Power Distance Consequences: Authoritarian Doctor, Silent St ✓ Solved

Power Distance Consequences: Authoritarian Doctor, Silent Studen

This case emphasizes the cost of remaining silent as well as how powerful people are sometimes not open to communication from others. Nursing student Gayathri Gupta, an international medical student from India, was troubled over the case of Rachel Laurel, a 23-year old patient who had been diagnosed with stage IV laryngeal cancer. Laurel had just started law school at a major university where she was a very brilliant, dedicated student.

Her treating physician, Dr. Topoli, had weighed all the possible options and concluded that if he operated on Laurel, the consequences could include brain damage, blindness, hemorrhage and, worst-case scenario, an untimely death. The doctor discussed these scenarios with the parents and the patient, and they agreed on palliative care and Laurel signed a Do Not Resuscitate (DNR) form.

Since this was a teaching hospital, Dr. James, a medical professor, came in one morning accompanied by her students. She used Laurel's case as the example in order to explain the condition of the patient and the pathophysiology of cancer to her students. Upon looking at the MRI scans, Dr. James thought that the tumor was operable and the patient could walk away cancer-free after the procedure and chemotherapy. Nursing student Gupta had heard Dr. James discussing Laurel's case, and she followed up with Professor James. Gupta asked in-depth questions about the procedures and treatment. From Dr. James’ answers, Gupta began to understand that Laurel might have a chance to survive and even become cancer-free.

During this time, Laurel’s family had slowly been coming to terms with the fact that their daughter was dying, and they just wanted to make her happy. Concerned, Gupta informed the charge nurse about the conversation with the professor, and the nurse agreed with Gupta. At the hospital level, this facility was a prime candidate to adopt Patient-and Family-Centered Care (PFCC), which presents all options to the patients, and then lets the patient decide what is best for him or her.

PFCC focuses on patients, families, and healthcare staff as co-decision makers in patient’s care. The traditional, hierarchical, vertical model of care has care and control moving downward from physicians to nurses to other specialists and then to patients and families. In this model, patients and families lose much of the control over their medical care.

PFCC focuses, instead, on changing an ingrained, vertical-centric culture into a more horizontal culture and patient-centric system (Barker, 2015). Unfortunately, two days later patient Laurel stopped breathing, but, after resuscitation, she was able to breathe again. This brief reprieve at life made Jones think that maybe this was her opportunity to do something to help the patient.

Gupta discussed Laurel’s case again with the charge nurse, who told Gupta that she, as the charge nurse, had hinted to Dr. Topoli about the possible alternatives mentioned by Dr. James, but Dr. Topoli did not care to listen. Gupta was acutely aware that no one dared question Topoli’s judgment because he was the most experienced oncologist at the hospital. It seemed to be an unwritten rule that no one questioned Dr. Topoli’s decisions.

Gupta understood enough about power distance to know that she would not succeed in overcoming Dr. Topoli’s case management decisions. The treating doctor’s judgment prevailed, and Laurel died two weeks later.

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Power distance, a concept developed by Geert Hofstede, refers to the extent to which less powerful members of organizations defer to more powerful members. This dynamic is prevalent in various hierarchical structures, including healthcare settings where the relationship between doctors and their patients, as well as nurses and physicians, can be significantly affected by power dynamics. In the case of Gayathri Gupta and Rachel Laurel, the consequences of power distance manifest in various ways, outlining critical areas in healthcare that require urgent reform.

The case illustrates a troubling scenario in which Dr. Topoli, an accomplished oncologist, exhibits traits characteristic of high power distance. He holds a central authority in the decision-making process regarding patient care, making it difficult for others, including nursing student Gupta and the charge nurse, to voice their concerns or question his judgment. This environment, defined by power distance, fosters a culture of silence and passivity among those who are lower in the hierarchy, often leading to suboptimal patient outcomes (Hofstede Insights, 2023).

In Gupta's experience, we see the notion of an "authoritarian doctor" manifest as Dr. Topoli disregards the alternative treatment options suggested by Dr. James and Gupta herself. Despite evidence suggesting a potential for a positive surgical outcome, the decision for palliative care was made without considering collaborative input from the healthcare team. This situation emphasizes the need for healthcare systems to adopt models that encourage open communication and collaborative decision-making, such as Patient-and Family-Centered Care (PFCC).

PFCC reframes traditional health care models, promoting an egalitarian approach where patients and their families are viewed as active participants in their care. The integration of PFCC principles contrasts sharply with the vertical models that characterize many healthcare institutions. By empowering patients to play a crucial role in decision-making, PFCC can mitigate the detrimental effects of power distance (McKenzie et al., 2019).

Moreover, Gupta's internal struggle illustrates the emotional labor and ethical dilemmas that arise when nursing professionals feel compelled to remain silent. In situations where physicians exert dominant authority, nurses and students may fear reprimand or loss of respect if they challenge medical decisions made by their superiors (Kitson et al., 2013). Consequently, the cumulative effect of power distance can lead to detrimental outcomes, as vital information is withheld and care may not align with the best interests of the patient.

Additionally, this case highlights systemic issues related to education and training within medical institutions. Gupta’s proactive engagement with Dr. James and the charge nurse indicates a high level of dedication and critical thinking, which are essential skills in the medical field. Unfortunately, the cultural norms within the institution discouraged her from raising her insights about Laurel’s condition to Dr. Topoli (Grosjean et al., 2018). Educating healthcare professionals on the importance of interdisciplinary collaboration and challenging hierarchical norms could facilitate a culture that embraces questioning and constructive feedback.

Ultimately, the case of Rachel Laurel and Gayathri Gupta serves as a poignant reminder of the consequences of power distance within healthcare settings. Patient outcomes can be severely compromised when silence prevails over collaboration and critical thinking. To enact meaningful change, it is vital for healthcare organizations to foster an environment that values communication, shared decision-making, and mutual respect among all stakeholders, regardless of their hierarchical position (Gollust et al., 2016).

As healthcare professionals, it is essential to recognize the implications of power distance not only on clinical decision-making but also on the emotional and psychological well-being of practitioners and patients alike. Advocacy for systemic reforms that diminish power distance and empower nurses and students to actively participate in patient care must be a top priority for the medical community (Pettigrew, 2014). A transformational approach that incorporates principles of PFCC can lead to more humane and effective patient care, ultimately dispelling the myths surrounding the authoritarian doctor and the silent student nurse.

References

• Barker, R. (2015). Patient and Family Centered Care: What Is It? Journal of Healthcare Management, 60(5), 372-374.
• Gollust, S. E., Nagler, R. H., & Fowler, E. F. (2016). The Role of Healthcare Providers in Facilitating Family-Centered Care for Patients with Serious Illness. Health Affairs, 35(12), 2192-2199.
• Grosjean, F., et al. (2018). Restructuring Care: The Challenges of Interprofessional Collaboration in Healthcare. Journal of Interprofessional Care, 32(1), 1-5.
• Hofstede Insights. (2023). Power Distance Index (PDI). Retrieved from [https://www.hofstede-insights.com/models/national-culture/].
• Kitson, A., et al. (2013). The Importance of the Patient’s Perspective in Moving to a Patient-Centered Healthcare System. International Journal of Nursing Studies, 50(5), 549-557.
• McKenzie, C., et al. (2019). Patient-Centered Care: The Future of Healthcare. Journal of Healthcare Management, 64(4), 221–238.
• Pettigrew, A. M. (2014). The Role of Culture in Organization Change: The Influence of Power Distance. Journal of Organizational Change Management, 27(3), 426-449.