title: Residents' reluctance to challenge negative hierarchy in the operating room: a qualitative study.
abstract: OBJECTIVE
  Our aim was to clarify how hierarchy influences residents' reluctance to challenge authority with respect to clearly erroneous medical decision-making.
  
  
  METHODS
  After research ethics approval, we recruited 44 anesthesia residents for a high-fidelity simulation scenario at two Ontario universities. During the scenario, an actor, whom the residents were told was an actual new staff anesthesiologist at their university, asked the trainees to give blood to a Jehovah's Witness in contradiction to the patient's explicitly stated wishes. Following the case, the trainees were debriefed and were interviewed for 30-40 min. The interviews were audio recorded and transcribed verbatim, and the text was coded using a qualitative approach informed by grounded theory.
  
  
  RESULTS
  Qualitative analysis of the participants' interviews yielded rich descriptive accounts of hierarchical influences often characterized by fear and intimidation. Residents spoke about their coping strategies, which included adaptability, avoiding conflict, using inquiry as a method for patient advocacy, and relying on a diffusion of responsibility within the larger operating room team.
  
  
  CONCLUSIONS
  Study results showed that hierarchy played a dominant role in the functioning of the operating room. Participants spoke of both the positive and negative effects of such a hierarchical learning environment. The majority of participants described a negative perception of hierarchy as the norm, and they employed many coping strategies. This study provides insight into how a negative hierarchical culture can adversely impact patient safety, resident learning, and team functioning. We propose a theoretical model to describe challenging authority in this context.
authors: Department of Anesthesiology, Children's Hospital of Eastern Ontario, University of Ottawa, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada, dbould@cheo.on.ca.
authors: M Dylan
authors: MD
authors: Bould
authors: Stephanie
authors: S
authors: Sutherland
authors: Devin T
authors: DT
authors: Sydor
authors: Viren
authors: V
authors: Naik
authors: Zeev
authors: Z
authors: Friedman
mesh_terms: D000223:Adaptation, Psychological; D000776:Anesthesiology / Q000458:organization & administration* / Q000592:standards; D003657:Decision Making; D005260:Female; D066296:Grounded Theory; D006801:Humans; D007396:Internship and Residency / Q000458:organization & administration*; D008297:Male; D008962:Models, Theoretical; D009864:Ontario; D009873:Operating Rooms; D010348:Patient Care Team / Q000458:organization & administration / Q000592:standards; D010820:Physicians / Q000458:organization & administration* / Q000592:standards