Subordination by Design: Rethinking Power, Policy, and Autonomy in Perioperative Nursing

ABSTRACT

This discussion paper critically examines how power, policy, and autonomy intersect within perioperative nursing practice. In surgical environments engineered for precision and control, perioperative nurses operate in spaces that simultaneously depend on their expertise and suppress their professional voice. Drawing on feminist theory, relational ethics, and organizational sociology, this paper interrogates the structural, spatial, and symbolic forces that subordinate perioperative nursing. Hospital design, procedural norms, and entrenched hierarchies are shown to reinforce the containment of nursing authority. Power dynamics manifest through gendered labor expectations, professional gatekeeping, and policy constraints, all of which limit nurses' capacity for advocacy, leadership, and autonomous decision‐making. Issues such as moral distress, workplace aggression, and educational marginalization are reframed as systemic, rather than individual challenges—embedded within a broader architecture of exclusion. Through comparative analysis and reform models, the discussion re‐articulates perioperative autonomy as a strategic reclamation of professional agency, grounded in interdisciplinary respect and structural inclusion. Ultimately, this paper argues that authentic transformation in surgical settings requires a cultural shift: one that repositions perioperative nurses not as assistants to innovation, but as architects of surgical care and co‐authors of policy and practice.

The evolution of perioperative nursing has been shaped by complex, historically contingent, and context‐dependent structural and symbolic forces embedded within surgical systems. These forces manifest in varied ways across institutional cultures, national healthcare policies, and intraoperative team dynamics. This paper conceptualizes perioperative nursing as a continuum of clinical practice encompassing the preoperative, intraoperative, and immediate postoperative (PACU) phases, with particular emphasis on the intraoperative environment, where symbolic, spatial, and procedural constraints on nursing autonomy are often most concentrated. Rather than portraying perioperative nursing roles or surgical authority as universally static, this analysis explores how hospital architecture, professional norms, and interdisciplinary hierarchies dynamically interact to enable or constrain nursing agency in localized and often contradictory ways.

To frame this analysis, five foundational concepts are defined: autonomy refers to the institutional capacity of nurses to exercise independent clinical judgment; professional agency denotes the ability to influence practice and policy within interdisciplinary systems; power is both relational and structural, enacted through hierarchies and procedural control; policy encompasses both formal rules and informal norms that shape surgical workflows; and subordination captures the institutional and symbolic mechanisms that suppress nursing leadership, voice, and visibility. Drawing on this framework, empirical studies highlight how spatial design and workflow structures constrain nursing authority. For instance, Eren and Özbaş (2023) found that operating room (OR) layouts often prioritize surgeon mobility and visual centrality at the expense of nurses' ergonomic safety and decision‐making access. Similarly, Timmons and Tanner (2005) documented how female nurses are expected to manage the emotional atmosphere of the OR without corresponding recognition or decision‐making authority—illustrating that nursing containment is not only logistical but also deeply symbolic.

While these dynamics are prevalent, they are not uniform. Institutional culture, leadership styles, and team composition significantly mediate how subordination is enacted. As Allen (2015) and Witz (1992) note, even reforms intended to empower nurses may inadvertently reinforce gendered divisions between masculinized medical authority and feminized nursing labor if symbolic hierarchies remain unchallenged. In this context, autonomy must be reframed—not as mere task delegation—but as the institutional capacity to participate meaningfully in clinical decision‐making, ethical deliberation, and procedural design. Hasanfard et al. (2024) emphasize that such autonomy is structurally contingent; it depends not only on individual expertise but also on governance models that formally legitimize nursing participation. In institutions where such models are adopted, empowered nursing practice has been linked to enhanced collaboration, increased patient safety, and procedural innovation (Blomberg et al. 2018; Ireson et al. 2019).

Although scholarship across feminist theory, sociology, and nursing studies has addressed many of these dimensions individually—such as space, gender, or hierarchy—this paper offers a more integrative approach. By examining structural, symbolic, and spatial constraints in concert, it provides a multidimensional framework for understanding subordination and reimagining nursing leadership. The analysis centers on four intersecting dimensions: spatial marginalization, gendered labor expectations, procedural governance structures, and intersectional exclusion. These elements are not presented as universal experiences but as patterned phenomena that vary across geographic, institutional, and demographic contexts. For instance, while scrub nurses in some ORs may wield considerable informal influence, their circulating counterparts may be excluded from even basic procedural input. Similarly, early‐career or racialized nurses may face unique forms of marginalization that differ from those of senior White colleagues.

By acknowledging these internal differences, the paper reframes perioperative nurses not as passive subordinates but as active agents navigating highly stratified and often contradictory systems. Meaningful reform, therefore, must extend beyond nursing‐led initiatives to include interdisciplinary collaboration and shared governance with surgeons, anesthetists, administrators, and policymakers. Importantly, this shared model of authority is not a redistribution of dominance but a reconceptualization of surgical leadership—one that recognizes the full range of expertise required for ethical, equitable, and effective care.

1. Institutionalized Subordination: Nursing's Spatial and Structural Containment

This vision, however, confronts enduring barriers. For many perioperative nurses, autonomy remains an aspirational goal—particularly for those seeking to exercise clinical judgment and uphold patient safety through strategic leadership. When framed as “aspirational,” autonomy reflects both the articulated ambitions of perioperative nurses and the entrenched systemic constraints that limit their influence. Recent findings by Assolari et al. (2024) affirm this tension, noting that even where advanced practice roles have expanded, structural and regulatory barriers continue to restrict nurses' ability to exercise full professional agency. While many nurses seek greater involvement in decision‐making processes, institutions and patients alike stand to benefit from a more distributed model of authority—one that enhances safety, team cohesion, and quality of care.

Realizing this vision demands a critical interrogation of the institutional frameworks that have historically constrained nursing authority in surgical settings. At the heart of this analysis are the spatial and symbolic dimensions of subordination: the ways in which hospital architecture, entrenched hierarchies, and professional training paradigms systematically marginalize perioperative nurses in both physical space and decision‐making roles within the OR.

Historical analysis by Hawkins (2010) reveals that 19th‐century nursing education systems were deliberately designed to reinforce nurses' subordination to physicians and administrators. These curricula emphasized discipline and moral character over independent thought, casting nursing as a vocation of obedience rather than a discipline grounded in critical reasoning. McPherson (2003), through a study of Canadian nursing institutions, shows how dormitory living and regimented routines—such as curfews—further isolated student nurses from leadership networks and reinforced their exclusion from institutional power.

Mid‐20th‐century reforms expanded nursing education and licensure yet did little to redistribute clinical authority. Mansell and Dodd (2005) argue that decision‐making power remained firmly concentrated in the hands of physicians. Similarly, Kirkwood (2005) and McPherson (2005) detail how institutions like St. Catharine's in Ontario implemented the Nightingale model as a mechanism of conformity—sustaining nurses' subordinate roles through surveillance and hierarchical discipline.

These symbolic and institutional hierarchies have long been embedded in the physical infrastructure of hospitals and ORs. Ethnographic research by Baker et al. (2012) and McPherson (2003) illustrates how nurses have historically been confined to peripheral workspaces—such as storerooms or prep areas—while physicians occupy central zones for strategic planning and procedural leadership. These spatial allocations mirror broader patterns of professional exclusion.

Contemporary ORs continue to reproduce these disparities. In a multi‐hospital study, Eren and Özbaş (2023) found that surgical suites are often designed to optimize surgeons' ergonomic comfort, visibility, and mobility, while nurses must navigate cluttered, inefficient environments with restricted access to essential tools. Schlich and Hasegawa (2017) likewise observed that OR designs continue to prioritize surgical dominance while minimizing nursing presence. Bayramzadeh et al. (2018) and Rodrigues et al. (2020) further report that nurses are frequently excluded from key planning areas—such as preoperative briefings—reinforcing their roles as logistical support rather than strategic participants.

Yet, nursing marginalization is not totalizing. In some surgical teams, scrub nurses exert informal authority through their procedural expertise and anticipatory judgment, directly influencing instrument sequencing and upholding aseptic integrity (Sandelin and Gustafsson 2015). In collaborative OR cultures, certain surgeons actively seek nursing input, recognizing its value for real‐time decision‐making (Weller et al. 2014). These examples suggest that power in the OR is not merely structural—it is also negotiated through relational dynamics and experiential capital.

Nonetheless, such exceptions remain bounded. Blane (2003) argues that systemic exclusion persists in most healthcare organizations, with nurses structurally marginalized from decision‐making processes. Kenny (2002) emphasizes that rigid communication hierarchies often suppress interdisciplinary dialogue, even when nurses are well‐positioned to raise safety concerns. Levesque et al. (2022) describe the critical role of scrub nurses in “invisible leadership”—managing instruments, predicting workflow disruptions, and safeguarding protocols—but note that these contributions are rarely acknowledged in formal governance. Instead, these acts of clinical judgment are often reduced to routine, task‐based functions.

Further exacerbating these inequities are ergonomic disparities that reflect institutional bias. Letvak et al. (2024) report that nurses routinely work in physically hazardous conditions marked by obstructive layouts, trip hazards, and inadequate equipment placement—all of which heighten fatigue and injury risk. Nahid et al. (2021) corroborate this with survey data showing that nurses endure significantly greater ergonomic strain than physicians. Gaines et al. (2017) add that access to higher‐grade personal protective equipment (PPE) frequently privileges surgeons, reinforcing unequal safety standards.

Despite notable advances in nursing education, licensure, and specialization, these spatial and procedural exclusions remain deeply entrenched in surgical infrastructure. Nurses are seldom consulted in OR design, are underrepresented in hospital governance, and are rarely involved in shaping the protocols they are expected to enforce. This paper calls for a shift toward equitable, nurse‐led perioperative models—yet such change must be built on collaborative engagement with the broader interdisciplinary team. Nurses' efforts to expand autonomy are most impactful when situated in dialogue with surgeons, anesthetists, and allied professionals. This collaborative imperative is underscored by evidence showing that interprofessional engagement improves both healthcare delivery and patient outcomes (Reeves et al. 2017).

Reframing perioperative nurses as clinical leaders—not merely task executors—requires dismantling these spatial, symbolic, and procedural legacies. As Kaye et al. (2018) and Paiste et al. (2018) contend, substantive reform demands structural inclusion of nurses in policy development, governance structures, and spatial planning. Only through such systemic integration can perioperative nursing leadership be genuinely enabled—rather than performatively acknowledged.

2. Gendered Dimensions of Perioperative Hierarchies

Systemic containment in perioperative nursing is shaped not only by professional hierarchies but also by enduring gendered power structures that have historically defined roles, expectations, and authority within surgical settings. While perioperative nursing is a highly skilled clinical specialty, its evolution has been profoundly influenced by 19th‐ and 20th‐century institutional norms that positioned male surgeons as dominant decision‐makers and female nurses as subordinate caregivers (Logghe et al. 2018; Teresa‐Morales et al. 2022). These hierarchies were reinforced through both formal policies and informal cultural scripts that cast nursing as an extension of domestic caregiving—situating it in opposition to the masculine‐coded sphere of surgical leadership (Sandelowski 2000; Witz 1992).

Witz (1992) emphasizes that these professional norms operated not only through explicit institutional rules but also through implicit gendered assumptions embedded in everyday practice. These scripts shaped authority, labor distribution, and interpersonal dynamics—positioning nurses as compliant, deferential, and emotionally attuned. Adams (2008), tracing the architectural history of hospital design, demonstrated how OR layouts were deliberately constructed to embody masculinist ideals of surgical control, spatial dominance, and rationalism—cementing gendered hierarchies into the physical and symbolic architecture of perioperative care.

These hierarchies, however, are not uniformly experienced. The growing presence of male nurses and female surgeons has disrupted traditional binaries, introducing new configurations of identity and authority. Still, these shifts do not erase embedded inequities. Etherington, Kitto, et al. (2021) found that gender continues to shape how credibility, leadership, and professional legitimacy are negotiated in the OR—often in ways that reinforce established power dynamics.

Ethnographic research by Timmons and Tanner (2005) revealed that female nurses were tacitly expected to “manage the mood” of the OR—mediating conflict, anticipating surgeons' emotional states, and maintaining team stability. Though essential to procedural flow, this labor remains absent from job descriptions and performance metrics, rendering it institutionally invisible. Male nurses, by contrast, were not held to the same emotional standards, highlighting persistent gender disparities in how labor is distributed and valued. Li et al. (2025) reinforce this dynamic, demonstrating that perioperative nurses frequently engage in surface acting—displaying composed emotions despite internal strain—a practice closely linked to emotional exhaustion and reduced quality of work life.

Gender bias also shapes task allocation and perceived competence. Evans (2002) found that male nurses, though often fewer in number, were more frequently assigned technical or physically demanding responsibilities and perceived as more authoritative, even when female colleagues possessed equal or greater qualifications. Similarly, Teresa‐Morales et al. (2022) observed that men in nursing were often funneled into leadership or manual roles based on gendered assumptions, rather than skill or preference. A systematic review by Lyu et al. (2022) offers further nuance, showing that while male nurses often benefit from enhanced clinical authority, they may simultaneously face skepticism about their caregiving legitimacy and experience social exclusion. These intersecting dynamics suggest that the feminization of nursing affects not only how work is assigned but how both women and men navigate their professional identities within it.

Gendered structuring is also spatially encoded in the design and functioning of the OR. Schlich and Hasegawa (2017) provide historical evidence that OR design has long been used to elevate surgical primacy while rendering nursing labor peripheral. Their analysis shows that spatial layouts were never neutral but intentionally configured to reinforce professional hierarchies and gendered divisions of labor.

In addition to emotional and spatial marginalization, perioperative nurses—particularly women—are disproportionately tasked with nonclinical responsibilities aligned with administrative or support functions. These duties include managing surgeon pagers, organizing operating schedules, and coordinating logistics for junior doctors. Sandelin and Gustafsson (2015) found that such “courtesy” tasks are disproportionately assigned to female staff, diverting time from direct clinical responsibilities and reinforcing occupational subordination. Gillespie et al. (2009) and Riley and Manias (2005) further found that even technically demanding tasks—like maintaining the sterile field or sequencing surgical instruments—are often mischaracterized as logistical rather than clinical, erasing the decision‐making expertise required for such roles.

These expectations mirror those placed on women in unpaid domestic labor, reinforcing a cultural view of nursing as service work rather than clinical leadership. S. Nelson and Gordon (2016), in their feminist critique of hospital labor, argue that tasks like tidying, interpersonal mediation, and emotional buffering sustain a service‐oriented narrative that marginalizes nursing's clinical contributions. Sandelowski (2000) likewise contends that the association of nursing with domesticity perpetuates its diminished status in medical hierarchies.

Female nurses who challenge these expectations often face reputational penalties. Pincha Baduge et al. (2024) found that women who assert themselves are frequently labeled as “difficult,” while men exhibiting similar behaviors are praised as confident and leadership oriented. Romem and Rozani (2024) link these reputational disparities to systematic barriers that limit women's access to leadership roles and research opportunities. Compounding this, the idealized image of the OR nurse remains feminized—described as “composed,” “accommodating,” and “self‐sacrificing”—traits misaligned with dominant models of clinical leadership (Buresh and Gordon 2020; Mathenge 2020). Ylitörmänen et al. (2018) argue that these cultural ideals normalize expectations for women to absorb stress and maintain interpersonal harmony, even when excluded from decision‐making. Lindsay (2008) further contends that such norms not only constrain leadership development but also inhibit innovation and broader professional growth.

Addressing these embedded inequities requires more than surface‐level policy reforms—it demands cultural and structural transformation. Wakefield et al. (2021) call for governance models that formally incorporate nursing insight into surgical decision‐making, recognizing perioperative nurses as integral—not auxiliary—contributors to care quality and patient safety.

Finally, gendered subordination is reinforced through ethical silencing. Arakelian and Rudolfsson (2021) found that perioperative managers frequently identified ethical concerns—such as unsafe practices or chronic understaffing—but lacked the institutional authority to intervene. Similarly, Lekens et al. (2023) reported widespread ethical distress, particularly among junior nurses, who often recognized safety risks but were discouraged from speaking up. These findings underscore a structural disjuncture between ethical awareness and professional agency. Bridging this gap requires the implementation of ethical impact assessments, formal channels for nurse advocacy, and guaranteed nursing representation in hospital policymaking. Until such structures are in place, the exclusion of nursing voices from ethical deliberation remains incompatible with the profession's standards—as articulated by the International Council of Nurses (2021), which mandates advocacy even in the face of institutional resistance.

3. Intersectionality and Perioperative Nursing Subordination

The subordination of perioperative nurses is shaped not only by gender, but also by the intersecting forces of race, ethnicity, age, disability, class, and gender identity. These social locations do not operate in isolation; they interact dynamically with institutional structures and cultural norms to determine how nurses gain—or are denied—access to leadership, clinical authority, and professional recognition within the OR (Minehart and Foldy 2020). An intersectional lens reveals that perioperative nursing is not a monolithic experience. Privilege and marginalization frequently coexist within a single professional identity: a White male nurse may benefit from gendered assumptions of leadership while navigating economic insecurity, whereas an Indigenous nurse may enhance patient care through cultural knowledge but still face racialized exclusion from strategic decision‐making. Understanding these layered and relational dynamics is critical to building surgical teams in which all nurses can lead, advocate, and contribute equitably (Varcoe et al. 2017).

Despite increasing demographic diversity in the nursing workforce, racialized perioperative nurses remain markedly underrepresented in leadership, policy development, and research agendas. A multi‐institutional study by Pincha Baduge et al. (2024) found that racialized nurses were routinely excluded from decision‐making forums—such as surgical planning meetings and patient safety briefings—even when their qualifications and clinical experience matched those of their White peers. These exclusions cannot be explained by individual performance; they are indicative of entrenched structural bias. Williams (2024) highlights how institutional gatekeeping, implicit bias, and unequal access to sponsorship continue to inhibit career progression for nurses from marginalized racial and ethnic backgrounds. Building on this, Adenusi et al. (2025) calls for reforms that move beyond tokenistic inclusion to dismantle systemic barriers—urging nurse leaders to address microaggressions, cultivate interprofessional alliances, and institutionalize equity through policy change.

These dynamics are rooted in a historical legacy of Eurocentric nursing models, which have long idealized White, middle‐class femininity as the professional norm (Camargo Plazas 2018). Beagan et al. (2022), through qualitative interviews with racialized nurses in Canadian hospitals, revealed that many felt they had to “over‐perform” to gain basic recognition, avoid negative stereotyping, or secure advancement. Coghill (2019) similarly underscores how White administrators and physicians dominate nursing leadership structures—often determining institutional agendas in ways that marginalize the voices and contributions of underrepresented nurses.

The experience of male nurses in the OR highlights the paradoxes of privilege and marginalization in gendered workspaces. Wingfield (2009) concept of the “glass escalator” illustrates how men in feminized professions often advance rapidly into leadership roles, benefiting from cultural assumptions about authority and competence. Brandford and Brandford‐Stevenson (2021) confirm that male nurses are often encouraged—early in their careers—to pursue management pathways. Yet these advantages are not evenly distributed. Blackley et al. (2019) found that male nurses, particularly those from racial minority backgrounds, frequently felt compelled to defend their legitimacy within a feminized profession, encountering skepticism from colleagues and patients alike. Moreover, while men are often assigned technical or physically demanding tasks, women continue to shoulder the emotional labor required for team cohesion—labor that is essential yet institutionally invisible (Etherington, Kitto, et al. 2021; Lyu et al. 2022). Lotan (2019) observed that female nurses who assert themselves are frequently labeled “difficult,” reinforcing gendered double standards in the evaluation of professionalism and leadership potential.

Age and career stage further compound these inequalities. Freeling et al. (2017) reported that experienced nurses often perceive new graduates as insufficiently prepared, contributing to hierarchical divisions that marginalize early‐career practitioners. Papathanassoglou et al. (2012) found that junior nurses were frequently excluded from critical safety briefings and discouraged from speaking during procedures. Lang et al. (2022) documented subtle yet pervasive forms of sanction—such as informal criticism and social exclusion—directed at younger nurses who challenged normative practices. Without structured mentorship, advocacy training, or institutional scaffolding, many early‐career nurses are left without the tools to assert clinical judgment or raise ethical concerns (Freeling et al. 2017; Kumaran and Carney 2014).

These disparities underscore the urgent need for reform strategies that address how professional voice is shaped—and constrained—by intersecting social positions and institutional design. A singular, decontextualized model of autonomy obscures the systemic inequities that govern access to authority. Equity‐oriented reforms must include targeted leadership development for racialized and underrepresented nurses, regular audits of task and labor distribution, and robust mentorship frameworks that empower early‐career staff to advocate for safety, ethics, and innovation (Ramseur et al. 2018). Advancing perioperative nursing as a profession rooted in shared authority demands direct confrontation with these intersectional inequities. Within this framework, autonomy must be reconceptualized—not as a selectively bestowed privilege or individual trait, but as a structural right grounded in institutional commitments to equity, inclusion, and representational justice.

4. Procedural Workflow as a Mechanism of Control

The advancement of perioperative nursing autonomy cannot occur in isolation; it requires a fundamental reconfiguration of the procedural and governance structures that currently prioritize physician dominance over nursing expertise. These entrenched hierarchies place disproportionate emotional, cognitive, and physical burdens on nurses, even as clinical decision‐making authority remains concentrated among physicians (Pattni et al. 2019; Wei et al. 2023; Yao and Zhang 2024). Rather than being recognized as autonomous clinicians, perioperative nurses are frequently positioned as operational support—tasked with ensuring surgical efficiency while denied influence over the very workflows they sustain (Power‐Horlick 2023).

Surgical scheduling serves as a primary site of inequity. Ireson et al. (2019) found that OR timetables are often structured around surgeon availability, intensifying staff turnover, reducing break times, and creating chronic understaffing during nights, weekends, and on‐call shifts. Tolliver (2025) expanded on this by showing that nurses regularly work extended hours with limited recovery periods, heightening burnout risk. Teymoori et al. (2022) further observed that scheduled breaks are routinely interrupted for emergent cases, undermining both physical resilience and mental alertness. Nahid et al. (2021) documented that nurses are expected to sustain high performance under these pressures, despite lacking institutional support for recovery or wellbeing. These patterns reinforce a role for nurses defined by stamina and responsiveness rather than strategic clinical input.

Governance structures amplify these inequities by restricting nurses' formal participation in surgical decision‐making. Etherington, Burns, et al. (2021) found that even when nurses possessed relevant insights, their input was routinely sidelined in hierarchical systems that center physician control. Unlike in primary care settings where shared governance is gaining traction, OR remain resistant to flattening hierarchies (Rodrigues et al. 2020). The persistence of top‐down authority impedes the integration of nursing perspectives into policy, practice, and ethical deliberation (Kaye et al. 2018).

Yet counterexamples demonstrate that this imbalance is not inevitable. In select institutions, nurses have been involved in co‐designing intraoperative protocols, including safety checklists and workflow innovations. While underreported in the literature, these cases show that shared authority can emerge when supported by institutional mandates and psychological safety. Etherington, Burns, et al. (2021) noted that when hierarchies are consciously disrupted and collaborative norms are cultivated, nurses engage more meaningfully in intraoperative decisions. These models affirm that structural inequality is not fixed but organizationally produced—and thus reversible.

Still, collaboration in the OR remains inconsistent and often superficial. Lingard et al. (2002) documented that communication breakdowns and rigid authority structures compromise coordination across disciplines. Siirala et al. (2019) observed that nurses may be present at planning meetings yet are routinely excluded from strategic input. Schot et al. (2020) similarly found that blurred professional boundaries limit nurses' ability to influence decisions they are expected to implement. Pattni et al. (2019) reported that nurses who raise concerns—such as unsafe schedules or workflow inefficiencies—often meet resistance. Lang et al. (2022) emphasized that these dynamics contribute directly to burnout, particularly when surgical convenience is prioritized over staff well‐being. Shoemark and Foran (2021) concluded that although nurses are nominally included as stakeholders, they remain functionally positioned as implementers. Teymoori et al. (2022) added that the emotional and operational burden of executing unilaterally determined plans disproportionately falls on nurses—compounding moral distress and institutional alienation.

The spatial design of surgical environments reinforces these hierarchies. Physicians and administrators are typically allocated private planning areas, while nurses operate from peripheral or supply‐adjacent zones—limiting their visibility and reinforcing symbolic marginalization (McDonald 2005). Allen (2015) argued that such spatial arrangements are not neutral; they encode and perpetuate professional hierarchies into the built environment. This imbalance is evident in the implementation of the WHO Surgical Safety Checklist. Although nurses are charged with initiating and completing the checklist, Facey et al. (2024) found their authority often undermined by disengaged surgeons—reducing a vital safety protocol to a box‐ticking exercise. Hammond Mobilio et al. (2022); likewise noted that nurses are frequently tasked with enforcing protocols they had no role in shaping, placing them in ethically untenable positions when met with resistance.

Communication structures further reflect and reproduce hierarchy. Tørring et al. (2019) found that physicians frequently dominate intraoperative dialogue, with nurses' input often dismissed unless reinforced by physician endorsement. Gardezi et al. (2009) reported that even experienced nurses rely on indirect cues to be heard, undermining real‐time advocacy for safety. Traynor et al. (2010) observed that speed, deference, and compliance are culturally expected from nurses—discouraging dissent or interruption. Although civility policies are in place, Chipps et al. (2013) found their enforcement inconsistent, particularly regarding normalized verbal aggression and lateral violence. Emotional labor—managing interpersonal dynamics and maintaining team morale—continues to fall on nurses, reinforcing gendered expectations that prioritize harmony over leadership (López et al. 2019; Timmons and Tanner 2005).

Collectively, these findings reveal a system in which perioperative nursing autonomy is structurally constrained across multiple axes—governance, space, communication, and procedural authority. Reforms must go beyond symbolic inclusion and address these embedded inequities through deliberate design. Integrating nurses into procedural planning, policy development, and ethical deliberation is a foundational step. Sillero Sillero and Buil (2021) emphasized that nurses possess anticipatory knowledge of intraoperative risk and coordination, which improves both efficiency and patient safety when meaningfully engaged.

Governance redesign must formalize nursing leadership in scheduling, resource allocation, and clinical protocol development. Root (2000) and Sieber and Luedi (2022) found that when nurses are empowered as full stakeholders—not informal advisors—interprofessional trust deepens and surgical outcomes become more equitable. This shift requires more than consultation; it demands defined leadership roles with real authority and institutional backing.

Access to space is equally critical. As Etherington, Burns, et al. (2021) argued, nurses are often excluded from key planning environments, limiting their strategic influence. Inclusion must begin at the design stage—not merely at the implementation phase. Moreover, leadership opportunities must extend across all shifts—including nights, weekends, and on‐call hours—where interprofessional breakdown is most likely (Levesque et al. 2022). Temporal inclusion is essential for building a surgical system responsive to 24/7 clinical realities.

Failing to enact these reforms will preserve the systemic limitations that undermine perioperative nursing. Autonomy must no longer be treated as a personal trait or reward but as a structural right. Reimagining the OR as a site of collective authority—where nursing leadership is embedded, visible, and respected—is vital to creating ethical, collaborative, and high‐functioning surgical care systems.

5. Psychological Consequences of Structural Subordination in the OR

Moving forward, structural subordination in surgical environments not only limits perioperative nurses' professional autonomy but also imposes substantial psychological strain—undermining emotional well‐being, job satisfaction, and long‐term workforce sustainability. Although not all nurses experience these impacts equally, a recurrent theme across empirical studies is that the framing of OR nurses as subordinate implementers—rather than autonomous clinicians—exacerbates moral distress, burnout, and disengagement (Registered Nurses Association of Ontario 2022). Despite the consistently high demands for technical precision, anticipatory judgment, and procedural adaptability, nurses are systematically marginalized from formal decision‐making structures, which weakens professional identity and dampens morale (Zou et al. 2025).

5.1. Burnout and Moral Distress: The Cost of Constrained Agency

Burnout is one of the most pervasive consequences of limited clinical agency. In large‐scale survey data from acute care settings, Dall'Ora et al. (2020) found that nurses with minimal input into care planning reported significantly higher levels of emotional exhaustion, cynicism, and intent to leave the profession. Moral distress—a related but distinct phenomenon—emerges when nurses recognize ethical risks but lack the institutional authority to intervene. Epstein and Hamric (2009) conceptualize this as a clash between ethical responsibility and systemic powerlessness, a dissonance that fosters emotional fatigue and long‐term disillusionment. These patterns are confirmed in perioperative contexts by Blanco‐Blanco et al. (2017), who found a strong correlation between suppressed clinical voice and indicators of moral injury.

5.2. Invisible Labor: Emotional Regulation as Unrecognized Work

Emotional regulation is another underappreciated demand placed disproportionately on perioperative nurses, particularly women. Brunges and Foley‐Brinza (2014) documented how nurses are expected to manage interpersonal dynamics, pre‐empt conflict, and stabilize team morale—tasks that are essential to procedural flow but absent from job descriptions and performance evaluations. Schlich and Hasegawa (2017) traced the historical roots of this expectation to gendered occupational norms that position nurses as emotionally responsive caregivers, even in high‐stakes environments like the OR. Reinforcing this, Öksüz et al. (2019) demonstrated that the invisibility of such relational labor correlates with decreased organizational commitment and elevated burnout risk—especially among nurses in high‐intensity roles.

5.3. Workplace Aggression: The Hidden Emotional Tax

Workplace aggression further compounds these psychological burdens. In a series of Canadian hospital studies, Villafranca et al. (2017, 2019) found that nurses—particularly women—regularly encounter verbal aggression and social exclusion from surgical colleagues, incidents often downplayed as manifestations of high‐pressure work culture. Abraham et al. (2021) similarly observed that despite anti‐bullying policies, hostile behaviors persist due to a cultural normalization of incivility in surgical settings. Notably, Jacobs and Wille (2012) identified a gendered double standard in emotional labor expectations: while women are expected to maintain composure in the face of aggression, men are less frequently subjected to such norms.

5.4. Toward Structural and Emotional Reform

Addressing these entrenched inequities requires more than resilience training—it calls for systemic redesign. Gillespie et al. (2020) advocate for protected ethical advocacy channels that allow nurses to report concerns without institutional retaliation. Complementing this, Anderson (2020) call for emotional intelligence and communication training among surgical leaders, emphasizing the collective responsibility for team climate. Tannenbaum and Greilich (2023) stress the value of integrating debriefing, peer support, and mental health services into daily surgical operations. In parallel, López et al. (2019) argue that emotional labor should be acknowledged as part of nurses' formal contributions and reflected in evaluations and role definitions.

Until such reforms are structurally embedded, perioperative nurses—especially women and early‐career professionals—will remain disproportionately vulnerable to emotional burnout and ethical silencing. This is not merely a matter of individual coping but reflects deeper institutional failures in how labor, authority, and responsibility are distributed. Reframing perioperative nurses as full clinical partners requires not only redistributing procedural power but also recognizing and valuing the emotional and ethical labor that sustains team performance and patient safety.

6. Structural Exclusion from Research and Leadership Expertise

Nursing's marginalized position within healthcare hierarchies is perpetuated by systemic exclusion from research, policymaking, and leadership—exclusions that are particularly acute in perioperative settings (Yap 2021). Despite being critical to intraoperative safety and coordination, perioperative nurses remain underrepresented in institutional leadership and scholarly discourse. This disparity persists even though their expertise—ranging from infection control to procedural optimization and team communication—offers vital insights into surgical system improvement (Allen 2015).

A foundational driver of this exclusion is the absence of structural support for nursing‐led research. Unlike physicians, who often receive protected academic time, grant access, and formal mentorship, perioperative nurses are expected to prioritize operational responsibilities over scholarly development. In interviews conducted across Canadian hospitals, Ramage and Foran (2023) found that nurses cited lack of institutional support, research mentorship, and time as major barriers to academic engagement. Byrne (2011) similarly observed that perioperative education disproportionately emphasizes technical execution over scholarly inquiry, leaving nurses ill‐equipped to contribute to research or policy development. As van Houwelingen et al. (2024) argue, these trends reflect a broader institutional bias—one that positions nursing knowledge as subordinate to surgical authority in the production of clinical evidence.

The consequences of this exclusion are evident in the scholarly literature. Oermann et al. (2019) found that leading nursing journals tend to emphasize bedside and community care, offering minimal coverage of intraoperative nursing despite its clinical complexity. Beitz (2019) further noted that key perioperative domains such as surgical ergonomics, instrument safety, and infection control are often explored through physician‐centric frameworks, sidelining the real‐time expertise of OR nurses. Echoing this, Lane‐Fall et al. (2018) reported that nurses are frequently excluded from surgical innovation projects, thereby limiting their influence on systems redesign and patient safety initiatives.

These research and publication gaps have direct implications for career progression. Pincha Baduge et al. (2024) found that perioperative nurses reported significantly fewer opportunities for promotion than peers in ambulatory or community‐based roles—despite comparable or greater clinical demands. Etherington, Burns, et al. (2021) emphasized that surgical leadership remains tightly aligned with physician identity, often marginalizing even the most experienced nurses. Whereas medicine offers structured advancement into research, executive leadership, and policy roles, perioperative nursing typically lacks formal pathways, resulting in career stagnation despite escalating responsibility and expertise.

Addressing these disparities requires systemic reform. Educational institutions must embed research mentorship, publication training, and grant‐writing support directly into perioperative curricula. Friesen and Compeau (2022) demonstrated that when supported institutionally, perioperative nurses can generate high‐impact research that drives clinical innovation and safety. Building on this, Gillespie et al. (2020) call for policy mandates that formally include nurses as co‐leaders—not just participants—in research planning, procedural redesign, and surgical governance. Buljac‐Samardzic et al. (2020) provide strong evidence that inclusive interdisciplinary collaboration enhances implementation outcomes, improves staff alignment, and optimizes clinical workflows. When nurses are fully engaged as intellectual and strategic partners, team cohesion strengthens, and the overall quality of care improves.

Unless these structural barriers are dismantled, perioperative nursing will remain undervalued in the domains of research, leadership, and systems innovation. Empowering nurses to shape surgical systems is not merely a matter of professional equity—it is a clinical imperative. Only by recognizing perioperative nurses as scholars, strategists, and institutional leaders can we advance safer, more collaborative, and more effective models of surgical care.

7. From Structural Constraint to Transformational Autonomy

Perioperative nursing autonomy must be redefined not as the accumulation of delegated tasks, but as a structural right rooted in clinical judgment, ethical discernment, and institutional influence. Current frameworks often reinforce subordination by casting nurses as executors of physician decisions rather than as contributors to the design and governance of surgical care. Instead, autonomy must be understood as a function of professional agency—the capacity to shape practice, policy, and innovation within complex surgical systems.

This conceptual reframing aligns with Fricker (2007) theory of epistemic injustice, which identifies how certain groups are systemically devalued in knowledge production. Within perioperative contexts, nurses' embodied expertise—developed through proximity to surgical events and real‐time risk anticipation—is frequently marginalized by physician‐dominated hierarchies. Yet, evidence from Nordic health systems (Pursio et al. 2021; Gunnarsdóttir et al. 2009) demonstrates that when nurses are structurally empowered to co‐lead decision‐making processes, significant gains follow in patient safety, workflow efficiency, and team communication. Thus, autonomy must not be viewed as a privilege selectively granted but as an institutional design principle embedded within governance models.

7.1. Structural Case Studies: Global Evidence of What Works

Comparative research confirms that structural autonomy is not only achievable—it is transformative. Scandinavian systems provide compelling case studies. In Sweden and Iceland, perioperative nurses routinely co‐develop intraoperative protocols and contribute to national policy initiatives. These systems embed shared governance, interprofessional training, and formal leadership development into routine perioperative operations, exemplifying how surgical leadership can be diversified through institutional design (Torjesen et al. 2017; Kokorelias et al. 2021).

Similarly, in the Netherlands and Finland, advanced nurse practitioners are granted diagnostic authority and participate in budgeting and procedural oversight—affirming the potential for expanded clinical roles when they are formally legitimized (World Health Organization WHO 2024). In contrast, in many low‐ and middle‐income countries (LMICs), nurses often assume expanded responsibilities out of necessity, not empowerment. Task‐shifting in resource‐limited settings may involve nurses taking on intraoperative responsibilities without legal protections, professional recognition, or adequate compensation (Raykar et al. 2016; Xie et al. 2024). These disparities underscore a critical distinction: task expansion without structural support does not constitute autonomy—it risks institutionalized exploitation.

Meanwhile, in high‐income countries such as Australia and the UK, investments in advanced perioperative roles—such as surgical nurse coordinators—have improved both system resilience and clinical outcomes (Assolari et al. 2024). Collectively, these international models make clear: surgical hierarchies are not immutable. They are constructed—and therefore, they can be reconstructed.

7.2. Building Transformational Autonomy: A Multidimensional Strategy

To realize transformational autonomy, systemic reform is required across governance, education, technological inclusion, and workplace culture. At the governance level, perioperative nurses must be recognized as formal stakeholders in procedural planning, institutional policy development, and quality improvement initiatives. This means holding voting roles on hospital boards, ethics committees, and regulatory panels—with decision‐making authority clearly delineated. As shown in Australian and Swedish case studies (Gillespie et al. 2020; E. C. Nelson et al. 2011), when nurses co‐lead safety initiatives and intraoperative redesigns, patient outcomes improve, interprofessional cohesion strengthens, and burnout rates decline.

Educational reform must go beyond procedural competencies. Most perioperative training remains task‐oriented, reinforcing assistive rather than strategic identities. To counter this, curricula must prioritize leadership, systems thinking, ethical advocacy, and policy literacy. Interprofessional education—in which nurses, surgeons, and anesthetists train collaboratively—has proven effective in flattening hierarchies and fostering mutual respect (Reeves et al. 2017).

Technological integration is another critical frontier. As ORs adopt artificial intelligence (AI), robotics, and data‐driven systems, nurses are frequently excluded from design and implementation processes. This risks perpetuating algorithmic bias and physician‐centric priorities (Rasheed et al. 2022). Ensuring technological equity means involving perioperative nurses in the development and evaluation of digital tools—so that clinical technologies reflect the collaborative realities of modern surgical teams.

Cultural transformation is equally essential. The language used to describe perioperative nursing must evolve. As long as nurses are positioned as “support staff,” their leadership will remain obscured. Instead, they must be recognized as clinical architects—professionals who not only maintain but design, troubleshoot, and optimize surgical workflows. Their exclusion from authorship, innovation, and procedural policymaking is not merely symbolic—it represents a systemic barrier to safer, more equitable care.

7.3. Reclaiming Institutional Voice

Redefining autonomy in perioperative nursing requires more than symbolic inclusion; it demands structural redistribution of authority. Autonomy is not earned solely through performance or tenure—it must be recognized as a professional right, realized through intentional, systemic redesign. Empowering perioperative nurses to shape surgical care through leadership, scholarship, and innovation is both a clinical and ethical imperative. Only by reframing nurses as co‐constructors of surgical systems—rather than peripheral implementers—can healthcare institutions achieve equitable, collaborative, and high‐performing surgical environments.

8. Confronting Subordination by Design

This discussion has demonstrated that the subordination of perioperative nurses is not a peripheral byproduct of surgical operations, but a deliberate and enduring feature of institutional design—encoded in the spatial configurations, procedural hierarchies, and cultural logics that govern OR environments. From the physical marginalization of nurses within OR layouts to their systematic exclusion from decision‐making forums and clinical innovation, nursing authority has been persistently constrained under the guise of tradition, efficiency, and discipline.

Both historical and contemporary analyses converge on this reality: surgical systems have long been optimized for the priorities of physician leadership—often at the expense of nursing autonomy, voice, and well‐being. Ethnographic accounts, spatial audits, and policy critiques collectively reveal how perioperative nurses' clinical expertise is undervalued, their ethical discernment sidelined, and their emotional labor rendered invisible. These are not aberrations—they are structural artifacts of hierarchical, gendered, and epistemically exclusive systems.

Critically, this subordination is not experienced equally. Intersectional frameworks expose how factors such as race, gender identity, age, class, disability, and institutional rank intersect to deepen exclusion for many nurses. Racialized and female professionals remain underrepresented in leadership, disproportionately burdened by emotional labor, and routinely silenced in clinical governance. These inequities demand more than superficial policy gestures—they require structural reckoning and cultural transformation.

Reclaiming perioperative nursing autonomy thus demands a multi‐level strategy for redesign. Nurses must be embedded as co‐leaders across governance, education, research, and innovation—not as token representatives, but as foundational architects of surgical care. Educational pathways must be reconstructed to emphasize systems thinking, ethical courage, interprofessional collaboration, and policy fluency. Procedural protocols, spatial design, and scheduling infrastructures must reflect a shared model of authority—where nursing insight is not optional, but essential.

Global case studies provide compelling proof that such change is not only feasible, but effective. Health systems that integrate shared governance, inclusive leadership, and interprofessional training consistently report improvements in team cohesion, safety outcomes, and institutional adaptability. These models challenge the presumed inevitability of nursing marginalization and offer blueprints for transformation that are both evidence‐based and ethically imperative.

Ultimately, the call for perioperative autonomy is not a call for incremental reform—it is a demand for structural justice. It is a call to dismantle inherited systems of exclusion and to rebuild surgical care as a site of collaboration, equity, and mutual respect. Autonomy, in this reimagined paradigm, is not granted by hierarchy—it is a professional and ethical entitlement, grounded in the critical knowledge, judgment, and relational labor that nurses bring to the heart of surgical care.

To realize this vision, nurses must be fully visible, fully valued, and fully empowered to lead. Only then can the surgical environment evolve from a space of constraint to one of possibility—where every member of the team is equipped and authorized to contribute to the highest standards of care.

Ethics Statement

This manuscript is a theoretical and conceptual analysis based on published literature and does not involve human participants, clinical data, or patient records. No third‐party material requiring permission has been included.

Conflicts of Interest

The author declares no conflicts of interest.

Data Availability Statement

Data sharing is not applicable to this article as no data sets were generated or analyzed during the current study.