Who Holds the Power? How Medical Hierarchies Silence Parents, Clinicians, and Care Itself
“Titles don’t make you right. True authority is earned through trust, empathy, and shared humanity.” - Mary Coughlin
The healthcare system is built on hierarchies. But when those hierarchies prioritize positional power (power that comes from a role or title) over relational authority (power that comes from lived experience, empathy, and shared humanity), something critical is lost: care itself.
This post shines a spotlight on medical hierarchies — the system of power that dictates who gets to speak, who gets to decide, and who gets to be heard in healthcare. From doctors overriding nurses to parents being silenced, medical hierarchies often prioritize control over care. But control is not care.
What is Positional Power?
Positional power is authority that comes from one’s role, rank, or title. In healthcare, this often means doctors, administrators, and senior clinicians hold the most power. But positional power is not always the same as expertise or insight. Parents, nurses, and frontline clinicians often have vital information about the baby, child, or patient — but their perspectives are frequently dismissed because of where they fall in the “hierarchy.”
Examples of Positional Power in Healthcare:
Doctors overruling nurses, even when nurses have critical, time-sensitive information about a patient’s condition.
Parents being silenced in NICU rounds or discharge planning, even though they are the most consistent caregivers for their child.
Clinicians being told to “stay in their lane” when offering insight or speaking up on behalf of a patient.
What is Relational Authority?
Unlike positional power, relational authority comes from trust, lived experience, and the relationships we build with others. A parent’s intimate knowledge of their child, a nurse’s hands-on expertise, or a clinician’s lived experience with a patient all represent relational authority. Relational authority centers the human experience, whereas positional power centers the “chain of command.”
When relational authority is honored, care improves. But when it’s dismissed, trauma and harm are often the result.
Stories of Impact
These aren’t abstract concepts. They play out every day in hospitals, NICUs, and care settings around the world. Here’s an example of how positional power silences care:
🫂 A Mother Silenced in the NICU A mother noticed something "off" about her baby’s breathing. She flagged it to the nurse. The nurse agreed and flagged it to the doctor. The doctor dismissed it, saying, “The numbers look fine.” Hours later, the baby was an acute respiratory decompensation. The nurse knew. The mother knew. But positional power kept their voices from being heard in time.
🫂 A Nurse Overruled by a Doctor A nurse in the pediatric unit noticed subtle changes in a baby’s oxygen saturation. She reported it during the shift change huddle, suggesting they keep a closer eye on the baby. The attending physician brushed it off, saying, “That’s normal at this stage.” Minutes later, the baby had an acute event that required emergency intervention. The nurse saw it coming, but her voice wasn’t given weight because of her position in the hierarchy. Her voice wasn’t heard. Her authority wasn’t honored.
Impact on Care
When positional power is prioritized over relational authority, the impact is profound.
Delayed responses to medical emergencies — Nurses, parents, and clinicians often see subtle warning signs before “the numbers” show a problem, but their insight is dismissed.
Loss of trust — When parents feel silenced in conversations about their baby’s care, trust in the system is fractured.
Moral injury for clinicians — When nurses and clinicians feel they aren’t being heard, they experience moral injury, knowing that harm could have been prevented if their voices had been valued.
This isn’t just about systems of power — it’s about the very core of care. If care is relational, then positional power is its greatest barrier.
How Trauma-Informed Developmental Care (TIDC) Disrupts the Hierarchy
One of the most powerful solutions to the harms caused by medical hierarchies is to shift toward relational authority. This is central to Trauma-Informed Developmental Care (TIDC) and the B.U.F.F.E.R. framework.
How does it work?
Center the Parent: Parents are not “visitors” — they are essential members of the care team. Their voice matters as much as any clinician in the room.
Empower the Nurse: Nurses are at the bedside 24/7. Their insights into subtle changes in a patient’s condition are invaluable. TIDC emphasizes that nurses’ voices must be heard and valued.
Use Relational Authority, Not Positional Power: Medical teams that prioritize power-with over power-over create care environments where clinicians, parents, and patients can advocate without fear of being dismissed.
When relationships lead, care improves.
Public Health Implications
Hierarchies aren’t just an internal issue for hospital teams — they’re a public health issue.
How many preventable emergencies happen because a parent or nurse wasn’t listened to?
How much burnout and moral injury do nurses experience because their voices aren’t valued?
How many parents walk away from hospitals feeling ignored, disempowered, and invisible?
When hierarchies are centered, human needs are overlooked. But when relational authority is honored, trust, healing, and care all improve.
Call to Action (CTA)
If you’ve ever felt dismissed, overruled, or silenced in a healthcare setting, you’re not alone. The next post in this series will explore another power system that impacts care: hospital policies and procedures. From visitation bans to discharge deadlines, we’ll explore how policies shape the experience of patients and clinicians alike. Stay tuned for Part 4.
Reflection Prompt
Have you ever witnessed a parent, nurse, or clinician being “overruled” by someone higher in the chain of command? How did it make you feel? Drop your reflections below — your story matters.
Take care and care well,
Mary
