Aim: This study explores how power dynamics between nurses and physicians in acute care settings influence nursing autonomy and the implementation of evidence-based practice (EBP). It also identifies organisational strategies that can enhance interprofessional collaboration, leadership, and shared decision-making.

Design: A qualitative case study approach was used, underpinned by social constructivism to explore nurses’ lived experiences within the context of acute care hierarchies.

Methods: Data were collected from two large NHS acute care hospitals in the Midlands, through 33 semi-structured interviews, 12 non-participant observations, and document reviews. The sample included 37 staff nurses, ward managers, nurse managers, and physicians. Braun and Clarke’s thematic analysis framework guided data analysis, supported by reflexive field notes and triangulation of data sources.

Findings: Nurses reported restricted autonomy due to entrenched medical dominance and were frequently excluded from key decision-making processes. These hierarchical imbalances contributed to moral distress, burnout, and disengagement from EBP. However, the study also uncovered everyday acts of resistance, including subtle negotiation and knowledge-based advocacy. Leadership training, interprofessional education, shared governance, and structural reforms were cited as effective strategies for enhancing collaboration and restoring nursing voice. Participants who experienced nurse-led initiatives and inclusive decision-making reported improved confidence and patient care outcomes.

Conclusion: Hierarchical power dynamics significantly constrain nursing autonomy and hinder EBP implementation in acute care. Nurses respond with resilience and agency, often advocating for evidence use in informal ways. Organisational reforms that promote shared governance, empower nurse leaders, and foster respectful collaboration are essential for shifting entrenched dynamics and improving care quality.

Impact: This study highlights the need for NHS organisations to address power imbalances by investing in leadership development, inclusive governance, and interprofessional teamwork to support sustained EBP and improve outcomes.

Reporting Method: The study followed COREQ guidelines.

Patient/Public Involvement: Patients were not directly involved; however, the focus on nurse-led care has implications for improving patient safety.