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Concepts and Commentary

Case and Commentary

Using Simulation to Address Hierarchy Issues During Medical Crises

Calhoun, Aaron W. MD; Boone, Megan C. RN, MSN, CCRN; Miller, Karen H. PhD; Pian-Smith, May C. M MD, MS

Author Information
Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: February 2013 - Volume 8 - Issue 1 - p 13-19
doi: 10.1097/SIH.0b013e318280b202
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Consider the following case. A patient experiences the sudden onset of supraventricular tachycardia, and a multidisciplinary clinical team responds. During the course of treatment, the physician team leader mistakenly orders amiodarone intravenous push rather than adenosine. Although team members are concerned about the appropriateness of this order, they choose not to speak up. The drug is given, resulting in severe hypotension and bradycardia. This real case illustrates the difficulty of challenging an authority figure even when significant negative consequences could result, a phenomenon that has been observed in a myriad of differing domains.1–5 Numerous studies have indicated that, even where harm to others is a possibility, numerous psychological factors converge to create a strong bias toward remaining quiet.1,3,6 This phenomenon can be discussed in the context of “power distance,” an expression referring to the degree of separation that exists between rungs in a particular culture’s social hierarchy.7,8 As power distance increases, it becomes correspondingly difficult to appropriately challenge authority. When coupled with a critical situation in which lives are at stake, a “perfect storm” can be created in which significant harm can occur.9

These findings apply particularly to medicine, a culture in which high power distance situations can coexist with opportunities for patient harm.10–12 Ideally, medical hierarchies function smoothly, with team leaders giving appropriate orders swiftly and transparently so that critical interventions can be deployed.13,14 What happens, however, when the leader gives an incorrect order, and the prevailing power distance prevents challenge of that order? Simulation has been used in the past to address this problem, focusing on language techniques that could be used to successfully question the leader.4,14–18 Scenarios used in these situations were intentionally ambiguous, presenting cases in which the inappropriate command or order was relatively incorrect but not always absolutely so.4 In many real-world situations, however, the order may not be ambiguous at all but quite clearly incorrect. Thus, although cases containing ambiguity have a valuable place, we perceived a parallel need for a case without the confounding influence of this ambiguity on a subordinate’s willingness to challenge. Therefore, we developed a case scenario in which a confederate gives an inappropriate order that is unquestionably wrong and will result in death if not addressed.

Although there are still some medical subcultures that maintain a high power differential, there is an emerging trend in medicine to foster psychological safety and teamwork, patient and physician autonomy, and personal responsibility.7 Given these positive developments, our hope was to craft a case that invoked these values and thereby increase the willingness of team members to “speak up.” The case, however, raises a number of interesting ethical and psychological concerns including the use of misdirection in education, the possibility of simulated “death,” and the potential for subsequent negative emotional impact on the learner.

The goals of this article are to describe the case, present the outcomes of several representative enactments, and discuss the educational, ethical, and psychological issues inherent in such cases.

Case Outline

The case involved a simulated patient with a hyperkalemic dysrhythmia and incidental hypophosphatemia. To generate the psychological dilemma discussed previously, a team leader (confederate) was scripted to order the administration of potassium phosphate (the typical phosphorous replacement used at our institution), a drug that would likely result in patient death in the setting of hyperkalemia. To better meet the learning needs of different clinician groups, two patient case stems were created—one involving the induction phase of chemotherapy for neuroblastoma and one involving renal failure. Regardless of the specific stem used, the case proceeded in a similar manner. Two members of the learner team entered the room to perform an initial assessment, during which the patient developed pulseless ventricular tachycardia. The team was expected to call for the assistance of additional participants, organize the team, initiate basic life support (BLS), ask for results of recently obtained laboratory tests, and order additional tests. Once the team was aware of the hyperkalemia, a confederate entered and assumed leadership. This leader noted the hypophosphatemia and asked that potassium phosphate be given. The scenario evolved based on the code team’s response, with patient survival contingent on a successful challenge of the leader. Case stems, specific details regarding case progression, and needed equipment are presented in Tables 1 and 2.

States for Hierarchy Scenario for Stem 1 (Neuroblastoma) and Stem 2 (Renal Failure)
Required Equipment and Supporting Laboratory Values

Preparation and Briefing of the Learners

To enhance the learning experience, participants were briefed about simulation, team training, and learning safety. Simulator capabilities, suspension of disbelief, basic principles of code team organization, and the concept of communication error (including fixation and failure to challenge inappropriate orders) were covered. Rules and expectations about confidentiality were explicitly stated and agreed upon. Finally, learners were informed that a supervising attending interested in simulation and their education (the confederate) might participate in a clinical capacity for a portion of the case.

By including hierarchy as a potential issue during the briefing, we attempted to make learners aware of the issue and thereby diminish the sense of “unfairness” that could otherwise be present. Given the high experience level of our learner group (pediatric intensive care unit clinicians), we chose to discuss the potential effect of such sensitive confounders alongside other common communication challenges.

Preparation of the Confederate

The confederate was a clinician known to the learners and possessed a degree of authority among them. He or she was told the basic story and instructed to enter the learning environment after the cause of the dysrhythmia (hyperkalemia) had been clearly ascertained, announce his or her presence, and assume formal leadership of the team. Upon learning of the abnormal laboratory values, the confederate was scripted to say “The phosphorus is low; we need to give a bolus of potassium phosphate to replenish it.”

We prepared the confederate for a number of possible responses.

  • If the team responded by simply giving the drug, the confederate was to appear surprised at the resulting asystole and appropriately direct the resulting arrest.
  • If the team responded by asking why potassium phosphate, the confederate was to say “We need to replenish the phosphate, so the heart can have enough ATP [adenosine triphosphate] to function,” a plausible but erroneous statement.
  • If, at this point, the team challenged this reasoning or the order itself in any way, the confederate was to acquiesce.
  • If the team simply challenged the order itself without asking for the rationale, the confederate was to say “he needs the potassium phosphate if we are going to get him through this” with no further explanation.
  • If the team sustained their challenge, the confederate should was to acquiesce.

For other possible responses, the confederate was asked to improvise, recognizing that the basic pattern should be to resist the first challenge, however phrased, but acquiesce to any subsequent challenges. We did this to enable practice of graded assertiveness in response to authority.4

Debriefing the Encounter

After an initial “reactions” phase, facilitators addressed communication and teamwork skills. Suspension of disbelief was addressed by asking participants if the situation was believable and if they experienced emotions similar to those experienced during real crises. This information was then used to gain a sense of the scenario’s impact. Next, team organization and maintenance (presence of leadership, teamwork, closed-loop communication, etc) were addressed. Finally, factors that contribute to errors, including fixation and hierarchy, were discussed. After participants were given a chance to share initial impressions regarding these errors, the discussion was steered toward hierarchy, and the role of the confederate was revealed. We explained that the intent was to recreate a realistic situation to highlight the importance of critical thinking and the responsibility of team members to challenge incorrect orders.

Participants were asked whether they realized the order was incorrect. During our debriefings, the answer was always “yes,” and we then focused the discussion on the prevalence of such errors. We disclosed real situations where we had also made these types of errors in an effort to contextualize and normalize the issue, defuse any sense of emotional isolation present in the team, and reinforce psychological safety. If the answer had been “no,” we would have redirected the discussion toward the therapy for hyperkalemia to address this significant knowledge deficit. We concluded this portion of the debriefing by charging each participant with the task of applying these principles to future real-life crises, stating that “it is the leader’s job to collate all orders and information so that the team can behave cohesively, but it is the entire team’s job to think about the problem and share its thoughts with the leader.”

Finally, we directed the debriefing toward a discussion of barriers to effective challenge that may have existed in the minds of the participants. We discussed possible approaches for addressing the confederate’s error. We suggested a stepwise approach similar to the “2-challenge rule”; an initial respectful challenge expressing concern about the order and requesting an explanation of the leader’s perspective, followed by a more direct challenge if this proved ineffective.4 We informed the team that if both attempts failed, participants had the right to refuse the incorrect order and should call for assistance and arbitration. It was discussed at each session that experiencing the consequences of errors in a simulated context and reflecting on the psychological underpinnings of such errors could help prevent these types of problems in real life.

Case Outcomes

We enacted this simulation 3 times. The first resulted in a successful challenge of the inappropriate order; the second resulted in a successful, but delayed, challenge, with the phosphate issue becoming a fixation point that delayed appropriate management; and in the third, the inappropriate order was not challenged and the simulated patient died. Table 3 shows the flow of events during enactments 2 and 3.

Sequence of Events During 2 Representative Enactments


Enactment of this case enabled us to engage in positive discussion about how to overcome such issues during future real situations. Even the session in which the simulated patient died resulted in a positive and productive conversation, with learners stating that the session represented a “safe way to consider the effects of hierarchy on care.” Despite this, ethical and emotional issues remain, which deserve consideration here.

The Ethics of Misdirection

The ethical challenge of teaching with this case relates to accurately recreating the effects of a serious hierarchy-related error (a process that may require learner misdirection to be realistic) while preserving the trusting and relationship-oriented environment valued by adult learners.19,20 This does not necessarily require shielding learners from emotionally charged outcomes and stressful situations but is based on shepherding trainees through these educational experiences with beneficence, justice, and respect for personal values.21 Many investigators have studied the effect of stress on acquisition and retention of new knowledge, and admittedly, the results have been inconsistent.22,23 One recent study examined the effect of stress during codes on participants’ long-term performance and found improved 6-month performance for the stressed group as compared with controls.24 Certainly, the scenario itself is only one part of the learning equation, and an expert debriefing can make a great difference in learners’ perceptions of stress, even in extreme situations.25 Violation of learner trust and potential harm to the instructor-learner relationship will always be possible in stressful scenarios but are not unavoidable.

An additional consideration for the ethical debate relates to the effect such lessons can have on the care of actual patients. Consider the case discussed in the introduction. If this example were only theoretical, it would be concerning enough, but this situation actually occurred twice in 1 year at our institution. Simulation provides a venue to address real learner needs related to patient safety and allows the grave consequences of such actual errors to be reliably recreated and explored without patient harm.

Case Outcome and Mannequin Death

The necessity of simulated patient death has been questioned and explored by education researchers with differing opinions.19,20,24–30 It is our position that it can be justified by the instructional intent. Unexpected patient death is a sobering reality in the practice of medicine, and it seems unrealistic and inappropriate to shield learners from this reality. Real patients die under a spectrum of circumstances, including situations where the actions of a single individual can make a key difference in outcome. A recent literature review suggested that simulated patient death should occur within teaching scenarios where death is pertinent or is likely.30 The authors further recommended that appropriate measures be taken to assure psychological safety during debriefing, including appropriate facilitator training, adequate facilitator experience with debriefing difficult cases, and consideration of learner experience. This last consideration is of particular importance for the primary participants in our case, seasoned clinicians who see patient death on a regular basis, because it is probable that they might need the possibility of simulated patient death to maintain suspension of disbelief and learner engagement.30 In contrast, novice students may benefit from a lower-stakes version of the scenario.30

Nonpunitive debriefing maintains the balance between recognition of the cause of death and consideration for the emotional state of the learner.30 One helpful approach is termed advocacy/inquiry, a method that uses comments on specific observed behaviors as a means of uncovering the thought process or “frames” behind those actions.31,32 There are also many other debriefing techniques, which could be successfully used to approach these issues.31–35

Briefing and Debriefing Considerations

It is clear that the long-term psychological consequences of a case such as this depend greatly on the approach used by session faculty. A skilled briefing should be used to frame the experience from the outset as a unique and valuable learning opportunity.33 By dispelling distrust and assuring learners that any events occurring as part of the scenario are intended for their educational benefit, faculty can create and maintain a nonpunitive learning environment.26,30,33 This is especially important when simulated patient death is a significant possibility.30 Based on our experiences, we recommend that learner and facilitator experience be used to dynamically decide how strongly to suggest the possibility of this error or the relative likelihood of patient death. For less experienced educators who wish to address this issue or for relatively inexperienced learner groups, we suggest declaring the possibility of misdirection outright to partially defuse the emotional tension generated.

The possibility of mannequin death can also be explicitly mentioned during debriefing as an additional psychological safeguard.30 Given the potential for simulator death, this scenario should only be facilitated by those with some formal training in debriefing techniques, and faculty should have enough repetitive practice at debriefing during simulated educational sessions to feel comfortable handling emotionally difficult conversations. For less experienced faculty, we recommend altering the outcome of the case to avoid death altogether, with the patient simply remaining in the initial pulseless dysrhythmia if the order is unsuccessfully challenged. Certainly, our specific briefing and debriefing approaches are not the only means of addressing these ethical issues. With any approach, an ongoing sensitivity to the experience level of the learners and their moment-to-moment emotional state will help ensure psychological safety and support.

Limitations of the Approach

The primary limitation of emotionally charged scenarios is the degree of educator expertise needed to manage participants’ reactions and stress. This scenario, in its original forms, is not for the novice simulation program. As discussed, however, alterations are possible that could mitigate this issue and render this and others like it accessible to less experienced educators. Modifications can also be made to best match the learning goals or “profile” of the participants. In fact, clinicians from different disciplines will likely respond differently to hierarchy. This effect may also extend to different institutional, geographic, and international regions, as each contributes to the background culture and behaviors of the learner team.6

It has yet to be determined if using scenarios like this frequently might diminish their efficacy within an institution. On the one hand, learners might discuss the scenario contents with future participants. Previous knowledge of the confederate’s existence could possibly obviate the impact of the required psychological dilemma. An “appropriate” response would then not be based on an authentic reaction to hierarchy but rather on a possibly distracting search for the confederate. Conversely, it is possible that initial knowledge of the situation could potentiate learning by increasing learner awareness of the issues and giving them a chance to consider how they would approach such a situation before the session. This is an area where more research would be useful.

Finally, educational outcomes were not assessed after the initial sessions of this case, and so the objective effect of this approach on learning cannot be commented upon.


Hierarchy exists in medicine, and failure to communicate across this hierarchy can have significant consequences. We describe the enactment of a scenario involving educator misdirection and potentially deadly outcomes resulting from hierarchy issues. Although misdirection and simulated patient death have generated significant controversy within the simulation community, we contend this approach can be ethically viable when conducted within a safe educational space. Currently, an empirical foundation does not exist to resolve this controversy, as we have little real data regarding the objective effect of such scenarios on the emotional state of participants or their long-term behavior. We suggest this as a fruitful locus of future research and envision a study using this or a similar case in which the emotional states of participants are ascertained via an appropriately validated survey before the session, immediately after the simulation and after the debriefing. With an appropriate control, such a study could shed light on both the stress generated by the scenario and on the effectiveness of debriefing in its mitigation. Further qualitative work could then assess learners’ perception of hierarchy and the impact of that perception on their practice over time. Clearly, this is a controversial area that requires thoughtful and sensitive exploration. It is our hope that regardless of the perspective readers presently hold, this article will serve as encouragement to pursue such investigations.


The authors thank Timothy Hatcher, PhD, Workforce and Human Resource Education, North Carolina State University, for his consultation on instructional ethics.


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Hierarchy; Teamwork; Crisis resource management; Dysrhythmia; Hyperkalemia; Medical error; Patient simulation; Medical education; Multidisciplinary simulation; Error avoidance; Ethics; Misdirection; Simulator death; Psychological safety in simulation

© 2013 Society for Simulation in Healthcare