This paper discusses the healthcare system in Australia through a review of literature and contextualizes the hierarchy, power struggle and stratification that epitomizes the healthcare system in Australia. The impact of power and hierarchy on healthcare practitioners is also discussed.
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Running head: HIERARCHY AND POWER IN HEALTHCARE SYSTEM HIERARCHY AND POWER IN HEALTHCARE SYSTEM Name of student: Name of university: Author note:
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1HIERARCHY AND POWER IN HEALTHCARE SYSTEM Hierarchy and power are intrinsic to the current health care system in Australia Introduction The aim of this paper is to discuss about the healthcare system in Australia through a review of literature. Secondly, the objective is to contextualize and make an effort in understanding the hierarchy, power struggle and stratification that epitomizes the healthcare system in Australia. The paper finally concludes with the impact of the power and hierarchy on me as a healthcare practitioner. Discussion Background of the healthcare system in Australia and analysis through sociological theories Studies have shown that the ward round as a practise provides opportunities to the healthcareprofessionalswho belongtomultiplebackgroundalongwithpatientswith different lifeworlds to exchange information and interact together. The ward rounds have come to be understood as the sites of key decision making. In Australia, the partnership approach adopted by the National Medical Policy espouses the management of medication through encouragement of the doctors, nurses, pharmacists and patients to engage in shared responsibility and participation towards a safe medication process. Despite this collaborative approach, ward has been discerned as a site of professional hierarchy and exercise of dominance (Lord, Jefferson, Klass, Nowak & Thomas, 2013). This is done through the organization of discursive practises. The passivity of the nurses and the submissive attitude of the patients are largely evident in the clinical environments of cancer care, general surgery, and internal medicine. There has been limited information on the on the medical exchange between the medical staff and the patient. In the context of Australia, it has been found that
2HIERARCHY AND POWER IN HEALTHCARE SYSTEM doctors make clinical decisions in the confines of a private room before deciding to move towards the patients who is in a critical care environment. On the contrary, nurses are found to be making decisions in theopen-floorof the hospital. This spatial distance between making decisions in the confines of the private room and that of the open-floor curtails the power of the power of the nurses in making clinical decisions. Scholars have termed the patients of the hospitals as audience offront-stage shows. The issue of power dynamics can be further witnessed in the bodily dispositions of the doctors before their round of the ward duty and after their round of the ward duty. There have been vast amount of studies in the field of spatial differences in the Australian healthcare system but the scholars have identified lacunae in literature. It has been found that there has not been substantial studies that encapsulates the interactions between the patients and families along with the healthcare professionals who belong to different disciplines. Another aspect that not been explored is the nature and dynamics of medication interactions that are organized in the spatial context of the ward rounds. Liu, Manias and Gerdtz (2012), in their study ofMedication communication during ward rounds on medical wards: Power relations and spatial practicesprovide a prolific account of power relations that are enmeshed in the everyday interaction and practises of ward duties. Medication communication can be defined as interaction pertaining to the treatment regimen among the nurses, doctors, family members of the patients, pharmacists and various other stakeholders of the medical profession. The manner in which the information on medication is communicated and the ways in which the information is disseminated is imbued in power relationships (Johnson, 2016). A critical social theory approach on this issue is imperative as it debunks the dominant worldview and delves deeper intothepowerrelationshipsthatdefine,structureandinformtheeverydayclinical interactions.Therefore,thesocialtheoryapproachbecomesatoolandalensfor understandingthepoliticalstrugglesandpowerrelationsexistingamongthevarious
3HIERARCHY AND POWER IN HEALTHCARE SYSTEM participants in the context of clinical environment (Manners, 2017). Keeping all these in mind, critical ethnography as a methodological tool becomes justified in unveiling the stratification of the Australian healthcare system A study conducted in a metropolitan teaching hospital in Melbourne found that in the wardfourresidentmedicalstudentswereemployedwhowereentrustedwiththe responsibility of taking care of the patients in that particular ward. In addition, the residents were rendered with the responsibility of looking after the patients across all the wards in the hospital. Another ward had two medical residents employed for a limited period of time. These residents had to be physically present as a large chunk of their responsibility included looking after the patients who have been admitted in that ward. These wards had one or two registrars whose duty is to supervise the clinical practises of the residents. The registrars had to visit different wardswith the aim to review the different patients who are being admitted to the hospital. Another responsibility of these registrars is to look after the admission of new patients and co-ordinate their transfers to their wards or discharge from the hospital. Then there are medical consultants who are assigned the wards for conducting ward rounds. The ward nurse manger in the hospital supervises the team of nurses, makes their roster and keeps a tab on the overall activities and the tasks performed by the nurses. These clinical nurses are embodies specialized knowledge in the field of general medicine. In addition, they are given the load of the patients (Schön, 2017). The onus of the staff nurses is to undertake the delivery of patient-care. The responsibility of the registered pharmacist is to remain present in each ward during the weekdays. The intern pharmacist of the hospital was involved in assisting with rapid patient turn-over in the Medical Assessment Ward. It has been found that medication communication during the course of the ward rounds reflects power relations that are intricately tied to the positions of theparticipantsand their spatial relations. Although the ward round became a podium for the discussion about the
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4HIERARCHY AND POWER IN HEALTHCARE SYSTEM patient care and variegated treatment settings that are to be made yet the discussions were conducted away from the bedside of the patients. Those sites may include the corridors and thestaffstation.Thedecisiononmedicationweremadeaccordingtotheclinical manifestations of the patients and their test results. The determination of the patients was based on the value of their placed on them by the consultants who are extensively involved in the decision-making (Duckett & Willcox, 2015). This connotes the power struggles that is enmeshed in the ward rounds where the participants take turn and prefer to speak at different locations and during different time. These ward rounds have been found to be chaotic as there is no fixed schedule for these. Sometimes, the ward round would take place during the morning or sometimes during the afternoon. During these ward rounds, a medical consultant was present along with the medical registrar and more than two medical residents who were assigned the responsibility of looking after a medical team. The presence of family members during this time was opportunistic, therefore emphasizing on the discretion of the hospital authorities to allow the family members to be present. During the ward round the presence of pharmacists and nurses were rare. Thespatial structureof the ward rounds can be divided into three stages. In the first stage, the doctors discuss about two or more patients in the clinical setting of the staff station. This is considered the private space for the ward rounds. In the second stage, the individual patients are reviewed at the bedside table that is considered as the public space for the ward rounds (Abbott, 2014). In the third stage, the doctors take the final decisions on the treatment plans and put forth issue with the aim of clarification. This third stage takes place in the setting of the corridor, which is representative of the semi-public space of the ward rounds as all the staff members share it. This semi-public space sets an invisibleboundaryspatialboundarythatbecomesprominentduringtheconversations between the staff, family members of the patients, doctors and the patients in the context of the corridor conversations. The spatial positioning of the doctor in the team highlight the
5HIERARCHY AND POWER IN HEALTHCARE SYSTEM hierarchy enjoyed by them in relation to the other members of the medical organization. This is followed by the superordinate position maintained by the consultants followed by the medical residents. The purpose of the ward rounds is to rationalize the process of medication and made decisions on alternative treatments for the team. The doctors review the medication orders for the patients and in case there are any long-term orders, those were discarded (Cockerham, 2014). The doctors employed scientific empiricism and medical rationality whist taking decisions on the medical treatment. The doctors are engaged in keeping a tab on the progress of the patients and in treatment decisions based on the test results and medical records. It is found that the autonomy of the nurses is largely missing. The epistemology of the nursing profession is that she would portray the maternal role for the patients and would supplement the tasks of the doctors (Fildes, 2013). Studies have shown that there is an inherent power struggle between the doctors and the nurses. In the popular imagination, nurses are treated as subordinate in comparison to the doctors (Currie, Lockett, Finn, Martin & Waring, 2012). They are believed to be the ones who did not make it through the medical entrance examination and therefore, she has landed in the less prestigious occupation of nursing. The stratification between the doctors and the nurses are deepened due to the difference in occupational mobility, class, gender along with a range of social factors exacerbate the position of the nurses. This has been documented in the study of Ehrenreich and English.Therefore, it is not surprising to find that the voices of the nurses are largely absent in the ward round conversations and in the clinical decision-making (Oh & Gastmans, 2015). It is found that the nurses are called to the bedside to seek information on the progress of the patients, however, those information are not recorded. According to the consultants, the incorporation of the nurses at the bedside would encroach the space of the room. For the residents, it is the doctors who should have the legitimacy of accessing the bedside space
6HIERARCHY AND POWER IN HEALTHCARE SYSTEM during the course of the ward rounds. However, there have been resistance from the nurses in challenging this spatial monopoly. This was accomplished by them through the adoption of strategies that were meant at resistance. This was done by the nurses by standing behind the doors and thereby, attacking the unilateral regulation of the wards by the doctors. There is an inhernt inequality between the doctor-patient relationship which can be illustrated through the silence of the patients and the dominant position enjoyed by the doctors. However, there are instances when the patients are able to manipulate the situation. The notion of power byMichel Foucaultbecomes an important framework to examine the dimensions of power, hierarchy and stratification in the Australian healthcare system. In the words of Foucault, power is a struggle. Power is present everywhere and is infused in the everyday interaction and everyday relationships (Elden, 2016). Foucault argued that power is enmeshed in the so-called scientific discipline and explanations that represent itself as objective, empiricist and neutral. For Foucault, power is discursive and is present in the institutions in the exercise of their superiority on the others (Ball, 2013). In the context of the Australian healthcare system the superior and authoritative position enjoyed by the doctors embodies the power enjoyed by the doctors owing to their medical knowledge. This medicalknowledgeisperceivedtobesupremeandcanbeacquiredsolelythrough meritocratic process. This renders the doctors the authority to take decisions in the clinical settings and be conspicuously present in certain spaces by excluding others. The power of the healthcare system lies in its ability to identify, label and categorize people as sick and classify their sickness according to the discourse of medicine (McHoul, McHoul & Grace, 2015). These dominant power structures have the ability to make the patients believe that they are sick and therefore make them comply with the medico-scientific codes of the medical discourse. The patients are turned into docile bodies through the execution of specialized knowledge that is embedded in power.
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7HIERARCHY AND POWER IN HEALTHCARE SYSTEM Impact on a health practitioner As a healthcare professional in the Australian healthcare system, it would by my position and the perception about that position in the healthcare system that would determine thedegreeofmyoccupationalmobility,powerstruggle,andsubordinationand superordintion. If I am a doctor then I will have more spatial mobility and power as compared to the other stakeholders of the medical profession. Conclusion Therefore, it can be concluded that the Australian healthcare system epitomizes power struggle, hierarchy and stratification. According to the ranking, it is the doctor who enjoys the superior position and therefore has access to certain spaces which are forbidden for others. This is followed by the consultants and the residents who have access to decision-making in the ward round and the autonomy of spatial mobility. However, it is the nurses occupy the most subordinate position and lack the autonomy of medication. They are considered to be the lowest in the hierarchy of the healthcare system and their observations of the patients are not given much importance. Hence, the Australian healthcare system becomes a site of power struggle, negotiation and resistance.
8HIERARCHY AND POWER IN HEALTHCARE SYSTEM References Abbott, A. (2014).The system of professions: An essay on the division of expert labor. University of Chicago Press. Ball, S. J. (Ed.). (2013).Foucault and education: Disciplines and knowledge. Routledge. Cockerham, W. C. (2014).Medical sociology. John Wiley & Sons, Ltd. Currie, G., Lockett, A., Finn, R., Martin, G., & Waring, J. (2012). Institutional work to maintainprofessionalpower:Recreatingthemodelofmedical professionalism.Organization Studies,33(7), 937-962. Duckett, S., & Willcox, S. (2015).The Australian health care system(No. Ed. 5). Oxford University Press. Elden, S. (2016).Space, knowledge and power: Foucault and geography. Routledge. Fildes, V. (2013).Women as mothers in pre-industrial England. Routledge. Johnson, T. J. (Ed.). (2016).Professions and Power (Routledge Revivals). Routledge. Liu, W., Manias, E., & Gerdtz, M. (2013). Medication communication during ward rounds on medical wards: Power relations and spatial practices.Health:,17(2), 113-134. Lord, L., Jefferson, T., Klass, D., Nowak, M., & Thomas, G. (2013). Leadership in context: Insights from a study of nursing in Western Australia.Leadership,9(2), 180-200. Manners, R. A. (2017).Professional dominance: The social structure of medical care. Routledge. McHoul, A., McHoul, A., & Grace, W. (2015).A Foucault primer: Discourse, power and the subject. Routledge.
9HIERARCHY AND POWER IN HEALTHCARE SYSTEM Oh, Y., & Gastmans, C. (2015). Moral distress experienced by nurses: a quantitative literature review.Nursing Ethics,22(1), 15-31. Schön,D.A.(2017).Thereflectivepractitioner:Howprofessionalsthinkinaction. Routledge.