Posted: 22 Oct. 2019 10 min. read

Perceived Power Hierarchy and Psychological Safety on Team Effectiveness

How does power distance, psychological safety and team cohesion impact team effectiveness?

Improving public health requires experts from diverse groups to work together. For high-functioning healthcare teams to provide safer, and more patient-centred care, coordination and collaboration among multiple professionals is required. Interprofessional education (IPE), has been used as a strategy to develop high-functioning healthcare teams where students from two or more professions learn together to cultivate collaborative practice (Institute of Medicine ([US]) Committee on Quality of Health Care in America, 2001). While research demonstrates that IPE in the team context improves knowledge and skills, it is unclear why (conceptually speaking).  

Professors Nital Appelbaum, Kelly Lockeman, Shelly Orr, Tanya Huff, Christopher Hogan, Brenda Queen and Alan Dow (Virginia Commonwealth University) sought to investigate the underlying constructs that determine the effectiveness of interprofessional team dynamics, including team cohesion, psychological safety, and power distance. Team cohesion has been identified as a key aspect of team effectiveness, yet the impact of team processes such as psychological safety and power distance in this relationship is not well understood. 

Psychological safety is the belief that one feels safe to express themselves without the fear of negative consequences. Psychological safety has received attention in recent years, and has been found to foster creativity, support learning from mistakes, and support the willingness to report patient safety events. Studies on team dynamics and decision making have identified power distance as an antecedent to psychological safety. “Power distance” refers to the distribution of power between high-and low-status individuals. The perception of high power distance can suppress open participation in group settings, and undermine collaborative efforts among interprofessional teams. That said, teams which operate in a culture of high power distance can overcome these constraints through efforts to increase psychological safety.

The researchers explored the perception of power (and the potential perception of imbalance) between interprofessional team members and whether it would hinder perceptions of psychological safety, team cohesion and team effectiveness.


To examine the effects of perceived power distance on team effectiveness, with ratings of psychological safety and team cohesion as intermediaries.


Researchers observed 156 students in a nursing program and 163 students completing a medical degree, using Interprofessional Critical Care Simulations (ICCS). 

1. ICCS included three, two hour sessions, where students engaged in simulations to practice critical care skills to:

a. Perform a diagnosis;

b. Communicate across professions, and; 

c. Escalate issues through a chain of command. 

2. Students were randomly assigned to one of 24 teams and given six scenarios related to a patient with rapid decline in their clinical status. Each scenario lasted about 4-8 minutes, with an additional 5-10 minutes of debriefing. 

a. Each scenario started with one student interacting with the simulator. The student could call for assistance from another student as desired

b. In most scenarios, all students were present in the simulation room and would be called upon, as well as a fictitious rapid response team, or more senior practitioners.

c. Faculty facilitators ended each scenario when the team reached a certain clinical endpoint, and then debriefed the scenario covering the students’ assessment and management actions, interprofessional collaboration, and escalation to higher levels of expertise.

3. At the end of the final session for each group, the nursing faculty distributed a retrospective survey in which students gave ratings on psychological safety, team cohesiveness, team effectiveness, and power distance. 


The researchers found that psychological safety and perceived team cohesion were mediators of the effect of power distance on team effectiveness. This meant that as power distance decreased between the nursing and medical students, perceived team effectiveness increased, as did psychological safety and perceptions of team cohesion. 

Other factors that affected the outcomes included:

• Team member consistency. Although member consistency was not a factor of investigation, team member consistency resulted in higher psychological safety and stronger perceptions of cohesion and effectiveness compared to teams with greater team instability. 

• Quality of interactions between team members. The quality of interactions appeared to be more strongly linked to perceptions of team cohesion and effectiveness, rather than the interprofessional roles in this study. 

• Team member professional role. Impressions of team dynamics were not linked to the student’s degree (i.e. nursing or medicine), suggesting that factors other than professional or individuals’ cultural norms may be shaping how students view the clinical learning environment.

• Learning environment. Students who witnessed power distant behaviours of role models emulated those behaviours with others. This suggests that the learning environment and role models may shape the impact of power distance and psychological safety.


IPE is an important part of the healthcare system and understanding the factors influencing team dynamics can positively impact interprofessional interactions and improve patient-centred care. The results of this study indicate that high power distance between professional roles affects team dynamics, but this can be reduced through a sense of psychological safety. 

As such, the two key takeaways for educators and leaders are: 

1. Identify ways to minimise power distance and increase psychological safety. Leaders who role model behaviours of interprofessional collaboration, reduce power distance and increase trusting relationships, are more likely to see these behaviours reflected in their teams.  

2. Maximise opportunities for interaction and collaboration with interprofessional team members. Leaders  can increase psychological safety by seeking out opportunities for interprofessional collaboration, as well as encouraging and supporting team members to interact with interdisciplinary teams.

A personal reflection on a leader’s influence 

Over the course of my work career thus far, I have experienced the styles of a variety of leaders. There are specific leaders that come to mind that have been successful in reducing the perceived hierarchy (power distance) in their leadership role and effectively managing relationships with their team members. A particular behaviour I observed that helped to reduce the hierarchy, was taking the time get to know team members as people, through personal conversations. The leader would check-in later, remembering details from the conversation, which left a positive impression that they truly cared. 

This leader also gave me opportunities to share new ideas, asked for my opinion and gave me constructive feedback on my work, making me feel valued as a team member. As I reflect, this allowed me to be more creative, share my new ideas and continuously improve, as well as to be more comfortable in raising issues or seeking support when needed. Being able to feel safe and share with my team on a project, at work or in my personal life is important to me in maintaining wellbeing at work.

Feeling psychologically safe and working in a team with reduced power distance has positively impacted the cohesion of the teams I have worked in. In these environments, the leader had a pivotal role in creating an environment where we were able to work effectively and complete deliverables to a high standard. We were more collaborative, productive and engaged, and they were also the teams where I built the strongest relationships. I am proud of the deliverables we completed and proud of the efforts of our team.  

Although I am fortunate to have had positive leadership experiences, I have also experienced leaders who were not as effective in reducing power distance or supporting the psychological safety of their teams. These experiences have challenged me about the leader I would like to be and the behaviours that I can start to role model to those around me to help support psychological safety, team cohesion, and thus contribute towards team effectiveness. 


Meet our author

Lisa Tang

Lisa Tang


Lisa is an analyst within the Human Capital Organisational Transformation practice in Brisbane. She is passionate about people and creating a supportive working environment for all.