that this was a process whereby they used their knowledge of the system to work around constraints presented by the organization that hindered a patient's ability to receive proper care. One such constraint often faced by patients and healthcare professionals was the care restriction mandated by insurance companies. N1 stated her approach for dealing with this organizational constraint:
Well this one patient, this little boy who has an undescended testicle and we give him HCT injections to try to bring it down before surgery....They’re on BPA, or they’re Illinois Public Aid….And I have tried for two days to get through on this one-eight-hundred Illinois BPA line that you can maybe- I could maybe talk to someone and get special approval for this or this….So you’re sitting there with time running out because you don’t know how far back they’ll grandfather in and pay for something. It could make a difference for this family.
N1 used her personal and professional knowledge for dealing with such constraints, thus exercising informal power not necessarily held by her patients. Her role as advocate for this family went beyond the formal scope of her professional duties as she advocated for this family because she believed she could make a difference due to her knowledge of organizational policies.
N1 further demonstrated how the advocate role influenced her choices to use informal power when confronted with additional organizational constraints in stating:
If he wanted to recommend you to a certain- or refer you to a certain physical therapist and it’s out of the network of this PPO or whatever, they won’t pay for it. The physicians are really limited. And a lot of the judgments that I think they should be free to make, and that freedom is being taken away....But it does make it hard. You have to really watch what you do.
In the formal scope of their role, participants generally felt obligated to abide by the mandate to work within the confines of organizational bureaucracies. However, as patient advocates, nurses often faced an ethical dilemma when these constraints were not beneficial to patient care. In these instances, nurses utilized informal power available to them to work around organizational constraints when they believed doing so was in the best interest of their patients.
Participants in this study expressed great frustration in dealing with a system they described as rigid in its approach to patient care. Of a new policy instituted in her clinic N1 stated, “So it’s this new thing and now more following the letter of the law instead of the spirit of the law. And that’s been real frustrating.” For these nurses, information regarding organizational structures helped them advocate for patients. Knowledge of organizational structures provided them with enough informal power to work around organizational constraints for the good of their patients. However, nurses stated that this was particularly challenging given the ongoing changes in how healthcare organizations are managed, and outside factors regarding decisions for patient care.
N5 highlighted her use of informal power to circumnavigate organizational restrictions that did not match her ideals of the advocate role. She noted:
You know that’s another thing that restricts you from doing a lot of things. You have to learn to get around their insurance. You know Medicare has become practically useless. I had a lady come in one day. Eighty years old….Well we were trying to put her into the hospital….Well if you’re book doesn’t say that they should be admitted, forget it, you don’t get them admitted….It should be automatic that this lady needs to be admitted. She’s normally mobile and fully functional but, stuff like that really gets on my nerves.
Organizational constraints often worked to keep nurses from fulfilling the role of patient advocate. When this occurred, participants expressed their willingness to use their informal power to circumnavigate organizational constraints for their patients. Thus, they made the most of a power available to them that patients did not have due to a lack of understanding of how healthcare organizations functioned. N1 further emphasized the conflict of the patient advocate role and organizational constraints:
We had one patient that had multiple problems, he had actually been a survivor from the Auschwitz concentration camp….And he wanted to order a battery of tests and the insurance company didn’t want to allow that to be done….And they want everything to be real limited and sometimes it’s limited to the point of being not beneficial to the patient....In fact it was just against the code of being a nurse to worry about the payment aspect.
The primary informal power strategy nurses used to confront organizational constraints was that of work-around strategies of the constraints themselves.Participants’ narratives emphasized a focus on patient well-being which framed the way they understood their professional role in healthcare organizations.
Participants emphasized their desire for professional autonomy to care for patients in ways they felt were appropriate, even when not sanctioned by organizational policies. When patient care was perceived as jeopardized, nurses had to choose how they would act within the boundaries of organizational policies. The primary informal power strategy nurses used to confront organizational constraints was that of work-around strategies of the constraints themselves.
Managing Hierarchical Constraints
It was not only the organizational constraints that made it difficult for nurses to carry out their role. In addition, the hierarchical nature of professional positions within these organizations challenged nurses and prompted them to exercise informal power as they interacted with physicians to care for patients.
Overall, participants stated that they had a professional obligation to follow physicians’ directives. Nevertheless, their narratives demonstrated that when the patient advocate role conflicted with this obligation, they did draw on informal power strategies to advocate for patients. Inherent in the performance of their role was the expectation that they not blindly follow physicians’ directives. N1 stated:
I’m supposed to be following his orders but I am supposed to also be trained enough to catch what should be normal. Like if an order is inadvertently written for a medication, it’s still my responsibility to check that chart to see what that patient’s on, see what they’re allergic to. Just because he writes an order for something doesn’t clear me to just blindly follow it. And that’s really important.
Part of the professional role of the participants was to “raise red flags” when uncertainty existed regarding physicians’ directives.
When nurses understood directives as beneficial for patients, they followed those directives. When nurses perceived directives as detrimental to patients, they utilized various informal power strategies to challenge and change them. N4 acknowledged the higher (formal) status of physicians, yet stated that her greater time spent with patients placed her in a better position to more accurately assess patient conditions. She explained:
It’s not that I have the same qualifications he does or knows as much as he does, but I work with the patient more than he does. I have a more thorough assessment of the patient then he does. Because you do the initial history, and I know he doesn’t want to talk to them but I’ve been there for two hours with them.
When nurses understood directives as beneficial for patients, they followed those directives. When nurses perceived directives as detrimental to patients, they utilized various informal power strategies to challenge and change them. N4’s narrative example emphasized the important fact that the amount of information she acquired about her patients gave her tremendous personal power to influence the direction of healthcare. Participants stated that when their assessment of patients differed from physicians’ assessments, they engaged in a variety of informal power strategies to act as patient advocates. These strategies included the doctor-nurse game-continued; direct confrontation; and circumnavigation of directives - the hierarchical work-around.
The doctor-nurse game–continued.
In the 1960s and 70s, Stein argued that one strategy nurses employ when they disagree with physicians regarding patient care is what he identified as the doctor-nurse game. While Stein’s work occurred four decades ago, participants concurred that they did, at times, participate in this game in their professional roles. N6 told this story in which a colleague engaged in this game to lead a physician toward her assessment of a patient’s status:
A colleague of mine….was telling me this morning how she was leading the physician. Giving him all the symptoms and pointing it in such a way that the only thing he could conclude was that what she thought was wrong was what was wrong. But the physician didn't seem to pick up that she was pointing him to the problem. But until she laid them all out in a fashion that made him stop and think, nobody had put it together. And that's really what I see a lot of times.
This narrative indicates an effective use of informal power to advocate for patient care, while the strategy also worked to validate the formal hierarchical position of the physician. Nurses described their participation in the doctor-nurse game as ‘diplomacy.’ N5 stated, “And it’s like I said, sometimes it’s in the way you approach a doctor. You don’t tell them, ‘Hey I think you oughta.’ Well, you ain’t getting nowhere with them.” N2 continued the sentiment saying, “And sometimes I find if I’m diplomatic...then I’m able to work with this person [physician].” Although the participants indicated that they did not receive formal professional recognition when they initiated treatment in this way, they stated their acceptance of this fact as long as patients received appropriate care. While participants’ narratives demonstrated their use of the doctor-nurse game, all of the participants indicated that they felt as though they had to rely on this game less and less, using instead other informal power strategies for confronting physicians.
Participants’ narratives established that as patient advocates they were willing to explicitly state their disagreement with physicians, despite possible formal and hierarchical resistance. In these situations, the formal power of physicians could still supersede the informal power of nurses, yet nurses were willing to exercise their informal (personal) power to try to change situations they believed to be detrimental by directly confronting physicians. N3 told of a situation where she directly stated her disagreement with a physician’s assessment:
So they had this appendage that was like this. And his arm was stuck to his leg. So I called the physician. So I was like, “He has pseudomonas. Do you want- can you fit him earlier so you can assess him and put him on some type of antibiotics? Or maybe switch to a different solution, like Dakin’s, or something to kill the pseudomonas?” “No. He can’t have pseudomonas. I just did that surgery four days ago.” I was like, “Well, it is pseudomonas.” “You’re just a nurse. You don’t know what pseudomonas is.” I was like, “Well, I don’t know how green you want it and how sweet you want it to smell, but it’s pseudomonas.” So I said, “Okay, I’ll just chart that you were notified and that you don’t want anything done at this time.” And that would really irk him but what else can you do?
Because nurses spend considerably more time with patients, and because of their strong belief in their patient advocate role, they told of how they assessed patients’ conditions and told physicians how to provide necessary care. While this strategy proved unsuccessful for N3, forcing her to fall back on formal policies to record her professional disagreement, she was willing to use the information she had about the patient’s condition to confront hierarchical boundaries. When this informal power strategy did not work, N3 relied on formal channels available to her to document her advocacy for the patient, forcing accountability back to the highest position in the organizational hierarchy.
Because nurses spend considerably more time with patients, and because of their strong belief in their patient advocate role, they told of how they assessed patients’ conditions and told physicians how to provide necessary care. N5 gave an example of this communicative strategy when she stated:
I had a guy and woman come in, they were both in their eighties. He had Alzheimer’s and she couldn’t hardly walk....She can’t hardly take care of him at home and he has Alzheimer’s so he’s liable to burn the house down because he smokes. You know you can put little notes on there that say, “Live alone. Been married sixty years. Both in their eighties. They need home health.” So a lot of times you’re telling them [the physicians] what the patients don’t know themselves. Yeah, a nurse has a lot of power if they’ll just use it and the doctor will listen.
N5’s narrative showed how she initiated treatment but highlighted that this was useful only if she could get the attending physician to listen and respond to her assessment and options for care. Using contextually appropriate communicative strategies was essential for the participants to succeed in this application of informal power.
Overall, participants indicated that their assessment of patients was generally taken into consideration by the physicians with whom they worked, and that these physicians generally listened to them. N2 highlighted the power of the advocate role for nurses in saying, “The thing that I notice about our doctors is they will back down and listen to the nurse. Usually they will. They really have a regard for the nurses in this department.”
While the formal organizational rule was to follow those in higher professional positions, the superordinate rule was to follow the code of the patient advocate role above all else. Participants framed their ability to work with physicians from the overarching perspective of their role as patient advocate. Thus, nurses monitored their communication with physicians in terms of how well it worked to promote patient care. N3 stated, “Some would say, ‘Oh, just do this and this.’ And you knew it was- so you would say, ‘How about this?’ You know, you felt like you were bargaining for the patient, but sometimes, you’d have to do that.”
Following the hierarchical chain of command was part of the fulfillment of the patient advocate role for these participants. However, they used informal power when they sensed a threat to the fulfillment of the advocate role. While the formal organizational rule was to follow those in higher professional positions, the superordinate rule was to follow the code of the patient advocate role above all else. When these rules conflicted, nurses identified their willingness to respond in ways that they believed benefited patients, even when it was detrimental to their own professional well being.
The formal power of physicians became problematic for the participants when they felt powerless to change the implementation of directives they believed were detrimental to patients. N5 demonstrated how she unsuccessfully tried to change the direction of care for a patient:
I had a six year old boy that said he was vomiting blood. So I tried to get the doctor to admit him to the hospital. Wouldn’t. Well he never did come back to the emergency room. So you know it’s really discouraging when a kid looks up at you and it’s like they beg you to help them. And if you ever see that kid again you know they look at you like, “Well, you were supposed to help me last time and you never did.” To me that is just terrible. I hate that feeling.
When these rules conflicted, nurses identified their willingness to respond in ways that they believed benefited patients, even when it was detrimental to their own professional well being. These encounters were difficult for the nurses when they tried to use their informal power, yet were unable to successfully advocate for patients. N5 continued, “And sometimes I think it’s at the cost of the patients’ safety that they [physicians] do that.” Despite formal organizational and hierarchical constraints that sometimes left the participants feeling powerless as patient advocates, the advocacy role remained central in guiding their interactions with others. By and large, participants seemed incredibly adept at maneuvering within formal hierarchies to facilitate appropriate care to patients. As N5 indicated in the above example, patient safety and health were primary in the performance of her professional role. It is to this end that nurses drew from a broad range of options available to them, including exercising informal (personal) power by engaging in direct confrontation with physicians regarding directives.
Circumnavigation of directives–the hierarchical work-around.
Participants stated that another informal power strategy occurred when they sought out a different physician to change the directives of the initial physician. Participants indicated that disagreements regarding physicians’ assessments and implementation of patient care were uncommon. Nevertheless, when participants believed physicians’ directives were detrimental to patients they sometimes relied on the same informal power they used to confront organizational constraints, namely Circumnavigation--The Hierarchical Work-Around.
N1 told of how she circumnavigated the directives of one physician by getting another physician to carry out a different approach for patient care:
And this lady had came in on evening shift and she had a broken hip. And, you know, we called the doctor at home, and his orders were just give her Demerol for pain. Well, I was kind of uncomfortable doing that and, you know, you have to use some judgment on your own sometimes when you’ve got the doctors’ orders and you don’t feel that that’s what the patient needs. You have a responsibility even if that’s the order to be able to assess and do what we think is the best thing to do.
N5 shared a similar narrative in which she used another physician to ensure that her patient received appropriate care:
We had a guy come up from the emergency room and I was supervisor, and he was in a tachy rhythm. The doctor sent him up and I asked him, I said, “Doctor, do you not think that he needs to go back to the unit?” “Oh no, he just needs to be put on the floor in telemetry.” Well the man’s heart rate went to 200 and he started sweating and got a little uncomfortable. I called his regular doctor and got something else for him. So yeah it makes you feel real good. Something like that makes you feel like, “Hey, I did my job. I knew what I was doing.”
Nurses demonstrated their informal power to change physicians’ directives even when they could not do so under the formal constraints of their professional position. The above examples exhibit how the nurses’ assessments were correct, yet they had to circumnavigate the original physicians’ directives by going to another physician. Although participants admitted these situations could “get sticky,” they stated their belief that it is worth the personal and/or professional consequences if patients received appropriate care.
The registered nurses of this study expressed a professional view of themselves as patient advocates as the basis for understanding, negotiating, and representing their interactions within healthcare organizations (Paynton, 1998). Porter (1993) suggested that it is important to attempt to explain the relationship between social structure and human action. Occupational groups in healthcare are continually, if not always openly, involved in maneuvering and negotiation concerning their professional roles (Rosengren, 1980; Zelek & Phillips, 2003). Nurses perform their professional role within the larger scope of an organizational culture and organizational constraints.
Despite the many organizational and hierarchical constraints expressed by the participants of this study, these nurses stated that they were generally able to perform their professional roles despite the many challenges they face each day. When obstacles presented themselves in such a way that they could not perform their roles in formally sanctioned ways, their narratives highlighted the various informal power strategies they used to successfully (and sometimes unsuccessfully) advocate for what they considered appropriate patient care.
The participants conveyed many of the dynamics described in literature regarding the execution of the nurse role and the manner in which formal organizational structures and physician authority influence how they are able to perform their jobs (Coombs, 2003; Carmel, Yakubovich, Zwanger & Zaltcman, 1988; Hanks, 2005; Kreps & Thornton, 1992). Literature indicates that collaborative approaches for providing healthcare lead to the best patient outcomes (Burke, Boal & Mitchell, 2004; Hader, 2005). Participants’ in this study indicated that, by and large, they were able to work collaboratively with other healthcare professionals. They also expressed that it was the organizational constraints of healthcare, insurance companies, and healthcare organizations themselves that significantly shaped how they performed their jobs. Organizations have taken greater control of patient healthcare decisions. While participants expressed that they were able to directly confront physicians regarding patient care decisions, they indicated that it was significantly more difficult to exercise informal power against organizations themselves to provide patient care.
Kreps and Thornton write, “Organization members can best cope with the rigidity and impersonality of highly formalized healthcare bureaucracies by becoming familiar with the rules and regulations....By learning the ropes of the system, individuals can utilize organizational structure to their best advantage” (1992, p. 104). Participants of this study demonstrated their ability to manage organizational constraints through their knowledge of their particular healthcare systems. When confronted with organizational constraints that kept them from performing their jobs as they felt appropriate, participants showed how they used “work-around” strategies to circumnavigate organizational constraints that limited patient care (Espin, Lingard, Baker & Regehr, 2006; Halbesleben, Wakefield & Wakefield, 2008; Zeitz & McCutcheon, 2005). While not always successful, the personal and professional information available to nurses placed them in a powerful position to work around powerful organizational restrictions to promote patient care.
While participants articulated that they generally were able to work with physicians collegially, they identified three informal power strategies they employed for managing hierarchical constraints. Each of these strategies demonstrated a degree of expressed conflict.
The first informal power strategy participants demonstrated they used coincided with Stein’s doctor-nurse game. This strategy was used as a way to influence decision making regarding patient care in directions the participants felt were appropriate. This game occurred when participants employed communication strategies to make their suggestions appear as if they were the physicians’ ideas. A consequence of playing this game is that it appeared to work to validate the formal power of physicians, while not acknowledging the value of these nurses as professional healthcare providers. Participants described this as ‘diplomacy,’ and stated that having knowledge of how each physician manifests his/her professional role put them in a place to effectively play this game.
Of course, this doctor-nurse game strategy is not unique to nurses. Of course, this doctor-nurse game strategy is not unique to nurses. Studies show that those who hold positions that are institutionally recognized as subordinate often use less direct communication (ambiguous recommendations) with those who hold institutionally recognized positions that are considered higher in status. The lower-status person uses these communication approaches in order to achieve intended outcomes while working to save face for the higher status person (Hall, Rosip, Smith LeBeau, Horgan, & Carter, 2006; Tourish & Robson, 2006). While participants stated that they employed this technique, they indicated that they did not have to play this game often, using it as a strategy only if other options were not available. Perhaps one reason we see less evidence of nurses engaging in the doctor-nurse game then we did in the 1960s to 1970s is due to the continually increasing formal recognition of the status of the nursing profession.
A second informal power strategy participants used to counter physicians was engagement in direct confrontation regarding options for patient care. The patient advocate role, in light of the amount of patient knowledge nurses held, placed them in a position to directly confront physicians they believed were making mistakes in caring for patients. Participants stated their willingness to confront physicians even if they were met by organizational and professional resistance (Thomas, Sexton, & Helmreich, 2003). The participants’ willingness to engage in direct conflict with physicians can be considered evidence of the increased recognition and validation of the important professional role of nurses.
The nursing profession continues to gain greater prominence as an autonomous professional group in healthcare. The narratives in this study demonstrated that direct confrontation with physicians is now a viable option for exercising informal power. Why is this considered informal power? Formally within organizations, physicians are still seen as holding higher ranking status. Thus, from the vantage point of the formal hierarchy, nurses can find it difficult to contest physicians’ directives using formal power (position status) as the basis of disagreement. This difficulty supports May’s (1993; 1995) contention that decisions from those who hold higher formal positions supersede decisions from those who hold lower formal positions. However, people are adept at working both within and outside of formal policies and hierarchies to achieve their goals. In this study, the knowledge nurses had of patients’ conditions (informal power) gave them the ability to directly confront physicians to influence patient care. The participants in this study stated that physicians generally listened to their assessments of patients. Yet, direct confrontation by nurses, when they disagreed with physicians’ directives, was exercised on the basis of informal power, personal knowledge of the patients.
A third informal power strategy nurses used when dealing with disagreements with physicians parallels the circumnavigation (work-around) techniques they used to manage organizational constraints. When the doctor-nurse game and direct confrontation did not work, participants stated their willingness to go to a second physician to get the directives of the first physician changed. This approach actually combines formal and informal power strategies to achieve patient care. Nurses used their knowledge of the patients’ conditions, as well as their knowledge of the healthcare organization and its personnel, to find a physician in a higher, formal position that would implement care the participants felt was appropriate. Participants stated their willingness to work around a physician to achieve the patient care they believed was appropriate, even when it risked straining the working relationship with the original physician.
The need of nurses to rely on informal power strategies is indicative of a reality in which formal structures still fail to provide nurses with the formal autonomy necessary to fully fulfill their role. The positive results of using informal power strategies occurred when patients received proper care. In these cases, nurses expressed satisfaction in achieving the fulfillment of their professional role as patient advocates. However, this use of informal power strategies can be detrimental to achieving greater professional recognition and autonomy if nurses sacrifice professional acknowledgment to fulfill the patient advocate role. Sacrificing professional recognition while implementing nursing care may continue to validate the formal power of healthcare organizations and physicians, thus perpetuating an imbalance in the professional work environment of nurses. As Kramer and Schmalenberg (2003) indicated, it is important for nurses to be professionally empowered through formal organizational structures in ways that recognize nurses professionally beyond their ability to simply make clinical decisions. The need of nurses to rely on informal power strategies is indicative of a reality in which formal structures still fail to provide nurses with the formal autonomy necessary to fully fulfill their role. Informal power strategies can act as a double-edged sword. These strategies may result in proper patient care and fulfillment of the patient advocate role; yet at the same time they may continue to “keep silent” the professional status and autonomy of nurses by failing to recognize and acknowledge the care nurses provide.
As these issues continue to be negotiated in healthcare organizations, there must be a continued focus on ongoing interdisciplinary approaches to educate healthcare professionals regarding ways to work collaboratively that both promote patient care and validate professional roles. A focus on teaching strategies that both serves to provide adequate patient care and validates the professional roles of all healthcare workers can move the healthcare profession toward a model that is holistic in its approach to the health of all professional groups that interact together in healthcare organizations.
In spite of the move toward collaborative communicative efforts among healthcare practitioners, the narratives of these participants revealed that nurses often continue to use informal power strategies to reach intended patient outcomes when formal constraints prevent them from doing so. Participants’ narratives demonstrated that these nurses felt generally obligated to follow the formal power of physicians and healthcare organizations in the implementation of care for patients. The exception to this rule manifested itself when participants believed that physicians’ and/or organizations’ choices for patient care were inappropriate. In these instances, nurses chose to utilize significant informal power to advocate for suitable patient care. The ultimate code for nurses throughout this study was to serve as patient advocates.
Scott T. Paynton, PhD
Dr. Scott T. Paynton is an Associate Professor in the Department of Communication at Humboldt State University in Northern California. His work addresses the communication of registered nurses in healthcare organizations, particularly focusing on the relationship of communication to the professional role of nurses, facilitation of professional relationships, and healthcare outcomes for patients.
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© 2008 OJIN: The Online Journal of Issues in Nursing
Article Published October 27, 2008
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