HLTH 4100 Week 6 Formal and Informal Power Analysis Example

The Title on the Door and the Person Nothing Moves Without: A Power Analysis of Emergency Admissions, Mapping Formal Authority and Informal Influence Separately

Student Name

Walden University

HLTH 4100: Healthcare Organization Theory and Behavior

Instructor Name

Month Day, Year

The Title on the Door and the Person Nothing Moves Without: A Power Analysis of Emergency Admissions, Mapping Formal Authority and Informal Influence Separately

Purpose and Framework

My Week 3 and Week 4 papers found that nobody under vice-president level here can formally direct an admitted patient into an upstairs bed, and that the hospital's culture treats cross-unit authority as illegitimate. Yet admissions do move, sometimes quickly. This paper asks who actually makes them move. It maps formal authority and informal influence separately, then compares the two maps. The framework is French and Raven's typology, which separates power that comes with a post, power to give or withhold benefits and penalties, power that rests on know-how and power that comes from being admired (French & Raven, 1959). Formal authority corresponds mostly to legitimate, reward and coercive power; informal influence to expert and referent power, along with control over information and relationships.

Map 1: Formal Authority

The chief nursing officer has legitimate authority over every nursing unit and the emergency department and can, in principle, direct any unit to accept a patient. She rarely does, because she is not on the floor and does not learn about specific delays in time. The directors of emergency services and medical-surgical nursing each have authority within their areas but not over each other. House supervisors have legitimate authority over the whole hospital at night and on weekends, but by policy they defer to unit nurse managers during the day. Unit charge nurses have formal authority to accept or delay admissions to their units. Hospitalists have authority over admission orders but not over bed placement.

Read formally, the person with authority to resolve a stuck admission during the day is the chief nursing officer, three levels above the problem. Formal structures, in the rational system view of organizations, are supposed to place authority where decisions are needed (Scott & Davis, 2007); here they place it far from the decision.

Map 2: Informal Influence

Interviews with eight staff members, and my own observation over two weeks in the quality department, produced a different map.

A veteran day charge nurse on the busiest medical unit. With 22 years on the unit, she is consulted by other charge nurses about whether to accept difficult admissions, and her judgment carries weight across units. Her power is expert and referent: people trust her clinical judgment and respect her. When she accepts an admission promptly, others tend to follow; when she delays, they feel justified in delaying too.

The hospitalist group's lead physician. Formally, she supervises hospitalists, not nurses. Informally, her calls to unit charge nurses about a deteriorating patient in the emergency department move admissions faster than any policy. Her power is expert, combined with relationships built over years.

The emergency department's evening charge nurse. She cannot require any unit to accept a patient, but she controls information: which patients are sickest and which can wait. Units trust her assessments, so her framing of an admission changes how quickly it is accepted.

The bed placement coordinator. Despite the title, she has little power of any kind. She tracks requests and makes calls but cannot assign beds, and charge nurses describe her as "the person who calls to ask."

A Night Without the Usual People

One night during the observation period shows how much the process depends on informal power. The veteran day charge nurse was on vacation, the hospitalist lead was at a conference, and the emergency department's evening charge nurse had called out. Five admitted patients were waiting at 7:00 p.m. With no one whose judgment the units trusted making the case for each patient, charge nurses on three units each asked for more information, waited for shift change and accepted patients one at a time. The median acceptance time that evening was more than two hours, against about 80 minutes on a typical evening. Nobody did anything wrong. The people who usually moved things simply were not there, and the formal structure had nothing to put in their place.

Comparing the Two Maps

The comparison shows a split between who has authority and who has influence. Formal authority sits high and far from the problem. Informal influence sits low and close to it, with a few experienced individuals whose judgment others follow. The person with the most relevant-sounding title, the bed placement coordinator, has the least power. The people nothing moves without, the veteran charge nurse and the hospitalist lead, have no formal authority over admissions at all.

This split matters because informal influence is not distributed evenly or reliably. Admissions move quickly when the veteran charge nurse is on duty and supports them, or when the hospitalist lead makes a call. On her days off, or when the lead physician is busy, the process slows. Pfeffer (1992) argued that organizations depend on informal power far more than their charts suggest, and that managers who ignore it misread how things get done.

What the Analysis Suggests

Two implications follow. First, any change to the admission process will succeed or fail partly on whether the informally influential people support it. A bed manager role imposed from above, opposed by the veteran charge nurse, would likely meet the resistance seen during the influenza week. The same role, designed with her input and supported by her, would have a much better chance. Second, the hospital could make informal influence more reliable by giving formal authority to the role whose informal influence already works. Making the bed placement coordinator a bed manager with real authority, and pairing the role with the hospitalist lead's support, would align the formal and informal maps rather than leave the process dependent on who happens to be on duty.

Limits

The informal map rests on eight interviews and two weeks of observation, and power is notoriously hard to observe directly. People may overstate or understate others' influence, and because I work in quality, some staff may have been more guarded with me than with a peer. The analysis also cannot say whether the veteran charge nurse would support a change; it can only say that her support would matter. A useful next step would be to discuss the analysis with her and with the hospitalist lead directly, which would also be the first step of any change effort they would need to support.

References

French, J. R. P., Jr., & Raven, B. (1959). The bases of social power. In D. Cartwright (Ed.), Studies in social power (pp. 150-167). Institute for Social Research.

Pfeffer, J. (1992). Managing with power: Politics and influence in organizations. Harvard Business School Press.

Scott, W. R., & Davis, G. F. (2007). Organizations and organizing: Rational, natural, and open system perspectives. Pearson Prentice Hall.