Power Distance is a term used and examined by organization seeking to become High Reliability Organizations (HRO). In the Healthcare Industry, a high degree of Power Distance can lead to patient harm and serious safety events. The George Floyd case is an extreme example of problems with Power Distance and is worth examining.
Let’s be clear, was George Floyd a victim of racism? Most certainly. Was George Floyd a victim of a Senior Police Officer making bad decisions? Most certainly. But George Floyd was also clearly a victim of Power Distance.
The Concept of Power Distance came as a result of research in the 1960s and 1970s by Dutch psychologist Geert Hofstede. Power Distance is defined as the extent to which the less powerful members of organizations accept that power is distributed unequally. It recognizes that most societies and institutions (such as a police force) have endorsed a certain level of inequality in decision making that is supported both by the leaders as well as the followers. The Higher the Power Distance, the less likely a junior officer or subordinate will question the actions of a superior officer.
George Floyd’s death was the most outrageous example of Power Distance gone wrong.
Obviously, the tragedy that happened to George Floyd illustrates an extremely High Power Distance as 3 other officers at the scene had the opportunity but did not speak up forcefully enough to stop the action that lead to his death. Not only did the culture support this Power Distance, but the experience of the officer’s involved contributed to this inequality of power.
In a culture already established to have a High Power Distance, Personnel records showing the disparity in experience at the scene became an additional major factor in the results. The Officer with his knee on George Floyd’s neck for 8 minutes and 46 seconds was the senior officer with 19 years experience. Two other officers were rookies, one with 4 days street experience and the other with 3 days street experience. The third officer had just rejoined the Minneapolis Police Department in 2012 with 8 years experience. Clearly the officer with his knee on the neck was the Veteran officer at the scene.
Although one of the rookies has stated he asked the senior officer, also identified as his training officer, “Should we roll him on his side?” The answer from the senior officer was clearly “no” and no further action occurred.
This brings up the discussion of “Duty to Intervene.” We are now hearing this term frequently discussed, but as it turns out this is not a new concept even for the Minneapolis Police Department. Evidently, they adopted this policy in 2016 which states officers are required to “either stop or attempt to stop another sworn employee when force is being inappropriately applied or is no longer required.” In this case the rookie had a duty not only to speak up but to physically intervene.
So how does this Power Distance issue apply to our own every day lives. We are all obviously impacted by the George Floyd case, but you may also see important examples not quite as dramatic in your own world. In many organizations within the fields of Medicine, Aviation, and the Nuclear Power Industry there is the concept of “High Reliability Organizations”. “High Reliability Organizations are organizations with systems in place that make them exceptionally consistent in accomplishing their goals and avoiding potentially catastrophic errors.” Part of being a HRO is the elimination of a High Power Distance and creating a culture allowing subordinates to speak up. This can be accomplished through training, but the training needs to include not only the junior members of an organization, but also the senior members so that they are aware of their role in the natural Power Distance.
The training also needs to include Key words so that everyone is aware a potential dangerous event is in process and is being recognized. You should not have to wait for someone to physically intervene, but should have key words and buy-in within the organization such that everyone has a role in preventing harm.
One tool ARCC (ask, request, concern, chain of Command) can be used to overcome perceived authority gradients while respectfully voicing a concern for safety. ARCC stands for Ask a question, make a Request, voice a Concern, and if all else fails, seek help from the Chain of command. It gives healthcare workers a measured way to elevate their concerns for a patient’s safety, working up the ladder until the concern is resolved. The third level – Concern – should be thought of as a safety code word.
The key is having key code words or phrases such as the word “Concern”. When this is expressed not only is the subordinate speaking up, but the senior member should also take notice and accept the warning as valid. This type of training, as shown with the DC-8 accident in 1978 could have avoided a fatal crash if only the co-pilot had shown his “concern”.
This same word is being used in Healthcare with the concept of “CUS” with respect. “CUS” stands for “Concern, Uncomfortable, Stop”. First express Concern with a situation, if no changes occur then elevate the conversation to express that you are Uncomfortable. If the situation still appears dangerous to the patient (such as wrong site surgery is about to occur), then simply state Stop or Safety Issue and ask for a supervisory support.
So what happens next? Each of us needs to take a look at our own organization and whenever possible eliminate the Power Distance that can result in harm. We also need to make sure that all our associates, peers, and employees are educated on key phrases or words that should heighten attention to the situation. It is great to have a rule on the books that supports a “Duty to Intervene”, but this duty needs to be accepted and understood by all.
Yes, there are circumstances where some degree of Power Distance is necessary. There needs to be a physician in charge when running a cardiac arrest situation. A CEO must make decisions that subordinates may disagree with. But Power distance should not be so evident and pervasive that harm occurs as a result. This usually means fostering a culture where subordinates feel safe and encouraged to speak up, but also a culture where supervisors and more senior members are educated and recognize that Power Distances naturally occur.
In healthcare a lack of Power Distance allows a nurse to speak up during surgery and prevent a wrong site (wrong leg or arm) surgery from occurring. A lack of Power Distance allows a nurse to question my own orders when they don’t make since and prevent harm when it is pointed out the computer orders were entered on the wrong patient. A lack of Power Distance allows a junior office in the cockpit of a commercial airliner to question the senior officer or allows the cockpit itself to question the tower, and avoid a deadly crash.
And a lack of power distance could have kept George Floyd Alive.
Sometimes the only way we can deal with tragedy is to hope that something good results. This is illustrated when Joe Biden mentions George Floyd’s daughter in his address at the funeral:
“Today, now is the time, the purpose, the season to listen and heal. Now is the time for racial justice. That’s the answer we must give to our children when they ask why. Because when there is justice for George Floyd, we will truly be on our way to racial justice in America.
And then, as you said, Gianna, your Daddy will have changed the world.”- Joe Biden
George Floyd’s death might have started with racial injustice and poor decisions, but ended with Power Distance.
-Mark Elliott, MD, MBA