Bould M Dylan, Sutherland Stephanie, Sydor Devin T, Naik Viren, Friedman Zeev
Department of Anesthesiology, Children's Hospital of Eastern Ontario, University of Ottawa, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada,
Can J Anaesth. 2015 Jun;62(6):576-86. doi: 10.1007/s12630-015-0364-5. Epub 2015 Mar 20.
Our aim was to clarify how hierarchy influences residents' reluctance to challenge authority with respect to clearly erroneous medical decision-making.
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.
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.
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.
我们的目的是阐明层级制度如何影响住院医师在面对明显错误的医疗决策时不愿挑战权威的情况。
在获得研究伦理批准后，我们在安大略省的两所大学招募了44名麻醉科住院医师参与一个高保真模拟场景。在该场景中，一名演员（住院医师被告知其为所在大学的一名实际的新入职麻醉科医生）要求实习生违背患者明确表达的意愿为一名耶和华见证会信徒输血。案例结束后，对实习生进行了汇报，并进行了30 - 40分钟的访谈。访谈进行了录音并逐字转录，文本采用基于扎根理论的定性方法进行编码。
对参与者访谈的定性分析得出了关于层级影响的丰富描述性记录，其特征通常是恐惧和恐吓。住院医师谈到了他们的应对策略，包括适应性、避免冲突、将询问作为患者维权的方法，以及依靠手术室团队中更大范围的责任分散。
研究结果表明层级制度在手术室运作中起主导作用。参与者谈到了这种层级学习环境的积极和消极影响。大多数参与者将对层级制度的负面认知描述为常态，并且他们采用了许多应对策略。本研究深入探讨了负面的层级文化如何对患者安全、住院医师学习和团队运作产生不利影响。我们提出了一个理论模型来描述在这种情况下挑战权威的情况。
