Analysis of the factors influencing patients’ power distance ：a qualitative study

doi:10.21203/rs.3.rs-5249177/v1

Background：Patient participation in patient safety (PFPS) has proved to be an effective measure to ensure patient safety. However, patients are insufficiently willing to participate, and lack initiative and enthusiasm.Patient power distance can be one of the influential factors.Whereas, how patient power distance affects participation in safety activities and factors influencing patient power distance are rarely reported nationally and internationally.

Objective：To explore and analyze the influencing factors of inpatients' power distance.

Methods：This study used a qualitative method. Semi-structured interviews were conducted with 21 patients hospitalized in internal medicine, surgery, obstetrics and gynecology from Hospital A.

Results：The factors influencing the patients’ power distance are：Patient factors (knowledge reserve, psychological stress, hospitalization experience); Medical factors (role cognition, professional qualification, communication skills); Environmental factors (clinical situation, social environment, cultural background).

Conclusion：Medical staff should attach great importance to the power distance of patients, and enhance the capacity of humane care. According to the individual differences of patients, appropriate communication methods should be adopted to narrow the distance between medical staff and patients so as to improve the patients' willingness to participate in patient safety.

Patients’ power distance

influencing factors

doctor-patient relationship

patient safety

Patient safety is central to medical care, and it is also a reflection of the quality of medical care. Over the last 15 years, patient safety has always been a global priority. It promotes international health policies and works with health organizations, health professionals and patients to effectively reduce and control the risks of health services. To promote patient safety worldwide, in 2005, the WHO in the "international alliance for safety of patients" summit of the European Union for the first time proposed the "patient participation in patient safety" action plan (Patients For Patients Safety PFPS action plan), refers to the patient-centered medical services, through the behavior of patients to assist medical services to reduce and avoid all harm the patients' health of medical negligence(Trier et al., 2015).The active participation of the patients can assist the medical service providers to timely find out the problems and mistakes existing in the medical treatment process, and to find out the effective ways and methods to solve the problems(Corina et al., 2019).But it is difficult to promote patient involvement in managing patient safety(Anel et al., 2021). The study shows that patients' lack of willingness to participate in their own security is one of the challenges that medical staff face in implementing this plan(Ringdal et al., 2017). Kolter P et al.(Kolter, 1987) demonstrates that culture is the fundamental determinant of people's desire and behavior.

Geert Hofstede, a Dutch psychologist, proposed a cultural dimension, a theory that can explain the factors that lead to cultural differences in a wide range of cultures.In this theory, it is emphasized that the difference in power distance will lead to different results about people's behavioral intentions(Hofstede, 2001). Recent studies have demonstrated that patients' willingness to participate in patient safety is related to their relatively high power distance and has a negative impact on their willingness to participate(Wang et al., 2022). Hofstede defines Power Distance as the degree of unequal power distribution that a society or organization can bear, or the degree of acceptance and expectation of individual members in social groups or organizations of a country towards unequal power distribution. Power relationships also exist in medical practice. Michel Foucault, a French philosopher and social thinker(Liu Pengfei & Jia Zhonghai, 2017), analyzed the power relationship between doctors and patients. He believes that the power relationship in the medical context is divided into two main aspects: one is the authority of the physician who is proficient in the professional knowledge and skills of medicine; the second is the right of patients to an independent and cognitive choice. The medical staff has rich medical knowledge and exquisite professional skills, which is unfair to patients, so the medical staff is given high power.But on the other side of the physician's authority, patients also have greater autonomy, they can choose the plan supplied by the physician. Therefore, after the concept of "power distance" is expanded, the "patient power distance" is defined as: the degree of inequality in the power distribution between patient perception and medical personnel.

Because of the dual constraints of external environmental factors and their own factors, even the same person will exhibit a different power distance under different situational factors(Bao Yan & Liao Jianqiao, 2019; Wang Yanyu et al., 2021). At present, most of the global studies on the influencing factors of individual power distance are limited to the scope of organizational management, which shows that gender, age, education level, occupation, income, technology and other aspects are the main influencing factors(Chen Jinshui & Ling Wen, 2012). However, there are few incomplete studies on the influence factors of patient power distance from the perspective of the doctor-patient relationship. Some studies have discussed the power distance of immigrant patients through interviews, and the results show that the power distance of immigrant groups is related to language, race and other factors(Fukuyama, 1983; Kim et al., 2000; Schinkel et al., 2019). The research objects reported in the literature above belong to a particular group and are not representative. Therefore, this study will focus on the qualitative study of Chinese mainland native patients to explore the deep-seated influencing factors of Chinese patients' power distance.

Only by investigating the influencing factors of patients 'power distance can medical staff formulate effective measures to reduce patients' power distance, then promote doctor-patient relationship and doctor-patient communication, so as to improve patients' willingness to participate in patient safety. Because of the lack of willingness to participate in patient safety at this time, the progress of PFPS is slow, this study is extremely urgent. In view of this, by exploring the influencing factors of patients' power distance, this paper provides a theoretical basis for formulating strategies to lower patients' power distance and improve patients' willingness to participate in patient safety.

2.1 Study design

This study used the in-depth interviewing method and the qualitative analysis software Nvivo12 to sort out the factors affecting the power distance of inpatients.

2.2 Study context and participants

Purpose sampling method was used to select inpatients from internal medicine, surgery, obstetrics and gynecology, with different ages, regions, education level, occupation, and income level, and 21 inpatients were finally identified as interviewees.

The outline of the interview is organized around three questions to explore the factors influencing the patient's power distance：“Do you think there is a distance between medical staff and patients? ”，“What causes the distance? ”and “How do you feel about health care while in hospital? ”

Inclusion criteria: (1) age> 18 years; (2) stable condition and good mental state; (3) competent and willing to participate in the researcher. Exclusion criteria: (1) mental illness, confusion, difficulty, etc.; (2) disputes have not been resolved.

2.3 Data collection

Semi-structured interviews were used in the qualitative research, and each interview lasted 30 – 40 minutes. More than 20,000 words of access materials were collated. Respondents were treated anonymously to protect their privacy.To ensure the richness and depth of each case, data were gathered from multiple sources. First, we obtained the basic information of patients through the home page of the medical record, got familiar with the basic information of the interviewer, and improved the semi-structured interview outline. In-depth semi-structured interviews were subsequently conducted, and 21 inpatient patients were selected as interviewees.

2.4 Data analysis

We used qualitative analysis of soft NVIVO12.0 for analysis according to Colaizzi seven-step analysis(Northall et al., 2020)，and the interview data were summarized to identify three major themes influencing the power distance of inpatients.

2.5 Ethic considerations

This study was approved by the medical ethics committee of Shanghai East Hospital, Shanghai,China.（Ethical approval number is 2018071). All participants were provided with a detailed informed consent form that outlined the purpose of the research, the methods used, the potential risks and benefits, and their right to withdraw from the study at any time without penalty. Those that agreed to participate selected “Agree” on the consent form, and then begin the interview.To ensure confidentiality, the recordings should be transcribed within 24 hours and deleted in time after a detailed recording. Answer the questions raised by interviewees in time during the interview. The personal information of the participants was presented in the form of anonymous alphabetic numbers.

3.1 Analysis of the qualitative study results

A total of 21 hospital inpatients were interviewed in this study.The demographics of participants are listed in Table 1.After summarizing and analyzing the interview data collected and summarizing the topic, the investigator summarized the factors influencing the power distance of hospitalized patients with the following three subjects: patient factors (knowledge reserve, psychological stress, hospitalization experience); medical factors (role cognition, professional qualifications, communication skills); and environmental factors (clinical situation, social environment, cultural background) as shown in Table 2

Table 1 General data of the interviewed patients (N=21)

No.	Gender	Age	Education	Occupation	Hospitalization Dept.	Living condition	Medical burden	Hospitalization Frequency
P1	M	45	Junior college	office clerk	Surgery	Downtown	General	1
P2	F	35	Undergraduate	office clerk	Internal medicine	Downtown	General	1
P3	F	42	Undergraduate	office clerk	Surgery	Downtown	General	1
P4	M	37	Junior middle school	Peasant	Surgery	countryside	Heavy	1
P5	F	26	Undergraduate	office clerk	Surgery	Downtown	General	1
P6	M	32	Undergraduate	office clerk	Internal medicine	Downtown	General	1
P7	F	28	junior college	schoolteacher	Obstetrics-Gynecology	Downtown	Lighter	1
P8	M	70	Junior middle school	Retired	Internal medicine	Downtown	General	1
P9	F	52	Junior college	Retired	Internal medicine	Downtown	General	3
P10	F	24	Undergraduate	Designer	Surgery	Downtown	Lighter	1
P11	M	48	Senior high school	office clerk	Surgery	Other provinces	Heavy	1
P12	M	29	Undergraduate	office clerk	Internal medicine	Downtown	General	1
P13	F	34	Master Degree	Physician	Obstetrics-Gynecology	Downtown	Lighter	1
P14	M	54	Junior middle school	Retired	Surgery	Downtown	General	1
P15	M	62	Junior middle school	Retired	Surgery	Downtown	General	1
P16	M	36	Undergraduate	Liberal professions	Internal medicine	Downtown	Lighter	1
P17	M	48	Doctorate	Corporate executives	Surgery	Downtown	Lighter	1
P18	F	42	Undergraduate	office clerk	Obstetrics-Gynecology	Downtown	General	1
P19	F	35	Undergraduate	Pharmacist	Obstetrics-Gynecology	Downtown	General	2
P20	M	26	Master Degree	schoolteacher	Surgery	Downtown	Lighter	2
P21	F	62	Senior high school	Retired	Internal medicine	Downtown	General	4

Table 2 Theme, sub-themes and coding

Theme	Sub-themes	Coding
Patient factors	knowledge reserve	Lack of medical knowledge；Insufficient awareness of the disease
	Psychological stress	Related to illness；Worry about privacy exposure；Low self-esteem
	Hospitalization experience	Length of stay；Frequency of hospitalization
Medical factors	Role cognition	Doctors know best；the duty of the physician；patients just need to follow the physician's arrangement；caregivers are partners with patients
	Professional qualifications	In awe of high-level doctors；Resident doctors are easy to communicate
	Communication skill	Empathy ability；Trans-positional consideration；Focus on the patient's emotional responses
Environmental factors	Clinical situation	Lack of communication time；busyness；Medical staff are overworked
	Social environment	A big gap between urban and rural areas；The health insurance system is imperfect；Health resources are unevenly distributed；Different level of income
	Cultural background	Concept differences between the old and the young；Women have strong language skills；Women are highly capable of building interpersonal relationships

3.1.1 Subject 1：Patient-side factors

Sub-theme1： knowledge storage

Due to the information asymmetry between doctors and patients, the thought pattern of "the doctor is the authority" and "the doctor-directed" is formed. During the interview, the lower the patient's lack of disease and related expertise, the greater the dependence on the physician.

P1: " I don't know much about my illness, and I still don't get it after the doctor explained it to me. In other words, I'm listening to the doctor.”

P13: " I'm a doctor as well.I know my illness very well, so there is no barrier to contacting medical staff. I have my own opinion, and we talk a lot and we make decisions together.”

Sub-theme2：Psychological stress

During the interview, a portion of the patients mentioned that they experienced high psychological pressure when communicating with medical staff. In addition to the psychological pressure caused by the disease itself, the patients also involve concerns about their privacy exposure and even being ridiculed by the medical staff, which leads to them to deliberately keep a certain distance from the medical staff.

P11: "To be honest, when the doctor came to me, I felt very stressed, fearful that he said I was diagnosed with a serious problem...".

P16："... When my attending doctor asked about my medical history, I told him I had sexually transmitted diseases, and when I saw this doctor, I felt embarrassed to talk to him more..."

Sub-theme3：Inpatient experience

The longer patients remain, the more they are in contact with the hospital and medical staff. At the same time, they have accumulated some knowledge and experience related to the disease, treatment and process, so that they show from a short power distance.

P12: " When I was admitted to the hospital, I was very weird about everything. Now I have been here nearly a week. I am very familiar with doctors and nurses and I often talk to each other.”

P9: " I hardly have any distance with medical care here. We have a very good relationship. I know all of them, and they know me, and I've been hospitalized many times for this disease..”

3.1.2 Theme 2: Medical care factors

Sub-theme1：Role cognition

During the patient interview, part of physicians believe that "doctors' expertise determine physicians' leadership positions in decision-making. It is the duty of the physician, and patients just need to follow the physician's arrangement.However, some doctors believe that medical staff are partners with patients.

P18: " When I ask questions, some doctors will say,'Am I a doctor or are you a doctor? Listen to you or listen to me?'I had to listen to him. But some doctors told me, Doctors and nurses are human beings too, and we are all equal.If you have any questions, please feel free to ask.Don't be afraid.’I prefer to contact such a physician.”

Sub-theme2：Professional qualifications

During the interview, patients were intimidated by high-level medical staff and demonstrated a high power distance.However, the same patient had a small power distance when dealing with doctors of low seniority.

P6: " I feel easy to talk to the resident, but whenever I visit the chief medical officer, I feel nervous.”

P15：“I remember once the hospital director came to make a ward round, and all the patients throughout our ward were afraid to talk...”

Sub-theme3： Communication skills

The ability to communicate medical care plays a significant role in the doctor-patient relationship. Good communication can effectively relieve patient anxiety and reduce the distance between physicians and patients.

P7: "My resident doctor has always thought for me, often stands in my point of view, from time to time to say my heart.”

P3: " When the physician questioned me about my medical history, I felt uncomfortable.The physician did not continue to consult, but said many words to comfort and encourage me.”

On the contrary, some physicians pay attention only to improving the recovery rate of patients., rather than the use of communication skills, which leads to the neglect of patients 'soft needs, resulting in the estrangement in patients' hearts.

P5: " Because half-body anesthesia was taken, I had to be very aware. When I was lying on the operating table, I heard the conversation between the doctors clearly: 'Do it now, get her out before twelve o'clock '.”

3.1.3 Theme3: Environmental factors

Sub-theme1：Clinical situation

The patient base in China, is significant, but the medical staff is seriously understaffed and the clinical task is burdensome，which dilutes the time between medical staff and patients and also limits the opportunities for patient engagement to some extent.

P15 " Doctors and nurses have always had their hands full.I'm embarrassed to ask questions and I'm afraid I'm going to cut them off.”

P14: " The doctor gave me a general idea about the treatment plan, said it very quickly, and asked me which one to choose? I didn't understand it yet, and I didn't know how to choose it, so I had to let the doctor choose it for me.”

Sub-theme2：Social environment

The doctor-patient relationship is the most common social relationship within medical facilities.In today's society, there are many problems in China, such as the large gap between urban and rural medical development level, the imperfect medical security system, and the unequal distribution of health resources.These problems affect the doctor-patient relationship to varying degrees, and thus affect the power distance of patients.

Patients in rural areas reported that they showed a high power distance due to the large gap between urban and rural areas, resulting in low knowledge and cognition.

P4：“I came from the countryside, I came to the large city for the first time, I know nothing, I did what the doctor said.”

One patient stated that he was willing to actively contact the medical staff so that doctors would understand in order to save as much money as possible.

P11: " We are not residents of the this city. We have no medical insurance and spend a lot of money to see a doctor, so we need to communicate with the doctor and tell him the actual situation, and he will not arrange the unnecessary examination.”

However, the majority of middle and senior managers belong to the middle class. They generally have a high socio-economic status. They tend to express their views, and they are prepared to actively communicate with medical staff.

In the interview, a company CEO, P17, said " I don't care about the cost, but time is of the essence.I think I should talk to my physician about a plan to cure the disease as soon as possible.”

Sub-theme3：Cultural background

Influenced by Confucian culture, China has a traditional concept of "men are superior to women" since antiquity. In the interviews, female patients showed a lower tendency to power distance.

P2: "I am polite with the doctor, the doctor is also polite with me ... We get along very happily.”

Elderly patients have deeper traditional ideas than young patients, so elderly patients show a tendency of higher power distance.However, young people believe that the difference between themselves and medical care is professional, and prepared to contact medical care when they encounter problems.

P8: " I should listen to the physician when I go to the hospital.If I don't listen to the doctor, then who is it going to be?”

P10: " Treatment is the profession of doctors, which does not mean that they are superior.”

4.1.Those who need medical care

4.1.1Medical knowledge reserve

The basic stock of medical knowledge is that before patients seek rational medical treatment and make meaningful scientific treatment decisions.Mastering certain basic medical knowledge is undoubtedly highly beneficial for the rational medical treatment of patients.The cure of the disease not only depends on whether the doctor's exquisite medical skills, whether the medication is accurate, and whether the medical equipment is advanced, but also depends on the patient's own cognition of the disease.In real life, there are still many people who do not understand pathogenesis and the risks of treatment and consider doctors as rescuers.In recent years, some studies have shown that some patients have little knowledge about basic medical knowledge, and believe that doctors are omnipotent, and the advanced medical technology can solve all diseases, which is an important reason for patients' excessive dependence on doctors(Birhanu et al., 2012).This conclusion is consistent with the conclusion of this study.

4.1.2 Psychological factor

Patients are under great psychological pressure in the whole diagnosis and treatment process, because of the physical torture and pain caused by the disease, and produce depression, anxiety and other negative emotions(Kowalenko et al., 2012).In this state, patients choose to maintain self-worth and self-esteem by suppressing emotions, hiding physiological needs.The study of Christine et al (McPherson et al., 2007)showed that patients were unable to work and assume traditional role responsibilities in the family after the illness, felt loss of self-esteem, showed reluctance to communicate with healthcare staff and participate in medical decision-making.This is consistent with the conclusions of this study.Additionally, some patients are concerned about the risk of exposure to privacy, the discussion behind medical staff, and so on, and are deliberately distancing themselves from medical staff.Studies have shown that infertility patients have great psychological fluctuations, subject to shame, guilt and low self-esteem, psychological avoidance, negative decision-making and other situations(Rooney & Domar, 2018).Patients with high psychological stress can be shown to have a high power distance.

4.1.3 Hospitalization experience

Patients spend more time and frequency in the hospital, and have a deeper contact with the hospital and medical staff, and find out more about them.After the increase of hospitalization experience, the patients have accumulated certain knowledge and experience related to diseases, treatment, hospital rules and regulations, and procedures, and also showed a higher cognitive level.Therefore, the more hospitalization experience, patients will show a tendency of low power distance in medical activities, tend to be equal in communication with medical staff, and are more willing to discuss the condition and the formulation of medical decision-making together with medical staff. On the contrary, patients with less hospitalization experience often show a tendency of high power distance, due to their unfamiliar environment, disease, fear and anxiety, and rely heavily on medical staff in communication, decision-making and knowledge(Pan Qijin et al., 2020).

4.2 Medical supplier

4.2.1 Medical staff communication ability factors

Doctor-patient communication is the direct manifestation of doctor-patient interaction. The communication and orientation mechanism is the foundation for a seamless physician-patient relationship (Hamasaki Tet al.,2008).Communication skills, attitudes and other aspects of physicians directly affect patients' psychological experience and then show varying degrees of sense of distance.This research shows that when medical staff lack communication skills when communicating with patients, patients show a high power distance.This conclusion is consistent with the research results of Weng H C et al.(Weng et al., 2008), showing that medical staff have blunt language, indifferent attitude and lack of humanistic care, leading to the neglect of patients 'soft needs, thus resulting in patients' mental estrangement.On the contrary, when the medical staff pays attention to each other's feelings and follows the principle of respect, the patient has good psychological feelings, has a good impression of the medical staff, and shows a low power distance tendency such as positive communication and willingness to participate.One study found that patient satisfaction increases when their psychological needs, which include respect, care and encouragement, are met(Kirk & Kane, 2016).

4.2.2 Role cognition

In this study, physicians' perceptions of the physician-patient role were found to be diversified.Some physicians believe that physicians are a symbol of authority, and patients only need to listen to their views. At this time, patients show a high power distance tendency to be fully obedient to doctors.Results from one study showed that Chinese physicians rely on physician-centric decision-making methods rather than physician-centric joint decision-making models. Patient participation was limited to physician adherence(Dai et al., 2016).However, some physicians have fully recognized the importance of the patient's view, believing that the treatment is bilateral and that the patient has the right to participate.The patient has a short power distance tendency to discuss participation with the physician with these physicians.Another study found that when doctors told patients that the relationship was collaborative and encouraged them to participate in developing treatment plans, patients showed a greater willingness to participate(Hayes et al., 2019).

4.2.3 Professional qualifications

This study found that when patients interact with medical staff with senior professional titles, they show a high power distance tendency such as nervousness, unnaturalness, and even have nothing to talk about, while they show a low power distance tendency such as high willingness to communicate with junior doctors.The reasons can be summarized as follows: on the one hand, medical staff with high professional titles have high authority, and patients have communication anxiety due to the fear of authority.A study has shown that the respect of a top social person in a hierarchical society strongly influences communication(Tran et al., 2020).Patients believe that physicians with a high status, but do not consider physicians as their partners. However, in Western countries, patients actively engage in consultation, and doctors and patients are equal(Makoul & Clayman, 2006). On the other hand, medical personnel with higher professional designations are busy and have little opportunity to communicate with patients.Studies have shown that the asymmetry of physician-patient information among physicians with advanced professional qualifications(He Ronggang & He Junzhou, 2018).Although senior professional title doctors control a large amount of medical information, doctors with low professional title communicate more with patients, and patients get relatively more medical information from low seniority doctors, which leads to serious information asymmetry between patients and doctors with high professional title.

4.3. Environmental factors

4.3.1. Clinical situation

This study shows that in practical clinical work, the lack of time makes doctors without enough time to communicate with patients, which may lead to doctors tend to adopt paternalistic communication methods, making patients show a high power distance tendency.This is consistent with the findings of a US study(Zisman-Ilani et al., 2020).On the other hand, because of the acute shortage of medical staff, the daily workload of medical care is significant.However, doctor-patient communication requires some time to complete, and the daily workload of medical personnel is in a state of saturation or even excessive. It is inevitable that there will be "words for gold" or impatience toward patients in the workplace.Domestic studies have shown that 64% of patients think that "physicians are too busy with time to work" is the main factor in the barriers to communication(Fangfang Liu et al., 2022).

4.3.2. Social environment

Social and environmental factors, primarily include two factors related to China's medical insurance system and the unequal allocation of medical resources.The introduction of China's medical insurance policy means that the proportion of patients' self-paid treatment is reduced, and most medical expenses can be covered by medical insurance.However, the reality is that the types of drugs in hospitals are limited, and drugs bought by designated pharmacies outside the hospital cannot be reimbursed, so the contradiction is still not resolved.As a result, both insured and self-funded patients have a high medical burden.Peter J et al.(Cunningham, 2009) found that patients with high medical burden would have high levels of involvement in medical decision-making and perceptions of overuse and underuse of services.

The gap between urban and rural areas is wide, rural economic development is lagging, information is lacking, and the level of medical care is low.To a certain extent, it helps to maintain the strong traditional concepts of the local society, and there are also great differences in values(He Xiaobin et al., 2020) (Yang Xiuyong, 2021).Therefore, When patients from rural cities arrive in large cities with advanced medical technologies and sufficient medical resources for treatment, they rely heavily on physicians and are prepared to give up their autonomy and leave it to medical staff for decision.Hence, these populations exhibit a high power distance.

4.3.3. Cultural background

China's power distance index is 80, which is a typical high power distance country. Power distance is a characteristic cultural value. Gender is an important variable that influences values, and there are significant differences in understanding and acceptability of each other's behaviour(Ridgeway, 2001).Gender role theory indicates that since gender has special social roles and behavioural expectations, men are seen as more confident, capable and independent, while women are seen as more helpful, considerate and benevolent(Lanaj & Hollenbeck, 2015).National studies show that female patients are more willing to contact medical staff about practical issues related to their treatment(Li Juan et al., 2012).This view is consistent with the findings of this study. However, several foreign studies revealed no statistical differences in physician-patient communication and involvement in decision-making(Roter & Hall, 2004; van den Brink-Muinen et al., 2006).

On the other hand, the elderly group in China today has experienced the special historical context of China, the "cultural revolution", which has made them lose the right to education.Moreover, they are profoundly connected with the influence of the planned economy system and traditional ideas, and they are often relatively conservative(Maohua Chen, 2020).Domestic studies have shown that most elderly patients are still an "authoritarian speech" dominated by the doctor-patient communication mode of "doctors decide"(Zheng Chen & Zhang Xilu, 2019).Older patients consider medical staff as "new parents", and they are more dependent on them in all aspects, so they show from a high power distance. However, foreign studies have found no statistical differences in physician-patient communication among patients of different ages(Baumann et al., 2008).Thus, it is seen that the difference in individual power distance of patients occurs due to differences in cultural background at home and abroad.Thus, it shows that the difference in individual power distance of patients varies due to cultural differences between different countries.

This study shows that patient power distance is mostly influenced by patient factors, medical staff factors and environmental factors. These three factors can not only play a role alone, they can also play closely related roles.Medical staff should attach great importance to the patients' power distance, and enhance their ability to communicate and humane care.Based on individual patient differences, appropriate communication methods should be adopted to reduce distance between physicians and patients and reduce patients’ power distance.Ensuring that patients change their medical ideas, guiding them to become their own health managers, building a "harmonious community with a common future for physicians and patients" fundamental guarantees patient safety.

Due to the limitation of the subject, the questionnaire survey of this study was only carried out in the tertiary hospitals in Shanghai, and the sampling scope and sample coverage had certain limitations.

In the future, it will be necessary to strengthen the representatives of the sampling, investigate and analyze patients in hospitals in different regions and levels of culture to fully understand the factors influencing patient power distance in various regions and cultures.Based on the findings of this study, the factors influencing patient power distance can be further explored in two main ways: patient psychological level and the power distance of medical staff.

Author Contribution

The authors were responsible for the paper as follows: Yinyu Wang and Haiping Yu, conception, design, analysis, and data interpretation, drafting the manuscript, revising the manuscript, and its final approval; Yanfen Gu， Danlei Yu and Youqing Peng, acquisition of data, formal analysis，project administration, manuscript revisions, and its final approval. All the authors have read and approved the final manuscript.

Acknowledgement

The authors wish to thank the anonymous reviewers, associate editors, and editors for their thoughtful reviews and suggestions for this manuscript.

FUNDING DECLARATION

This work has received funding from Tongji University School of Medicine Nursing School (Provisional) Three-Year Action Plan for Discipline Construction (Grant No.JS2210305)and Shanghai East Hospital Angel Program and Young Nurses Growth Program (Grant No.DFTS-2225). The funders had no role in the study design, data collection, analysis, interpretation, or writing of the manuscript.

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No competing interests reported.

Analysis of the factors influencing patients’ power distance ：a qualitative study

Status:

Version 1

Abstract

1. INTRODUCTION

2. METHODS

3. RESULTS

4. DISCUSSION

5. CONCLUSION

6 LIMITATIONS AND PERSPECTIVES

Declarations

Author Contribution

Acknowledgement

References

Additional Declarations

Status:

Version 1