Todays blog looks at Power and Influence and how this impacts on evidence based medicine (EBM).
I believe that discussing how power interacts with EBM is uncomfortable, as it suggests inequality which I think makes this a particular challenge for those of us who believe in Equity and Fairness.
My personal experience which has spanned roles on Boards, being a doctor and being a nurse, alongside being a patient and a family member supporting others, enables me to really understand how power, status and ‘being a patient’ are important considerations.
As a doctor, my ideas seem to have more validity and carry more weight, however as a nurse, communication is easier with people and leads to different conversations. As a patient, I may not identify as a healthcare professional as feel this might lead to consequence, but I do use this when supporting family members and have leveraged this to direct outcomes.
It is critical therefore that we understand how power, relationships and communication underpin shared decision making and therefore form a core component of EBM and that power, finance and resources, feeling safe and knowledge are intimately related.
What does power look like?
The ‘actors’ can be at an individual, team or organisational level, a placed based system or even a global community.
In life, the decisions we make create winners, losers, positive and negative outcomes.
How this is shaped is through our knowledge and experience, our situational awareness and the predictability of the decision including how much control we have over our actions. Resources and infrastructure all inform our ability to move forward.
We all have power in a situation to act, to be inactive or to be a counter power and act as resistance.
Interactions can also be blocked. If A knows B and B knows C, but A does not know C, both A and C require B to mediate. B occupies a ‘structural hole’. They may act as a bridge overcoming the gap, exploit this gap creating competitive advantage, or block the gap completely.
Hierarchies and complex systems have ‘structural holes’ which can be overcome in fully distributed networks, where all nodes are effectively connected to all other nodes, enabling shared understanding.
Mismatched structures and resources, knowledge ownership and status or having different value sets leads to differences of opinion which creates tension. How we manage these tensions will ensure success or failure for collaboration.
Problems arise when powerful actors, have a blind pursuit of relative advantage and neglect structural order and rules particularly when they have access to wider resources.
By understanding these dynamics, we can influence how our world changes.
- You can enable agency of others, creating the capacity to achieve goals.
- Through sharing of knowledge, you can enable facts to be discovered, and create the mechanism for this to be available and others to create change.
- By role modelling, you can influence how we all behave.
Looking across our health and social eco-system, we know hierarchies exist, with many structural holes and power, finance, safety and knowledge interact which impact on the achievement of EBM.
Power and our Patient Relationship
Healthcare interactions are characterised by socially prescribed roles which have status creating an imbalance of power and influencing our behaviour. This includes both professional roles and the role of ‘Patient’.
In a consultation, the professional is perceived to have higher status, greater familiarity with the system, greater academic knowledge of disease processes, and more extensive access to further information and resources. They typically control the agenda and the use of time and direct the outcomes offered.
The Inverse Care Law
Because of the impact of social determinants of health, such as poverty, social exclusion, education and other structural inequalities, individuals most in need of healthcare are least likely to seek it or receive it.
Patients, in order to gain access services, have to continually reframe their symptoms and concerns to fit organisational categories and some are better at this than others.
Even when patients have greater knowledge about their condition than the person treating them, the power dynamic is such that the professional views tend to trump the patient’s perspective. This is particularly true when the patient does not follow the rules expected of them and may be perceived as a ‘heart sink’ patient or a problem.
Power imbalances suppress the patient’s voice.
We need to create mechanisms to amplify our patients voices and include the role of those with ‘lived experience’ to co-produce EBM.
Peer support is founded on a non-coercive, human rights-based approach that focuses on building relationships purposefully sharing their own experiences, and through the mutual sharing and commonality of experience, embodying hopefulness. They maintain equality with, and work alongside, others facing similar experiences underpinned by mutuality and reciprocity, widely recognised as core principles, with the central focus being on building trusting relationships rather than intervention.
By acknowledging these power dynamics and building a new skill mix, we can ensure that the patient voice and their families and carers are represented and this will be key to successful personalised care.
This requires fit for purpose systems, along with appropriate allocation of resources across the landscape of health and social care. Part of the transformation needed is to recognise concepts such as psychological safety, so that we can share our perspectives and the knowledge gained, including those with lived experience. This knowledge then should be perceived as ‘valuable and credible’ as part of our evaluation.
Power and Team Dynamics
When we undertake roles in organisations, we form teams and become leaders, followers or resistant power holders who have the capacity to action but also influence other’s attitudes and behaviours.
Understanding the power we hold is critical to building success in our organisations enabling people to flourish and the health and social eco-system to thrive.
Power can be related to our job title or as part of a role as gate keeper to resources however this is a simplistic view with social assets such as knowledge, information, expertise, respect, friendship, social approval, decision-making opportunities and cultural considerations all being key in understanding how power unfolds in our teams.
Power and politics go hand-in-hand so understanding the context that surrounds our teams is important and understanding whether there is a single source of power, distributed power or a power struggle will enable us to identify strategies for success.
Individuals or teams, who are content with the status quo, feel safe and are satisfied will be empowered to lead, follow, advocate and challenge effectively. Where conflict occurs and tension arises, people become more focused on negative aspects of team dynamics leading to paranoia, anxiety and harm performance.
We need to be able to consider the dark side of power in teams alongside the benefits of leveraging our power.
Power dispersal which elicits differences in perspectives and interests between members and is critical for inclusion and distributed wisdom, can also have negative outcomes if there is confusion of goals and ambitions, or lack of structure to facilitate decision making.
We also need to identify our ‘structural holes’ in our teams and bridge these to ensure that we communicate effectively across whole teams.
At times, power struggles are overt, and can be explicitly seen but often they are more subtle with disagreements about goals and outcomes, personality or value clashes, and conflicts over team logistics, such as meeting times or task allocation.
In order to gain more power, individuals, teams or organisations, may both try to pull others down or to bring oneself up. They may engage in behind-the-scenes coalition formation, purposely withholding information from each other, or gossiping about one another. They may explicitly refuse activities or more implicitly ignore them or take credit for others work.
Power struggles are notoriously difficult to clearly identify and resolve and divert energy away from our true purpose.
Conflicts can only ever help performance when the real issues are brought to the table and discussed. This requires trust which is often absent. Power, therefore, is a sensitive topic, which people find difficult to openly talk about, making their eventual resolution very problematic and the chance of escalation likely.
Power struggles are contagious and create a wave of negative behaviour.
By understanding the mechanisms and levers by which power can harm teams, we can seek to remove the deleterious effects of power for team outcomes. Without understanding the dynamics of power, you create the unintended consequence of perceived unfairness and of toxic cultures.
In order to create safe systems in which EBM can be delivered, we need to create teams, that build on psychological safety, understand how power feels within that team and have organisations that ensure inclusion including that of our patients, families and staff.
The Power of Organisations in Health and Social Care
It is well known that socio-economic factors play a huge role in determining people’s long-term health, and contribute significantly to inequalities and therefore working collaboratively at an eco-system level is essential to improve outcomes but we have paid little attention to the power holders across our environment including Integrated Care Systems although we will be aware of models such as: Mendelows Matrix to analyse stakeholders.
Anchor institutions are large organisations that have a significant stake in a local area. They have sizeable assets that can be used to support their local community’s health and wellbeing and tackle inequalities, through procurement, employment, training, professional development, and buildings and land use. These anchor organisations are therefore critical power holders in our communities.
The Kings Fund has identified that the NHS is a significant stakeholder in terms of its role as an anchor institution with local authorities holding significant infrastructure. Wider, place based assets include commercial organisations, voluntary sectors and other stakeholders such as housing and education all participate in the health and social care eco-system.
Currently, many organisations are in crisis but hold power and at the same time are ‘stuck’ in reactive management.
We need to support all our organisations, including our anchor organisations, to provide psychological safety, active open-mindedness, distributed power models, collaboration and focus on improvement over time, rather than comparison.
The challenge is that our current model of health and social care is built on competition for finance and workforce resources, alongside regulatory oversight, reputation concerns and achievement of outcomes which leads to tension.
What we can achieve by understanding our power
No one can gift us power.
We may be promoted, elected or admired and be senior in roles, however if we do not own or understand our power and influence, this will dissipate and lead to a lack of achievement in the opportunities which present.
Organisations may be assumed to hold power, but if we are not responsible with this or understand how we impact on others, we create unintended consequence and systems fail to achieve their potential.
Authentic power does not come from an external source or important title. True power is generated from within.
Understanding and role modelling Psychological Safety, allows connection and empathy to be shown.
Wisdom allows an understanding of facts, procedures, perspectives and emotional responses and through participation, we generate distributed understanding and transform.
Owning our power leads to increased confidence and an understanding of our role in current situations and how we can help in the achievement of objectives.
Understanding power allows us to connect and maintain relationships and address our ‘structural holes’. It enables negotiation and adjustment.
When we understand our values and those of others, we create visibility and credibility enabling advocacy for ourselves and others.
The admission that we don’t have all the answers, rather than making us powerless is a power move.
Addressing culture that rewards busyness, and moving to one that creates opportunities to discuss topics allows creativity to be born.
Ensuring we all have an open mind and create learning journeys leads to growth and mobilisation of power.
Through this understanding of power and influence, our model of EBM will be created that meets the next generation of health and social care outcomes for everyone.
