Essex Ryan, Kennedy Jack, Miller Denise, Jameson Jill
Institute for Lifecourse Development, University of Greenwich, London, UK.
Nurs Inq. 2023 Oct;30(4):e12571. doi: 10.1111/nin.12571. Epub 2023 Jun 20.
Healthcare organisations are hierarchical; almost all are organised around the ranking of individuals by authority or status, whether this be based on profession, expertise, gender or ethnicity. Hierarchy is important for several reasons; it shapes the delivery of care, what is prioritised and who receives care. It also has an impact on healthcare workers and how they work and communicate together in organisations. The purpose of this scoping review is to explore the qualitative evidence related to hierarchy in healthcare organisations defined broadly, to address gaps in macro-level healthcare organisational research, specifically focusing on the (1) impact of hierarchy for healthcare workers and (2) how hierarchy is negotiated, sustained and challenged in healthcare organisations. After a search and screening, 32 papers were included in this review. The findings of this review detail the wide-reaching impacts that hierarchy has on healthcare delivery and health workers. The majority of studies spoke to hierarchy's impact on speaking up, that is, how it shaped communication between staff with differential status: not only what was said, but how it had an impact on what was acceptable to say, by whom and at what time. Hierarchy was also noted to have substantial personal costs, impacting on the well-being of those in less powerful positions. These findings also provide insight into the complex ways in which hierarchy was negotiated, challenged and reproduced. Studies not only detailed the way in which hierarchy was navigated day to day but also spoke to the reasons as to why hierarchy is often entrenched and difficult to shift. A number of studies spoke to the impact that hierarchy had in sustaining gender and ethnic inequalities, maintaining historically discriminatory practices. Importantly, hierarchy should not be reduced to differences between or within the professions in localised contexts but should be considered at a broad organisational level.
医疗保健机构是层级分明的；几乎所有机构都是围绕个人的权威或地位排名来组织的，无论这种排名是基于职业、专业技能、性别还是种族。层级制度之所以重要有几个原因；它塑造了护理的提供方式、优先事项以及接受护理的对象。它还对医护人员以及他们在机构中的工作和沟通方式产生影响。本范围综述的目的是探讨与广义定义的医疗保健机构中的层级制度相关的定性证据，以填补宏观层面医疗保健机构研究的空白，特别关注（1）层级制度对医护人员的影响，以及（2）层级制度在医疗保健机构中是如何被协商、维持和挑战的。经过检索和筛选，本综述纳入了32篇论文。该综述的结果详细阐述了层级制度对医疗保健提供和卫生工作者的广泛影响。大多数研究都谈到了层级制度对直言不讳的影响，也就是说，它如何塑造了不同地位员工之间的沟通：不仅包括说了什么，还包括它如何影响什么是可以说的、由谁来说以及在何时说。研究还指出，层级制度会带来巨大的个人代价，影响权力较小者的福祉。这些发现还深入了解了层级制度被协商、挑战和重现的复杂方式。研究不仅详细说明了日常应对层级制度的方式，还探讨了层级制度为何常常根深蒂固且难以改变的原因。一些研究谈到了层级制度在维持性别和种族不平等、维持历史上的歧视性做法方面所产生的影响。重要的是，层级制度不应被简化为局部背景下不同职业之间或内部的差异，而应在广泛的组织层面上加以考虑。
