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Reducing Power Distance and Increasing Collaboration Can Reduce Errors and Improve Patient Care

Posted on Mon, Mar 13, 2017
Reducing Power Distance and Increasing Collaboration Can Reduce Errors and Improve Patient Care

By Adam Corley, MD, FACEP, FAAEM

Error reduction, quality improvement, patient safety and staff satisfaction are all impacted by a little-discussed concept known as power distance.

Traditionally in medicine, physicians were thought of as the “captains of the ship,” whose wisdom was unquestioned and whose instructions were to simply be followed. Doctors gave orders to nurses, allied health professionals and patients. Most members of the healthcare team went by their first names, but doctors still required a formal title.

This traditional hierarchy can be called a high power distance environment. Power distance is a term coined by Geert Hofstede, a Dutch social psychologist. In such systems, power relationships are autocratic, paternalistic and draconian. There is little premium put on collaboration, and subordinates are expected accept their lower positions. Authority and authorities (doctors, in this example) are rarely questioned, and their instructions are regarded as certain and inflexible.

In low power distance cultures, power is more evenly distributed, and there is a relatively small emotional distance between those in charge and others. Leaders and their teams are less concerned with status or title and more concerned with collaboration, communication, partnership and teamwork.

Luckily, medicine has begun transitioning from a high to low power distance environment, but we still have a long way to go. We have begun to shed titles between co-workers. We are encouraging all members of the healthcare team to share ideas and strategies with their colleagues. Nurses and allied healthcare workers are encouraged and empowered to challenge physicians if they notice errors or have concerns about the prescribed treatment plan. Physicians have begun to not only accept but to appreciate suggestions from their co-workers.

Medical specialists in fields like emergency medicine, anesthesia and surgery are developing team-based approaches to medicine. While the doctor is most often still at the helm, these highly functional team of RNs, advanced practice providers and other clinicians work collaboratively to deliver care. In most cases, these teams function in a very low power distance environment.

There still are elements of higher power distance that make sense in medicine and should remain. For example, emergent surgeries, CPR, code blue situations and trauma resuscitations still require a more rigid element of hierarchy, given the shortened timeframe for success and critical nature of the work.

Although it makes sense in medicine, a low power distance culture is not right for every field. The military is a classic example of an environment that works well with high power distance relationships. The features of a low power distance culture that make that hierarchy favorable in fields like medicine and aviation would not necessarily work well when fighting a war or keeping the peace.

A 2013 study published in the Journal of Patient Safety estimated that approximately 400,000 people die from preventable harm in medicine each year. We must continue to flatten our medical hierarchies, reduce our power distance and empower and encourage all members of the healthcare team to identify and report errors. Not only do patient’s benefit from the collaborative environment allowed for in a low power distance culture, but doctors and their nursing and allied health colleagues will be much happier practicing medicine this way.

Adam Corley, MD, FACEP, FAAEM, is an emergency physician with more than 10 years of clinical and leadership experience. Dr. Corley serves as Executive Vice President for EmCare’s West Division. He also serves as the medical director for several EMS services and the Anderson County Texas Sheriff’s Department. Dr. Corley lectures and writes on a variety of topics, including decision science and behavioral economics, management of disruptive behavior in healthcare, conflict resolution and healthcare leadership.

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