Challenging authority during a life-threatening crisis: the effect of operating theatre hierarchy

Br J Anaesth. 2013 Mar;110(3):463-71. doi: 10.1093/bja/aes396. Epub 2012 Nov 27.


Background: Effective operating theatre (OT) communication is important for team function and patient safety. Status asymmetry between team members may contribute to communication breakdown and threaten patient safety. We investigated how hierarchy in the OT team influences an anaesthesia trainee's ability to challenge an unethical decision by a consultant anaesthetist in a simulated crisis scenario.

Methods: We prospectively randomized 49 postgraduate year (PGY) 2-5 anaesthesia trainees at two academic hospitals to participate in a videotaped simulated crisis scenario with a simulated OT team practicing either a hierarchical team structure (Group H) or a non-hierarchical team structure (Group NH). The scenario allowed trainees several opportunities to challenge their consultant anaesthetist when administering blood to a Jehovah's Witness. Three independent, blinded raters scored the performances using a modified advocacy-inquiry score (AIS). The primary outcome was the comparison of the best-response AIS between Groups H vs NH. Secondary outcomes included the comparison of best AIS by PGY and the percentage in each group that checked and administered blood.

Results: The AIS did not differ between the groups (P=0.832) but significantly improved from PGY2 to PGY5 (P=0.026). The rates of checking blood (92% vs 76%, P=0.082) and administering blood (62% vs 57%, P=0.721) were high in both groups but not significantly different between the groups.

Conclusions: This study did not show a significant effect of OT team hierarchical structure on trainee's ability to challenge authority; however, the results are concerning. The challenges were suboptimal in quality and there was an alarming high rate of blood checking and administration in both groups. This may reflect lack of training in appropriately and effectively challenging authority within the formal curriculum with implications for patient safety.

Publication types

  • Multicenter Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Anesthesiology / education
  • Blood Transfusion / ethics
  • Communication
  • Crisis Intervention
  • Electrocardiography
  • Ethics, Medical
  • Hierarchy, Social*
  • Humans
  • Internship and Residency
  • Intraoperative Complications / therapy
  • Jehovah's Witnesses
  • Ontario
  • Operating Rooms / organization & administration*
  • Patient Care Team / organization & administration*
  • Personality
  • Prospective Studies
  • Referral and Consultation
  • Sample Size
  • Social Environment
  • Surveys and Questionnaires