Navigating Power Dynamics in Acute Care: Enhancing Nursing Autonomy and Implementing Evidence-Based Practice Through Interprofessional Collaboration

doi:10.21203/rs.3.rs-5334395/v1

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Navigating Power Dynamics in Acute Care: Enhancing Nursing Autonomy and Implementing Evidence-Based Practice Through Interprofessional Collaboration

https://doi.org/10.21203/rs.3.rs-5334395/v1

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Aim: This study explores the impact of power dynamics between nurses and physicians in acute care settings, focusing on how these dynamics influence nursing autonomy and the implementation of Evidence-Based Practices (EBPs). It aims to identify strategies that promote interprofessional collaboration, enhance nurse leadership, and support shared decision-making to improve patient outcomes.

Design: An exploratory qualitative methodological approach grounded in the philosophy of social constructivism was utilised in this study.

Methods: Data were collected through non-participant observations, semi-structured interviews, and document analysis across two large NHS acute care hospitals in the Midlands. Thematic analysis, following Braun and Clarke’s framework, was used to identify key themes related to hierarchical barriers, nursing autonomy, and interprofessional collaboration. The participants included 37 staff nurses, ward managers, nurse managers, and physicians.

Findings: The study revealed that hierarchical power imbalances, particularly medical dominance, significantly limit nursing autonomy and hinder EBP implementation. Nurses reported limited decision-making authority and were often excluded from critical care discussions. However, interprofessional collaboration, leadership development, and shared governance models were identified as effective strategies to reduce these power imbalances. Nurses who engaged in leadership training and participated in nurse-led initiatives experienced increased autonomy and reported improved patient care outcomes.

Conclusion: Power imbalances hinder the implementation of EBPs by nurses in acute care settings. Enhancing nursing leadership, promoting interprofessional collaboration, and adopting shared governance models can empower nurses, improve autonomy, and enhance patient outcomes.

Impact: The findings highlight the importance for healthcare organisations to invest in nursing leadership development, implement collaborative governance models, and foster interprofessional teamwork to support EBP implementation and improve patient care quality.

Reporting Method: The study adheres to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines.

Patient/Public Contributions: Patients and the public were not directly involved in this study. However, the study’s focus on nurse-led initiatives has significant implications for improving patient care quality.

Nursing

Power dynamics within healthcare, particularly the hierarchical structure that positions physicians at the top and nurses in subordinate roles, have long been a critical issue (1, 2). Nurses, often closest to patients, frequently find their insights marginalised in decision-making processes, limiting their professional autonomy (3). This imbalance affects not only professional relationships but also the implementation of Evidence-Based Practices (EBPs), which are vital for improving patient outcomes by integrating clinical expertise, research evidence, and patient preferences (4). In acute care settings, where rapid decision-making is crucial, hierarchical structures are particularly detrimental. They constrain nurses' autonomy, hinder the adoption of EBPs, and ultimately compromise patient care (5). The impact of this power imbalance extends beyond professional dissatisfaction, influencing patient safety, care quality, and the effectiveness of healthcare teams (6).

Freidson's concept of medical dominance refers to the structural power physicians have historically held over healthcare, maintained through institutional structures and cultural norms that reinforce physicians as the primary decision-makers (7). Despite their expertise, nurses remain in subordinate roles even in modern healthcare systems (8). In acute care settings, physicians are often viewed as the sole decision-makers, with nurses' clinical judgment undervalued, reducing team effectiveness, and limiting the autonomy necessary for patient-centred care (2). Current research highlights how these power dynamics obstruct the implementation of EBPs in nursing practice (9). Nurses in acute care face significant barriers due to medical authority favouring traditional practices over evidence-based innovations, which limits nurses' professional autonomy and compromises patient outcomes (9, 10).

EBP is essential in healthcare, combining clinical expertise, research, and patient preferences to improve outcomes (4). In nursing, EBP holds great potential to enhance care quality, but its implementation is frequently hindered by organisational and cultural barriers, particularly in environments dominated by hierarchical power structures (3). Studies have identified barriers, including limited access to resources, time constraints, and insufficient organisational support (6). Nursing autonomy is a key factor in successful EBP implementation, as it allows nurses to make independent decisions based on their clinical judgment (5).

To address these issues, organisational support and leadership development are necessary. Leadership training empowers nurses to take on more influential roles within healthcare teams, enabling them to advocate for EBPs (3). Leadership development helps nurses challenge hierarchical norms, particularly in settings where medical dominance is entrenched (11).

1.1 Aim and Objectives

This study aims to explore the impact of power dynamics between nurses and physicians on nursing autonomy and the implementation of EBPs. Specifically, the study’s objectives include to 1) explore the organisational barriers that hinder nurses’ autonomy and the implementation of EBPs 2) examine the strategies nurses use to challenge hierarchical dynamics and assert their professional knowledge in clinical decision-making 3) explore strategies that promote nurse autonomy, foster interprofessional collaboration, and reduce hierarchical barriers.

3.1 Research Design

The study employed an exploratory qualitative methodological approach grounded in the philosophy of social constructivism, which was considered the most suitable design for obtaining detailed information (12). Qualitative exploratory studies are typically the preferred method when the aim is to describe a particular phenomenon, such as EBP implementation. The research and reporting process followed the guidelines of the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist (13).

3.2 Participants and setting

Two large hospitals in the Midlands, England, were purposively selected for this study. These settings were chosen for their hierarchical organisational structures, which provided an ideal setting to examine power dynamics between nurses and physicians. With a diverse range of departments, including surgical, medical, and emergency care units, the study was able to comprehensively explore how power dynamics affect EBP across various clinical environments. The high-pressure nature of acute care, where nurses often have limited autonomy despite their critical role in patient care, made these settings particularly relevant.

Similarly, purposive sampling was employed to recruit nurses across different hierarchical levels, including ward managers (WM), staff nurses (SN) nurse managers (NM), hospital managers (HM), ensuring diverse perspectives on power dynamics. Convenience sampling further accounted for nurses' shift patterns.

3.3 Sample size and eligibility

Tables 1 and 2 present the demographics of participants, including 12SNs,14WMs, 2NMs, and 2 physicians. Eligibility criteria included: 1) willingness to discuss EBP implementation, 2) at least five years of clinical experience, and 3) fluency in English. The nursing staff profiles in both study sites were similar, with nurse-patient ratios indicating some staff vacancies, although these were not advertised. The participants' years of experience ranged from 6 to 35 years, reflecting a broad spectrum of clinical expertise across both cases.

Table 1

Participants' Demography (Site 1)
ID	Participant Rank	Gender	Age (Years)	Interviewed/Observed
1	Physician	M	52	Interviewed
2	NM	F	57	Interviewed, Observed
3	WM	F	58	Interviewed, Observed
4	WM	F	52	Interviewed, Observed
5	WM	F	46	Interviewed
6	WM	M	44	Interviewed
7	WM	F	57	Interviewed, Observed
8	WM	F	57	Interviewed
9	WM	M	38	Interviewed, Observed
10	WM	F	36	Interviewed, Observed
14	SN	F	26	Interviewed, Observed
15	SN	M	29	Interviewed, Observed
16	SN	M	26	Interviewed, Observed
17	SN	M	27	Interviewed, Observed
18	SN	F	25	Interviewed, Observed

Table 2

Participants' Demography (Site 2)
ID	Participant Rank	Gender	Age (Years)	Interviewed/Observed
1	Physician	M	47	Interviewed
2	NM	F	62	Interviewed, Observed
3	WM	F	52	Interviewed
4	WM	F	40	Interviewed, Observed
5	WM	F	44	Interviewed, Observed
6	WM	M	51	Interviewed, Observed
7	WM	F	47	Interviewed
8	WM	M	43	Interviewed
13	SN	F	25	Interviewed, Observed
14	SN	M	28	Interviewed, Observed
15	SN	M	24	Interviewed, Observed
16	SN	M	28	Interviewed, Observed
17	SN	F	29	Interviewed, Observed
18	SN	M	28	Interviewed
19	SN	F	31	Interviewed, Observed

3.7 Data collection

Data collection lasted between April and November 2022, using semi-structured interviews and non-participant observation. Observations, conducted during both day and night shifts across various clinical wards, provided real-time insights into nurse-physician interactions, offering additional insights into the power dynamics affecting nursing autonomy and EBP implementation. This helped triangulate interview data and offered a more complete picture of discrepancies between participants' statements and their actions (14).

Semi-structured interviews, conducted face-to-face, allowed participants to freely share their perceptions of EBP implementation. Open-ended questions encouraged detailed responses, while follow-up prompts explored key issues further (15). Interviews were digitally recorded, except for two participants who declined, and ranged from 45 to 90 minutes in duration. Table 3 shows the interview guided that was used. This integration of data sources enhanced the depth and validity of the research findings (16).

Table 3

Interview guide
Key question: Can you describe your experiences with implementing EBP in your hospital?
Prompts: 1. What are the main challenges you face in implementing EBP in your daily clinical practice? 2. How do organisational structures or hierarchies influence your ability to apply EBP in decision-making? 3. Can you share a specific instance where you successfully integrated EBP into patient care? What factors contributed to this success? 4. How do you and your colleagues access and utilise evidence-based resources (e.g., guidelines, research) during your shifts?

3.8 Data analysis

Data were analysed using Braun and Clarke’s (17) six-phase thematic analysis, which provided a systematic approach to identifying patterns within the data: 1) The researcher thoroughly engaged with interview transcripts and observation notes, allowing them to recognise recurring issues 2) Open coding identified relevant data segments, focusing on organisational power, barriers to EBP, and nurses' adaptive strategies. Codes like “limited decision-making,” “moral distress,” and “exclusion from discussions” consistently surfaced, highlighting key challenges faced by nurses 3) Codes were clustered into broader themes, reflecting both the constraints imposed by hierarchical structures and the ways nurses negotiated autonomy. Themes such as “autonomy and professional power,” “nurse-physician power imbalance,” and “emotional and psychological impact of power imbalance” emerged 4) Themes were reviewed to ensure coherence and relevance to the research questions. Subthemes like “advocacy through knowledge” and “burnout and emotional fatigue” were refined, ensuring each theme was well-supported by the data 5) Each theme was clearly defined and linked to participant quotes, such as “nurse-physician power imbalance,” exemplified by the exclusion of nurses from decision-making, supported by quotes like 6) A cohesive narrative was constructed, detailing how nurses experienced and navigated power dynamics, the impact on EBP implementation, and the emotional toll of these hierarchical structures. Each theme was illustrated with participant quotes and observational notes, providing a rich, contextualised understanding of the data. Table 4 shows a A summary of key themes and subthemes identified through Braun and Clarke’s (16) thematic analysis, along with verbatim quotes from participants and observations.

Table 4

Key themes and subthemes with verbatim some quotes
Key Themes	Subthemes	Verbatim Quotes (Codes)
Autonomy and Professional Power	Limited Decision-Making Authority	“I don’t have the power to decide what needs to be changed or not; the doctors do.”
	Subordination in Care Decisions	“We just follow the orders, even when we know better. It feels like we are just here to assist, not to decide.”
Nurse-Physician Power Imbalance	Exclusion from Key Discussions	“We’re rarely consulted, even when we’re the ones with the most information about the patient’s daily care.”
	Power Imbalance in Clinical Settings	“The way it is done here is that the doctors decide, and we obey.”
Resistance and Professional Empowerment	Advocacy through Knowledge	“I may not have the final say, but I will speak up when I know something is not right.”
	Subtle Negotiations	“Sometimes it’s not about arguing it’s about finding a way to get them to consider another option without making it a fight.”
Emotional and Psychological Impact of Power Imbalance	Burnout and Emotional Fatigue	“It’s exhausting we put in so much effort, but it feels like it doesn’t make any difference.”
	Moral Distress	“I knew the decision was wrong, but I didn’t have the power to stop it. It’s heartbreaking.”
Addressing Power Dynamics in Interprofessional Healthcare Teams	Promoting Collaborative Practice	“Through interprofessional workshops, we learned to appreciate each other’s roles and contributions, which improved our teamwork.”
	Enhancing Communication and Transparency	“Weekly interprofessional meetings have helped us address issues collaboratively and ensure everyone is on the same page.”
	Empowering Nursing Leadership	“Leadership training has given me the confidence to advocate for my patients and my team more effectively.”
	Policy and Structural Changes	“Policy changes that recognise all team members’ contributions have created a more inclusive environment.”
	Fostering Mutual Respect and Understanding	“Cultural competence training has helped us understand and respect each other’s backgrounds and perspectives.”

3.9 Ethical considerations

This study followed the ethical principles of the Declaration of Helsinki of 1964 and received approval from the University of Northampton Research Ethics Committee. Each hospital’s management also granted permission for participant recruitment. Broader ethical approval was not required, as the study did not involve minors, clinical trials, or pose any risks to participants, per UK regulations. Participants received electronic and written invitations detailing the study’s purpose, confidentiality, data handling, and their right to withdraw without consequences. Informed consent was obtained in line with GDPR. The researcher shared their professional background and explained the study’s aims to build trust (20), ensuring anonymity in reporting. All data will be securely stored and destroyed after publication, and participants were treated with respect throughout.

3.10 Rigour and Reflexivity

The study adhered to principles of credibility, transferability, dependability, and confirmability (20, 24). Triangulation, prolonged engagement, and multiple data collection methods, including interviews and observations, were employed to capture diverse perspectives. Spending eight months in the field enhanced credibility by providing a thorough understanding of issues affecting EBP implementation. The research process was meticulously documented, with detailed contextual information and a clear audit trail, ensuring transferability and potential replication (12). Participant quotes supported data analysis, ensuring transparency (18). Reflexivity was maintained through explicit acknowledgment of the study’s philosophical foundations, and a research diary preserved consistency during analysis. Finally, the COREQ guidelines were followed in reporting the qualitative results (13)

Five primary themes emerged from the participants' narratives. Table 4 presents the key themes, their operational definitions, theme clusters, and a summary of relevant keywords. The individual themes are in turn reported below.

4.1 Autonomy and Professional Power

This theme explores the restricted autonomy nurses experience within hierarchical healthcare systems, highlighting the pervasive influence of physician dominance on clinical decision-making and nursing practice.

4.1.1 Limited Decision-Making Authority

Nurses consistently reported feeling constrained in their ability to make independent clinical decisions, despite their direct involvement in patient care. The ‘doctor knows best’ culture, deeply entrenched in these settings, often undermined their professional expertise. Both SNs and WMs described how this culture limited their ability to contribute meaningfully to patient care, even when they believed their input could improve outcomes: “I don’t have the power to decide what needs to be changed or not; the doctors do. It’s frustrating because we spend more time with the patients, but our insights are not valued.” (Interview RN, S1). This illustrates how nurses feel undervalued and powerless in decision-making processes. Similarly, during an observation, a nurse hesitated before carrying out a doctor's directive she disagreed with, later commenting, “I wanted to suggest something different, but I knew it wasn’t my place to question the doctor’s orders.” (Observation note, S1). This observation exemplifies the internal conflict nurses experience when they are unable to exercise their clinical judgement.

4.1.2 Subordination in Care Decisions

The sense of subordination that nurses experience further limits their capacity to act as equal members of the healthcare team. This subordination, reinforced by hierarchical structures, diminishes nurses’ professional identity, making them feel more like assistants than partners in patient care. In an interview, one of the nurses expressed, “We just follow the orders, even when we know better…it feels like we are just here to assist, not to decide. That’s what’s expected of us.” (Interview RN, S2).

An observational note also captured this dynamic: “During a team meeting, the nurse attempted to offer a suggestion, but the doctor dismissed it, quickly moving on to the next topic without acknowledging her input.” (Observation note, S2). This highlights how nurses’ contributions are often overlooked in decision-making processes, reinforcing their subservient role.

4.2 Nurse-Physician Power Imbalance

The power imbalance between nurses and physicians is a dominant theme, particularly in acute care settings where rapid decision-making is crucial. Despite their proximity to patients, nurses are often excluded from key discussions that affect patient care.

4.2.1 Exclusion from Key Discussions

Nurses frequently expressed frustration at being left out of important discussions about patient care, despite their detailed knowledge of the patient's daily needs. This exclusion not only limits their professional contribution but also affects the implementation of EBP as one nurse reflected, “We’re rarely consulted, even when we’re the ones with the most information about the patient’s daily care. It’s like our input doesn’t matter.” (Interview RN, S2). This frustration reflects a wider issue of nurses feeling side-lined during critical decision-making processes. In an observation, it was noted, “The doctor gathered the team for a discussion about the patient’s care plan. The nurses were not invited to participate, even though they had been closely monitoring the patient for the past 24 hours.” (Observation note, S2).

4.2.2 Power Imbalance in Clinical Settings

The hierarchical relationship between nurses and physicians, where doctors hold a dominant position in clinical decision-making, was evident across both interviews and observations. This imbalance inhibits collaborative care and hinders the integration of EBP. One nurse shared, “The way it is done here is that the doctors decide, and we obey. That’s just how it’s always been.” (Interview RN, S1). Similarly, during an observation, a nurse reluctantly carried out an order that contradicted her assessment, later explaining, “I didn’t agree with the plan, but what can I do? The doctors have the final say.” (Observation note, S1). This scenario highlights the limited influence nurses have in clinical decision-making, even when their assessment may be more aligned with patient needs.

4.3 Resistance and Professional Empowerment

Despite the restrictive power dynamics, nurses often found ways to assert their professional knowledge and challenge physician dominance. This theme explores the subtle forms of resistance nurses employed to advocate for their patients and influence care decisions.

4.3.1 Advocacy through Knowledge

Nurses leveraged their clinical expertise to advocate for patients, particularly when they believed physician decisions were not in the patient’s best interest. Even though they lacked formal authority, they used their knowledge to influence care outcomes. One of nurses described, “I may not have the final say, but I will speak up when I know something is not right. Sometimes they listen, and that’s what matters.” (Interview RN, S1). This demonstrates how nurses can indirectly affect decision-making by asserting their expertise. An observation further illustrated this dynamic: “The nurse hesitated before administering a treatment prescribed by the doctor. After a brief discussion with the doctor, she convinced him to adjust the dosage based on her observations of the patient’s condition.” (Observation note, S2). This example shows how nurses subtly negotiate for better care outcomes through advocacy.

4.3.2 Subtle Negotiations

Rather than direct confrontation, nurses often engaged in subtle negotiations with physicians, offering alternative suggestions without challenging the physician’s authority outright. These negotiations allowed nurses to implement small yet significant changes in patient care. One of the nurses explained, “Sometimes it’s not about arguing it’s about finding a way to get them to consider another option without making it a fight.” (Interview RN, S2). This reflects the strategic communication nurses employ to influence clinical decisions without escalating conflicts. During an observation, it was noted, “The nurse offered a suggestion to the doctor in a casual manner, framing it as a question rather than a directive. The doctor agreed to the suggestion without realising it was a subtle challenge to his original plan.” (Observation note, S2). This demonstrates how nurses navigate power dynamics through tactful communication.

4.4 Emotional and Psychological Impact of Power Imbalance

The emotional toll of working in a hierarchical environment was evident throughout the study. Nurses reported feelings of burnout, frustration, and moral distress, which affected both their professional identity and emotional well-being.

4.4.1 Burnout and Emotional Fatigue

The constant undermining of nurses’ autonomy led to emotional exhaustion, with many nurses expressing feelings of burnout. This fatigue often resulted from the emotional labour required to maintain professional composure while being excluded from decision-making. One nurse shared, “It’s exhausting…we put in so much effort, but it feels like it doesn’t make any difference. At the end of the day, we’re just following orders.” (Interview RN, S1). This may be a reflection of the emotional fatigue that comes from being in a subordinate role despite one’s expertise. An observational note captured a similar sentiment: “The nurse appeared visibly tired after a long shift. She sighed deeply when the doctor overruled her suggestion, saying, ‘I don’t know how much longer I can do this.’” (Observation note, S1). This quote highlights the physical and emotional strain nurses experience in hierarchical environments.

4.4.2 Moral Distress

Moral distress was a significant issue for nurses when they were forced to comply with decisions they knew were not in the patient’s best interest. This internal conflict had profound psychological consequences, leading some to question their role in the healthcare system. One nurse explained, “I knew the decision was wrong, but I didn’t have the power to stop it. It’s heartbreaking, and it stays with you long after your shift ends.” (Interview RN, S2). This quote captures the deep moral conflict nurses face when they cannot act on their professional judgement. During an observation, a nurse was seen visibly upset after a patient’s condition worsened due to a decision she disagreed with. She later confided, “I knew this would happen, but I had to follow orders. It’s hard to sleep at night knowing you could have done something different.” (Observation note, S2). This illustrates the lasting emotional impact of moral distress on nurses

4.5 Addressing Power Dynamics in Interprofessional Healthcare Teams

Participants identified several strategies for addressing power imbalances and enhancing collaboration within healthcare teams. These strategies focused on promoting interprofessional respect, improving communication, empowering nurses, and fostering an inclusive decision-making process.

4.5.1 Promoting Collaborative Practice

Joint training programmes, such as IPE, were widely viewed as effective in fostering mutual respect and understanding between nurses and physicians. Through these programmes, healthcare professionals were able to appreciate each other's roles and contributions more fully, which improved teamwork and reduced hierarchical barriers. One nurse shared, “Through interprofessional workshops, we learned to appreciate each other’s roles and contributions, which improved our teamwork significantly. It created a sense of respect for what each of us brings to the table.” (Interview RN, S1). This quote highlights how collaborative training can bridge gaps in understanding between professions. During an observation, a multidisciplinary meeting involving both nurses and doctors was noted to be effective in breaking down silos: “The meeting was run in a way that everyone had a chance to contribute. The nurse offered insights on patient care that were actively discussed by the team, including the lead physician.” (Observation note, S2). This example shows how interprofessional engagement can promote inclusivity and shared decision-making.

4.5.2 Enhancing Communication and Transparency

Open and transparent communication channels were considered crucial for addressing power imbalances. Participants suggested that regular interprofessional meetings and an open-door policy could encourage better collaboration and allow concerns to be raised without fear of retribution. One doctor noted, “Weekly interprofessional meetings have helped us address issues collaboratively and ensure everyone is on the same page. We discuss everything openly, and that has made a huge difference in how we work together.” (Interview, physician, S2). This comment emphasises the importance of structured, regular communication for improving collaboration. In one observation, a nurse voiced her concerns during a team huddle: “The nurse spoke up about a patient’s care plan, and the physician thanked her for bringing up the issue. It was a small but significant step towards open dialogue between the professions.” (Observation note, S2). This demonstrates how open communication can shift power dynamics towards a more balanced interaction.

4.5.3 Empowering Nursing Leadership

Leadership training for nurses was seen as critical for helping them take on more influential roles within healthcare teams. Participants highlighted the need for structural support to develop leadership skills and empower nurses to advocate for their patients and teams. One nurse reflected, “Leadership training has given me the confidence to advocate for my patients and my team more effectively. I no longer hesitate to speak up when something needs to be addressed.” (Interview RN, S2). This comment illustrates how leadership development can empower nurses to challenge the status quo and assert their professional expertise. An observational note highlighted the positive impact of nurse leadership: “The nurse in charge confidently led the discussion during the morning briefing, ensuring that all team members, including junior doctors, had a voice in the care plan.” (Observation note, S2). This shows how empowering nurses in leadership positions can foster a more collaborative and inclusive environment.

4.5.4 Policy and Structural Changes

Participants called for organisational policy changes that reduce hierarchical barriers and promote more equal decision-making across the healthcare team. Several suggested the adoption of shared governance models, which distribute decision-making power more equitably among healthcare professionals. One hospital administrator commented, “Policy changes that recognise the contributions of all team members have helped create a more inclusive environment where everyone feels valued, regardless of their title.” (Interview Admin, S1). This quote underscores the importance of revising policies to foster a more inclusive culture. During an observation of a shared governance meeting, it was noted, “The meeting allowed nurses, doctors, and administrators to contribute equally to the discussion, with decisions made collaboratively. The atmosphere was noticeably less hierarchical than in typical meetings.” (Observation note, S1). This demonstrates the potential of shared governance to create a more egalitarian decision-making process.

4.5.5 Fostering Mutual Respect and Understanding

Cultural competence and respect for diverse perspectives were identified as essential for improving interprofessional relationships. Participants suggested that training in cultural competence could help healthcare teams better understand and value each other’s backgrounds and contributions. One nurse noted, “Cultural competence training has helped us understand and respect each other’s backgrounds and perspectives. It has made our team more cohesive and reduced some of the tension between professions.” (Interview RN, S2). This comment highlights the role of training in fostering respect among healthcare professionals from diverse backgrounds. An observation of a team meeting demonstrated this impact: “Team members from different cultural backgrounds shared their views on patient care, and their contributions were welcomed by all present, creating an atmosphere of mutual respect.” (Observation note, S2). This shows how fostering mutual respect can enhance collaboration and reduce power imbalances.

4.5.6 Recognition and Valuing Contributions

Participants stressed the importance of recognising and valuing the contributions of all team members, regardless of their role or seniority. Recognition programmes that highlight the achievements of all professionals were viewed as beneficial in boosting morale and promoting collaboration. One physician stated, “Recognition programs that highlight the achievements of all team members have boosted morale and improved collaboration. Everyone feels like their contributions matter.” (Interview physcian, S1). This quote underscores the role of recognition in creating a positive team dynamic. An observation of a recognition event captured this sentiment: “During the meeting, the nurse was praised for her initiative in improving patient care protocols. The applause from the team showed a shared respect for her contribution, regardless of the usual hierarchical boundaries.” (Observation note, S1). This illustrates how valuing each team member’s contribution can foster a more collaborative and supportive environment.

The findings of this study offer critical insights into the entrenched power dynamics between nurses and physicians in acute care settings and their impact on nursing autonomy, EBP implementation, and patient care. The study aligns with existing literature, demonstrating that hierarchical structures limit nurses' decision-making authority, which affects their ability to integrate EBP into practice effectively (6, 26, 19). Nurses in this study expressed dissatisfaction with being excluded from critical care discussions, despite their intimate knowledge of patient needs. This exclusion compromises patient safety and reduces job satisfaction, echoing findings from McHugh and Stimpfel (15).

These results confirm that power imbalances negatively affect patient outcomes when nurses' contributions are marginalised (15). The need for more collaborative models of care, where nursing expertise is valued, is highlighted (1). Despite these constraints, nurses in this study demonstrated subtle forms of resistance, asserting their professional expertise through "everyday resistance" strategies (7, 21). However, such efforts come at a cost, with participants reporting emotional fatigue and burnout, consistent with Schaffer et al.'s (23) findings on moral distress caused by hierarchical barriers.

Findings highlight the potential of interprofessional collaboration to mitigate the negative effects of power imbalances. Participants noted that joint training programmes, such as IPE, were effective in fostering mutual respect and improving teamwork between nurses and physicians. This finding is supported by Reeves et al., (22), who demonstrated that IPE reduces professional silos and encourages shared decision-making. Regular interprofessional meetings and shared governance models were also cited as important strategies for enhancing communication and empowering nurses to participate more fully in decision-making processes. Shared governance, in particular, has been shown to improve both job satisfaction and patient outcomes by distributing decision-making power more equitably across healthcare teams (13). Participants in this study advocated for the adoption of shared governance structures, suggesting that such reforms would allow nurses to have a more active role in shaping patient care decisions, which would in turn improve patient outcomes and nurse satisfaction.

Furthermore, the study emphasised the importance of organisational reforms to support nurse leadership and empowerment. Leadership training was found to increase nurses' confidence to advocate for their teams, aligning with Schaffer et al.'s (23) argument that empowering nurses enhances their ability to contribute to clinical decision-making. Nurse-led initiatives, particularly in infection control, further highlighted the value of nursing leadership in improving clinical outcomes (9).

Findings from this study may be limited by the reliance on self-reported data from nurses and physicians, which could introduce bias, as participants may be reluctant to fully disclose their views on hierarchical power dynamics. The absence of patient or public involvement further narrows the scope of the findings, as it overlooks the impact of power dynamics on patient care experiences. Although the study provides valuable insights, its cross-sectional design limits the ability to assess the long-term effects of interventions such as leadership training or interprofessional collaboration on nursing autonomy and EBP implementation

5.1 Implications for Practice

Healthcare organisations must address hierarchical power imbalances that undermine nursing autonomy and limit EBP implementation. Promoting interprofessional collaboration through IPE and adopting shared governance models will enhance nurses' formal roles in clinical decision-making. Leadership development programmes should be prioritised to empower nurses to advocate for EBP and assume influential roles within healthcare teams. Open communication channels and regular interprofessional meetings are essential to fostering collaborative practice and improving team dynamics.

5.2 Implications for Research

Future research should explore the long-term psychological effects of power imbalances on nurses, including how moral distress and emotional fatigue affect job satisfaction and patient outcomes. Investigating the efficacy of nurse-led initiatives and the organisational policies that support nurse empowerment is also needed. Additionally, research on how interprofessional collaboration, particularly through shared governance, can reduce hierarchical barriers will provide valuable insights for healthcare systems. Lastly, examining the role of cultural competence training in fostering mutual respect within diverse healthcare teams would provide insights into improving team dynamics and addressing power differentials, contributing to better patient care and professional relationships.

5.3 Conclusion

This study highlights the pervasive influence of hierarchical power dynamics on nursing autonomy and EBP implementation in acute care settings. Nurses' professional expertise is often marginalised by physician-led decision-making, negatively impacting patient outcomes. Despite these challenges, nurses use subtle resistance to advocate for patient care. Promoting interprofessional collaboration, shared governance, and leadership development can mitigate these power imbalances, empowering nurses to take on more influential roles and integrate EBPs into clinical practice effectively.

Data Availability

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions

Conflict Interest

The author declares that there are no conflicts of interest.

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The authors declare no competing interests.

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Navigating Power Dynamics in Acute Care: Enhancing Nursing Autonomy and Implementing Evidence-Based Practice Through Interprofessional Collaboration

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Abstract

Introduction

1.1 Aim and Objectives

Methods

3.1 Research Design

3.2 Participants and setting

3.3 Sample size and eligibility

3.7 Data collection

3.8 Data analysis

3.9 Ethical considerations

3.10 Rigour and Reflexivity

Results

4.1 Autonomy and Professional Power

4.1.1 Limited Decision-Making Authority

4.1.2 Subordination in Care Decisions

4.2 Nurse-Physician Power Imbalance

4.2.1 Exclusion from Key Discussions

4.2.2 Power Imbalance in Clinical Settings

4.3 Resistance and Professional Empowerment

4.3.1 Advocacy through Knowledge

4.3.2 Subtle Negotiations

4.4 Emotional and Psychological Impact of Power Imbalance

4.4.1 Burnout and Emotional Fatigue

4.4.2 Moral Distress

4.5 Addressing Power Dynamics in Interprofessional Healthcare Teams

4.5.1 Promoting Collaborative Practice

4.5.2 Enhancing Communication and Transparency

4.5.3 Empowering Nursing Leadership

4.5.4 Policy and Structural Changes

4.5.5 Fostering Mutual Respect and Understanding

4.5.6 Recognition and Valuing Contributions

Discussion

5.1 Implications for Practice

5.2 Implications for Research

5.3 Conclusion

Declarations

References

Additional Declarations

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