Within many healthcare systems, there is a long standing history and tradition of a hierarchical structure where physicians, CNOs, and CEOs are at the top of the rung and nurses are at the bottom. Policies and procedures are developed at the top with little if any input from those who are in direct care of patients. Although empirical evidence tells us that collaboration and teamwork is the best way to produce high-quality results, nurses working within hierarchical systems have virtually no input. Often nurses are viewed as "the economy of care" with a role of carrying out "doctors orders."
I recognize that long standing culture and traditions are difficult to change. There are many possible explanations for this: There may be a lack of understanding by nurse executives on how organization structures leads to barriers to the full scope of practice among nursing staff; they may for personal reasons not want to challenge the existing structure; they may be met with resistance by physicians, the CEO, and nurses; or, they may lack the leadership skills to promote a collaborative work environment.