Please read the case “Power Distance Consequences” and analyze the following questions.

1. How do we see “cultural differences such as attitudes toward [Hofstede’s] power distance, individualism or collectivism, uncertainty avoidance, and masculinity or femininity influence people’s perceptions about competent behavior” in this case? Please focus your discussion on the dimension(s) that you perceive to be relevant to this case.

2. What responsibility did the student nurse (or a less powerful employee) have to advocate for the patient based upon the information she overheard? What should the student nurse do?

3. What responsibility does the charge nurse (a supervisor-type employee) have to advocate for the patient to Dr. Topoli based upon the new information from Dr. James, the professor?

4. How can junior staff and other professional personnel discuss intimidation by senior, more powerful leaders? How can people come to better understand power distance in the general culture as well as the work culture?


Power Distance Consequences: Authoritarian Doctor, Silent Student Nurse

This case emphasizes the cost of remaining silent as well as how powerful people are sometimes not

open to communication from others.

Nursing student Gayathri Gupta, an international medical student from India, was troubled over the

case of Rachel Laurel, a 23-year old patient who had been diagnosed with stage IV laryngeal cancer.

Laurel had just started law school at a major university where she was a very brilliant, dedicated

student. Her treating physician, Dr. Topoli, had weighed all the possible options and concluded that if he

operated on Laurel, the consequences could include brain damage, blindness, hemorrhage and, worst-

case scenario, an untimely death. The doctor discussed these scenarios with the parents and the

patient, and they agreed on palliative care (care to minimize pain without invasive treatment) and Laurel

signed a Do Not Resuscitate (DNR) form.

Since this was a teaching hospital, Dr. James, a medical professor, came in one morning accompanied by

her students. She used Laurel’s case as the example in order to explain the condition of the patient and

the pathophysiology of cancer to his students. Upon looking at the MRI scans, Dr. James thought that

the tumor was operable and the patient could walk away cancer free after the procedure and


Nursing student Gupta had heard Dr. James discussing Laurel’s case, and she followed up with Professor

James. Gupta asked in-depth questions about the procedures and treatment. From Dr. James’ answers,

Gupta began to understand that Laurel might have a chance to survive and even become cancer free.

During this time, Laurel’s family had slowly been coming to terms with the fact that their daughter was

dying, and they just wanted to make her happy. Concerned, Gupta informed the charge nurse about the

conversation with the professor, and the nurse agreed with Gupta.

At the hospital level, this facility was a prime candidate to adopt a communication and care strategy

known as Patient-and Family-Centered Care (PFCC) which presents all options to the patients, and then

let the patient decide what is best for him or her. PFCC focuses on the patients, families, and the

healthcare staff as the co-decision makers in the patient’s care. The traditional, hierarchical, vertical

model of care has care and control moving downward from physicians to nurses to other specialists and

then to patients and families. In this model, patients and families lose much of the control over their

medical care. PFCC focuses, instead, on changing an ingrained, vertical centric culture into a more

horizontal culture and patient centric system (Barker, 2015).

Unfortunately, two days later patient Laurel stopped breathing, but, after resuscitation, she was able to

breathe again. This brief reprieve at life made Jones think that maybe this was her opportunity to do

something to help the patient. Gupta discussed Laurel’s case again with the charge nurse, who told

Gupta that she, as the charge nurse, had hinted to Dr. Topoli about the possible alternatives mentioned

by Dr. James, but Dr. Topoli did not care to listen. Gupta was acutely aware that no one dared question

Topoli’s judgment because he was the most experienced oncologist at the hospital. It seemed to be an

unwritten rule that no one questioned Dr. Topoli’s decisions. Gupta understood enough about power

distance to know that she would not succeed in overcoming Dr. Topoli’s case management decisions.

The treating doctor’s judgment prevailed, and Laurel died two weeks later.