RN, PhD

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From Hospital “Caste System” to “Everybody Matters”

No matter how much experience I have, no matter how many deliveries I’ve done, I’m a nurse and not a doctor. What I say isn’t quite as good as what the doctor thinks.

This comment came from a nurse midwife who was a participant in my study Effects of Shame and Guilt on Error Reporting Among Obstetric Clinicians.

Does it surprise you?

Though the comment specifically refers to the social status differential between nurse midwives and obstetricians, perceptions of inequities exist among all of the roles and disciplines within the hospital system.

Hospital culture has been one of the most hierarchical cultures of all industries in the U.S. Overlaid on the traditional management hierarchy is also a well-understood collective mindset of who is more important than who among the different roles and disciplines. This widely present but mostly unspoken status hierarchy works much like a caste system where one’s value is determined by one’s position.

This social order is a remnant from the industrial age gone by, and although still predominant in our industry, there are beacons of light out there doing it differently in the name of better care for patients and a better experience for workers.

The typical hospital caste system

While you may be able to move a few of the pieces around depending on the characteristics of your hospital, in general a typical hospital caste system looks something like this:

Hierarchies within hierarchies

To make things more complicated, each of these categories has its own status hierarchy within it. For instance, when I asked physicians about their internal hierarchy, surgeons were at the top, then specialists, then generalists.

It is perhaps unsurprising to you that those who rank higher receive more privileges than those on the lower end. They are the ones who:

  • Get to call the shots
  • Get listened to
  • Feel safe to speak up

Complexity requires a new configuration

The traditional hierarchy is not just a problem of fairness regarding who gets more attention it’s actually a liability for delivering optimal care to patients due to the effects it has on worker communications.

Amy Edmondson, the Novartis Professor of Leadership and Management at the Harvard Business School and author of Teaming: How Organizations Learn, Innovate & Compete in the Knowledge Economy, studied the impact of the hospital hierarchy and says,

Unfortunately, research shows that those with lower status in a group or department generally feel less psychologically safe than those with higher status. This makes them less likely to check with others when they are unsure about something, more fearful that mistakes will be held against them, less able to bring up tough problems, and less certain that others value their skills.

The implications of Edmonson’s statement are profound when we face the reality that in healthcare, the most complex environment there is, where patients’ lives are at stake – a large number of our workers don’t feel safe to raise questions and concerns.

Given this, is it any wonder that there has been slow progress in improving hospital performance?

Its members can’t learn because learning requires asking questions and taking risks, precisely the things individuals at the lower end of the hierarchy believe are threats to their psychological safety.

Is hierarchy always a detriment?

If you’re wondering whether a professional hierarchy is always a detriment, the answer is an emphatic “no”. Its utility depends on the type of organization, the situation, and the goals – different configurations lead to different results.

In healthcare, a hierarchy can be highly effective in emergencies and high-risk situations that require quick and decisive action. But otherwise, it can be a major obstacle for the collaboration needed to develop, decide and deliver best practices. The best performing clinical teams understand these differences and know how to move in and out of hierarchy as needed.

How to move toward “Everybody Matters”

Many hospitals have been adopting various forms of team training and activities, such as simulations and debriefs, to improve collaboration and coordination among the disciplines. These popular mechanisms are potentially effective vehicles for leveling the playing field, however, their success depends on two critical factors that in their absence could actually strengthen and reinforce the traditional hierarchical order. They are:

  • Leaders who are skilled at making it safe for all participants to speak honestly about their experience, and
  • The incorporation of these team activities as part of an overall strategy of culture change.

An illustration of the importance of these factors can be gleaned from a comment from one nurse I interviewed. She tells how debriefs and huddles at her hospital are merely institutionalized finger-pointing sessions where those at the top are running the show. Unfortunately, many team training programs describe the “what to do” in terms of the structure and activities, but not the “how to do it” in terms of facilitating the team process so that everyone can contribute equally.

The steps

To create an all-inclusive experience in your team meetings, debriefs, and huddles, I advise the following:

  • Share this article with your teams and have a discussion on how it relates to your team’s experience.
  • When leading a meeting, debrief, or huddle, be explicit that one of the goals is to level the playing field among the team members. Describe what that looks like (e.g., hearing from everyone on the team, being able to safely disagree with someone higher in the hierarchy) and how it connects to a larger organization goals (e.g., patient safety and worker engagement).
  • Practice positive reinforcement for speaking up, especially when someone lower in the hierarchy takes the risk to do so. Acknowledge the individual and thank him/her for sharing this perspective.
  • Gently address when someone higher in the hierarchy is not considering the views of those on the lower end (e.g., “The point [name] made is important, how can we incorporate it?”).

The need to retire the hospital caste system is undeniable. We have transitioned from the industrial age to the network age which offers us amazing opportunities for advances in healthcare should we accept the challenge.

The call for leaders is to engage all stakeholders, those at the top of the hierarchy and those at the bottom, to understand the consequences of the current configuration and to envision a new way forward together.

Learn how to address other aspects of our healthcare culture that prevent psychological safety by reading my article Effects of Shame and Guilt on Error Reporting Among Obstetric Clinicians.

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