Abstract
Dedicated to Martha Mills. 'Nature hath given men one tongue but two ears, that we may hear from others twice as much as we speak'. ―Epictetus
On my first day of paediatric critical care training, I was given a piece of advice by the on-call consultant: ‘It is a brave person that ignores a worried PICU nurse’. Of course, from bitter experience I have also learned that in healthcare, bravery and foolishness are close neighbours.
That piece of advice has served me well as a clinician and is wisdom that I now impart onto new generations of paediatricians. This anecdote is an example of 'flat hierarchy'. Whilst colleagues working in multidisciplinary roles within healthcare have different training and distinct responsibilities, we share a common goal, ensuring delivery of safe, high quality patient care.
Flat hierarchy is not a new concept in clinical literature. Traditional structures in healthcare organisations such as the NHS are overtly pyramidal. The setup is usually rigid with a clearly demarcated chain of command from the (perceived) lowest to the (perceived) highest echelon of employees within an organisation. By contrast, a flat hierarchy model denotes that there is minimal middle management between 'shop floor' personnel and decision-making executives. The number of people directly supervised by higher management is large, but the number of people in various chains of command is small (Ghiselli and Siegel, 1972).
This gives an advantage: lines of communication between office-based medical or nursing leaders and frontline workforce become much shorter. As a result, teams operating within that structure can be much more responsive to change and feedback.
In the context of healthcare, it is intuitively right that decisions relating to management and care of patients should be influenced primarily by those at the frontline that are closest to the bedside. The collaborative ethos at the heart of flat hierarchy models empowers staff to raise patient safety concerns and enhances feelings of belonging to a team that has similar goals. This positive culture of psychological safety, one that allows anyone within the team to raise concerns directly to even the most experienced member of that team, addresses several threats to patient safety. It allows for better, more transparent communication, it gives a powerful message that we act as a unit to do what is best for patients, and it enables everyone to be more approachable regardless of job role. The collective effect is to improve transparency, morale, staff retention and feeling valued and also to minimise tribalism at the workplace.
Flatter hierarchical structures nurture self-actualisation in staff. Maslow (1971) places self-actualisation at the tip of hierarchy of needs. All healthcare workers ultimately want to feel they are doing the best they can in their position; this motivates them to continue on their career path and succeed. A self-actualised employee feels trusted, valued and empowered, and this is what encourages growth and engagement. Beneficiaries are not just employees but also the patients. Anything that hinders self-actualisation, and steep hierarchy is a significant hindrance, harms both the employee and the patient.
There are numerous examples of public inquiries in the United Kingdom that highlight failures in leadership stemming directly from an overly rigid, hierarchical structure, a set-up that fuels the disconnect between managers and frontline staff. The Bristol Royal Infirmary scandal addressed by the Kennedy report (Dyer, 2001), the Mid-Staffordshire NHS Foundation Trust (Francis, 2013) and the Gosport inquiry (Powell, 2023) were all mandated by parliament for different healthcare failures. At the receiving end of those failures were patients that had sub-standard levels of care and came to significant harm or even death as a result. All three reports, despite taking place many years apart from one another and involving hospitals hundreds of miles away from one another, had one theme in common: a profoundly hierarchical structure that largely ignored patient safety concerns that arose from those not in leadership positions.
Whilst public inquiries are important and lessons learned from them are vital so as not to be repeated, because of their sheer magnitude, they fail to tell individual stories, stories of patients that we failed. A poignant piece published recently in the Guardian (Mills, 2022) speaks of the agony a family went through when doctors in training and nurses were too afraid to challenge a consultant on a clinical decision he had made in relation to Martha, their 13-year-old daughter. The result was a delay in the diagnosis of sepsis and appropriate escalation of management contributing to Martha’s death. This story is tragic and powerful in equal measure. Whilst rigid hierarchical structures rarely have such ‘cataclysmic’ results as the author eloquently puts it, the three inquiries are full of such stories that haven’t been told. Every single one of those stories matter and many of those would have had much better outcome if leaders had put structures in place that enabled them to listen to staff better, but also if staff advocated for their patients louder and without fear of impunity. Alas, within the United Kingdom at least, the health service does not have a good track record of how organisations treat whistle-blowers and those that vociferously raise patient safety concerns. In fact, instead of actively listening and implementing change, the overall culture, as highlighted by the aforementioned inquiries, is one of hierarchical 'rank closure' and punitive action against the very people that flag-up these concerns. With the advent of 'freedom to speak up guardians' within each hospital and the formation of the Care Quality Commission, there has been some nationally implemented change to make raising concerns easier and safer for staff. A lot more groundwork and cultural change is needed in healthcare before everyone’s concerns can be heard, free from fear of stigmatisation and with the confidence that their voice will be heard and taken seriously.
There is of course evidence to support that a culture of flatter hierarchy in healthcare organisations is better for patient safety. A meta-analysis by Sfantou et al. (2017) explored the association between different leadership styles and healthcare quality measures in nursing. The study found that transactional leadership, which is the hallmark of an autocratic, hierarchical leadership style, had a weak relationship with effective nursing unit organisation culture. In contrast, a flat hierarchy, incorporating transformational leadership, was positively related to effective nursing unit organisation culture and led to lower patient mortality rates and higher patient satisfaction. Louder for those at the back, flatter hierarchy breeds positivity, collaboration and inter-personal support and improves staff retention.
As a senior clinician, there is often the notion that I know everything related to my speciality. This misconception hinders the principles of flat hierarchy and cross-speciality care. Medicine is as vast as it is ever-evolving; the moment we believe our own hype that we are all-knowing is the moment when we stop learning as healthcare providers and when we start declining as clinicians and leaders. Admitting that we do not know something can be misconstrued as a vulnerability, I assure you it is a strength. The safest clinicians are ones that are honest about their limitations and the ones that do not see themselves better than others. When leading ward rounds, or when giving clinical advice over the phone, I make sure that I invite questions on my clinical plan. I am secure enough in my own knowledge and training that any questions that follow are not an insult to my clinical capabilities but rather an opportunity for others to either learn from me or to advocate for the patient by putting their ideas across. What I say should not be seen as dogma, and inviting people to ask questions not only ensures that everyone has a clear idea of the collective plan but also serves to identify any of my own blind spots or biases. This collaborative approach has served me, my team and patients, well over the years. Allowing myself to be openly questioned has helped me avoid clinical errors on more than one occasion, proving that beneficiaries of this approach are not just the patients but clinicians themselves.
Ernest Hemingway once said: I like to listen. I have learned a great deal from listening carefully. Most people never listen. (Rogers and Farson, 2020)
If you are reading this as a healthcare leader, be the change your staff and patients need. Be the lighthouse for all those that work with you, become available, become approachable, set the tone.
If you are not in a leadership position, advocate for your patients louder, be fearless when doing so, support those around you, be the colleague you yourself would like to work with.
Do it for yourselves, do it for each other, do it for your patients. Do it for Martha.
