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. (shrink)

Physicians, nurses, and healthcare professional students openly participated in the medical atrocities of the Shoah. In this paper, a physician-bioethicist and nurse-bioethicist examine the role of hierarchical power imbalances in medical education, which often occur because trainees are instructed ‘to do so’ by their superiors during medical education and clinical care. We will first examine the nature of medical and nursing education under National Socialism: were there cultural, educational, moral and legal pressures which entrenched professional hierarchies and thereby commanded obedience (...) in the face of an ever-diminishing individual and collective conscience? We will then outline relevant parallel features in modern medical education, including the effects of hierarchy in shaping ethical decision making and conscience formation. We then propose several solutions for the prevention of the negative effects of hierarchical power imbalances in medical education: universal Holocaust education in medical and nursing schools; formative and experiential ethics instruction, which teaches students to ‘speak up’ when ethical issues arise; acceptance of, and adherence to, a personalistic philosophical anthropology in healthcare; support for rigorous conscience protection laws for minority ethical views that respect the role of integrity without compromising patient care. (shrink)