Medical errors and patient harm continue to be a problem at all levels of healthcare delivery (Canadian Institute for Health Information, 2019; Makary & Daniel, 2016; Vogel, 2016) and while the antecedents of harm are complex and span all facets of health systems the causes can generally be categorized as Latent and Active (Kohn, Corrigan, & Donaldson, 1999). Active causes of error include those attributable to human actions (Kohn et al., 1999). Human causes that contribute to harm are widely explored yet there are human factors in need of further elucidation, including group dynamics (Kaba, Wishart, Fraser, Coderre, & Mclaughlin, 2016). A group is three or more people gathered for a common reason whose activity results in some kind of output; the processes, outcomes, and perceptions or experiences of the group are the dynamics (Tasca, 2020). Within the complexity of group dynamics and possibilities for patient harm compliance behaviour needs further research (Kaba, Wishart, et al., 2016). Compliance behaviours can be classed primarily as conformity and obedience. Conformity is behaviour aligning with peers, while obedience is acquiescence to a request made by an authority (Cialdini & Trost, 1998). When compliance produces harm, such as when a person does not speak up or alter a course of action believed to be inaccurate or unsafe it is considered negative compliance (Green, Oeppen, Smith, & Brennan, 2017). The challenge for understanding compliance in the context of healthcare is identifying or predicting when harm may occur as conformity and obedience tend to be socially and ecologically adaptive and positive (Marsh, Todd, & Gigerenzer, 2004; Todd & Gigerenzer, 2012). Much of our learning is social (Bandura, 1971) and compliance behaviours are important for learning and understanding norms for appropriate social interactions, learning skills and engaging in accurate behaviour, and self-concept and identity development (Cialdini & Trost, 1998). As adaptive behaviours conformity and obedience are so functional that it becomes extremely difficult to override them and speak out against an authority or group, to engage in positive deviance, when one thinks what is occurring is wrong (Cialdini, 2006; Holmes, Harris, Schwartz, & Regehr, 2014).
A large degree of the literature published on negative compliance in health care has been focused on student compliance. Students occupy a low position in healthcare hierarchies and as a result are susceptible to negative compliance through conformity and obedience (Coombs, 2003; Delaloye, 2017; Delaloye et al., 2017; Sexton et al., 2015). It is assumed that the issues with negative compliance and the prevailing issues are well documented and understood as negative compliance is becoming more frequently discussed in the literature. However, much of the existing literature covers anecdotal experiences with situations that caused compliance and theoretical suppositions about causes and student experience (Liao, Thomas, & Bell, 2014; Sur, Schindler, Singh, Angelos, & Langerman, 2016; Wray, Yu, & Philbey, 2016). There is a small though emerging body of experimental work on these constructs based in psychological theory (Beran, 2015; Beran, McLaughlin, Al Ansari, & Kassam, 2013; Kaba & Beran, 2016; Kaba, Beran, & White, 2016) yet currently lacking are explicit frequencies with how often health professional students experience negative compliance.
It is not possible to determine these experiences retrospectively through reviews of cases or patient records (Norman et al., 2017). Patient records only provide an indication of harm and not the antecedent conditions that led to the outcome. Through observation, it may be possible to see a case where a person should have spoken up but did not. Yet this does not provide information as to why a person did not speak up. Did a person know that something was wrong? Did a person not speak up out of a concern for causing a disturbance? Did the person believe what others were doing was probably correct despite personal uncertainty? The most direct method to understand these questions is to obtain student reports. Without foundational empirical knowledge about the rate of an experience or event it is not possible to fully understand the phenomenon.
In addition to knowing frequencies there are numerous variables influencing compliance (Bègue et al., 2015; Blass, 1999; Cialdini & Goldstein, 2004; Delaloye, 2017; Lepage, Bègue, Zerhouni, Courset, & Mermillod, 2018; Milgram, 1965). To understand group dynamics and compliance, it is useful to look at areas outside of the traditional silos of medical knowledge such as psychology (Croskerry, Cosby, Graber, & Singh, 2017; Kaba, Wishart, et al., 2016), which has an extensive history of studying the cognitions and behaviours of compliance (Reis, 2010). Three variables that relate to the frequency with which people may engage in compliance that can result in harm are impression management, displacement of responsibility, and moral distress
Impression management is the way people attempt to control the perceptions, or impressions that others have of them, the person’s self-presentation (Goffman, 1963). Impression management consists of two components, impression motivation and impression construction. Impression motivation is comprised of the goal-relevance, desired outcomes and discrepancy between current and desired image. Impression construction consists of the image created in relation to self-concept, desired and undesired identity images, role constraints, targets values, and current social image (Leary & Kowalski, 1990). Expectations of people based on place in a hierarchy can create the conditions for compliance as a person attempts to fulfill the expected role in the context of individual self-presentation, as well as group presentation. Impression Management has been shown to influence compliance behaviours with people being more likely to acquiesce to requests that will present themselves in a positive light to a desired other (Rind & Benjamin, 1994). For example, in an interprofessional health context nurses in a hospital would engage in impression management to maintain the perception of collaborative work though collaboration was often not possible because of constraints imposed by the practice setting (Lewin & Reeves, 2011). Expectations regarding different roles have been shown to cause people to behave in accordance with those roles in a professional setting (Guadagno & Cialdini, 2007).
Displacement of responsibility is identified as one of the most important and strongest influences on submission to authority (Bandura, 1999; Bould, Sutherland, Sydor, Naik, & Friedman, 2015; Davis, DeZoort, & Kopp, 2006; Milgram, 1963). When a person can, or is given the opportunity to, displace responsibility for actions or outcomes the person is spared engaging with the outcome and possible rapprochement (Bandura, 1999). One of the primary ways people deal with the displacement of moral control or responsibility is through plausible deniability. The cognitive enactment of plausible deniability is the method through which people engage in motivated reasoning and uncritical acceptance that allows the person to deny they behaved immorally (Bersoff, 1999) and make themselves believe they did not act immorally (Ariely, 2008). People engage in motivated reasoning for plausible deniability in two ways (Epley & Gilovich, 2016). First, when considering propositions that people would prefer to be true, they ask “Can I believe this?” Can I believe this has a low evidentiary standard e.g. I did not act immorally because someone else told me to do it. Second, when considering something a person does not want to be true, they will ask “Must I believe this?” Must I believe this has a higher evidentiary standard as some confirmatory evidence is often available e.g. someone became ill because I did what I was told, and requires more rigorous search for a reason not to believe it e.g. if I didn’t do what I was told I would have failed placement and someone else would have done it anyways. The influence of displacement of responsibility has been demonstrated in healthcare (Bould et al., 2015) and numerous other areas (Bandura, 1999; Davis et al., 2006; Meeus & Raaijmakers, 1986; Richardot, 2014).
Negative personal outcomes can occur because of compliance, whether compliance occurred through impression management, displacement or responsibility, or other means. A highly impactful negative outcome is Moral Distress. Jameton (1984) defined moral distress as: “negative feelings that arise when one knows the morally correct response to a situation but cannot act accordingly because of institutional or hierarchical constraints.” Wilkinson (Wilkinson, 1987) further accounts for the psychological factors of distress “the psychological disequilibrium and the state of negative feelings experienced when a person makes a moral decision but does not follow through by performing the moral behaviour indicated by that decision”. Moral Distress can arise in healthcare due to conflict that occurs between the maintenance of a person’s moral integrity, the internal consistency of a set of personal standards, and behaviour constrained by external factors (de Raeve, 1998); or more simply the experiencing of a moral event and the resultant psychological distress (Morley, Ives, Bradbury-Jones, & Irvine, 2019). Institutional, environmental or system factors can create moral distress through challenges imposed to the maintenance of moral integrity creating a sense of futility and can lead to negative psychological and physical outcomes including burnout, fatigue, disengagement and increased susceptibility to negative compliance (Atabay, Çangarli, & Penbek, 2015; McAndrew, Leske, & Schroeter, 2018; Monrouxe, Shaw, & Rees, 2017; Schwenzer & Wang, 2006; Wiggleton et al., 2010).
The principles of compliance are nearly universal (Avorn, 2018; Graham et al., 2011; Greene, 2015; Haidt, 2007, 2012) and function similarly in healthcare as in other contexts. Obtaining insight into how students experience and think about compliance and in what ways these are related to, or reflect, frequency of behaviour can aid in developing a better understanding of where more detailed research is needed and what means might be taken to address negative compliance. It is necessary to know the extent of the problem and why it occurs. Is negative compliance something only rarely experienced but because of its impact it is highly salient and frequently discussed or is it something experienced daily and the risk of harm is even higher than anticipated? Does impression management factor into compliance or is it strictly a matter of displacement of responsibility? These things are unknown.
The present study will take an exploratory approach to understand the frequency with which students experience negative compliance related to obedience and conformity, and three related psychological phenomena. Two research questions have been developed utilizing a multi-method approach to examine experiences and cognitions around compliance behaviour.
Research Questions:
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Experiences and Expected Behaviour: How frequently do students experience negative compliance through conformity and obedience and what are some of the possible underlying social and psychological influences and outcomes?
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Perceptions of Compliance: What are students’ perceptions of obedience and conformity? Can common themes be derived from these?