Negotiating authority and hierarchy amongst UK and Australian nurses
Ryan Essex, Lydia Mainey, Ada HuiBackground
Authority and hierarchy shape nursing practice, influencing professional relationships, decision-making, advocacy and patient care. Although these concepts are widely present in healthcare, they are often examined indirectly through issues such as communication, bullying, professional status or organisational culture, rather than as phenomena in their own right.
Research question/aim/objectives
The aim of this study was to explore how nurses and midwives in the United Kingdom and Australia experience authority and navigate hierarchy in their work, and the consequences of these dynamics for ethical practice.
Research design
A qualitative study was conducted using online semi-structured interviews. Data were analysed inductively using reflexive thematic analysis, following COREQ reporting guidance.
Participants and research context
10 registered nurses and midwives from the United Kingdom and Australia participated. Participants worked across clinical, educational and academic contexts, with some still in full-time clinical practice and others having moved into non-clinical roles.
Ethical considerations
Ethical approval was granted by an institutional ethics committee. Participants provided informed consent. Given the sensitivity of the topic and the small sample, detailed demographic information was not collected or reported to protect confidentiality.
Findings/results
Five interconnected forms of authority were identified: professional, regulatory, theoretical, institutional and political. Authority was experienced as dynamic, relational and context-dependent, shifting across roles, relationships and settings. Participants described nursing as often positioned as subordinate within healthcare hierarchies, while also exercising authority through advocacy, expertise, influence and everyday resistance. Regulatory and institutional structures were experienced as both enabling and constraining, legitimising professional action while also limiting what could be said or done.
Conclusions
Authority in nursing is not fixed or determined solely by role or position, but it is continually negotiated in everyday practice. Nurses both reproduce and resist hierarchical structures while managing tensions between advocacy, compliance, professional risk and patient care, with authority and hierarchy shaping a range of ethical features of practice, including autonomy, communication and moral distress. Greater recognition of these dynamics may support safer, more ethical and more responsive healthcare systems.