Charles Hofling, Eveline Brotzman, Sarah Dalrymple, Nancy Graves & Chester M Pierce, 1966

AIMS: to investigate aspects of the nurse-physician relationship – specifically what happens when a nurse is required to carry out a procedure which goes against her professional standards.

A secondary aim was to see whether nurses were aware of how obedient they tended to be.

PROCEDURE (METHOD):  3 psychiatric hospitals in the American Midwest took part in this study, with one of them acting as a control.

22 uncomprehending nurses from the other two hospitals were used for the experiment - 12 public wards and 10 private. Participants were closely matched for age, sex, race, marital status, length of working week, professional experience and area of origin.

While alone on the ward on night duty - 7-9 PM, just before evening visiting to just after it, when doctors are not normally around and medication is not normally administered - they received a phone call from an unknown “Doctor Smith from the Psychiatric Department” asking them to administer 20 mg of ‘Astroten’ to a patient, ‘Mr Jones’, who needed the drug urgently. The caller, who claimed to be running late, said he would sign the authorisation papers when he arrived at the hospital in about 10 minutes time. Amongst the ward’s drugs were bottles containing fake pills labelled Astroten 5 mg. Maximum dose 10 mg. Do not exceed the stated dose. (The capsules in fact contained glucose, harmless to most patients.)

The researcher playing Doctor Smith used a written script to standardise the conversation and all conversations were recorded. The conversation was planned to end when either:-

• the nurse complied and went to administer the medication
• refused consistently to give the medication
• went to get advice
• became emotionally upset
• the call went on for more than 10 minutes

A researcher (a real doctor) stopped nurses that were moving towards the patient’s bed with the ‘medication’ and all nurses were debriefed within 30 minutes of the telephone conversation. The researcher offered ‘psychiatric first aid’ and played back the audiotape of the call during an unstructured interview.

12 graduate nurses and 21 student nurses  from the control hospital completed questionnaire about what they would do if they were asked to administer a medicine unauthorised for use on their ward by a doctor they didn’t know.

FINDINGS (RESULTS):  The telephone conversations were generally brief without much resistance from the nurses. 16 nurses in debrief said they felt they should have been more resistant to the caller. None became hostile to the caller.

21 of the 22 nurses started to administer the Astroten.

During the debrief only 11 nurses admitted to being aware of the dosage limits for Astroten. The other 10 did not notice it but judged that it must be safe anyway if a doctor had ordered them to administer it. Nearly all admitted they should not have followed the orders as they were in contravention of hospital policy – viz:-

• orders to administer medication have to be given in person - though several nurses stated they expected ‘Dr Smith’ to appear promptly
• the nurse is required to know the order is from a genuine doctor and to check if not sure
• drugs unauthorised for use on a ward cannot be administered

However, many of the nurses stated obeying a doctor’s orders without question was a fairly common occurrence. 15 nurses said they could recall similar incidents and that doctors were displeased if nurses resisted their orders.

Amongst the control group, 10 of the 12 graduate nurses and all 21 students said they would not have administered the medication. Most believed other nurses would behave in the same way.

One nurse questioned the identity of the observer/researcher and why he was on the ward.

CONCLUSIONS: Nurses will knowingly break hospital rules in a way that endangers a patient’s life, if given orders by a doctor.

CRITICISMS (EVALUATION): The study has high ecological validity. The nurses were unaware of the set-up so their behaviour was natural. Comparison between the control group’s questionnaire responses to the actual practice of the nurses in the experimental situation shows the difference between what people think they would do and what they actually do.

Population validity was high as the nurses were simply those on duty at the time. However, from a 40+ years retrospective viewpoint, it could be argued that the study suffers from historical bias and cultural bias as people in the USA at the time were more likely to obey authority than people from other cultures.

Charles Hofling’s study had high experimental validity – in other words, it did test what it set out to test: the nurse/doctor relationship.

The experiment had high reliability. It was run 22 times, with the procedure and conditions the same each time. The results were very similar each time. However, as with any field study, it is hard to control all of the variables and some of the nurses may have been distracted or busy such that they reacted to Doctor Smith’s call without thinking.  Against this possibility must be weighed the fact that Hoffling had an observer (the real doctor) on each ward to signal when the time was most appropriate to commence the study.

The results support  Stanley Milgram’s Agency Theory. The nurses’ actions indicated they were in an agentic state, recognising and responding to the doctor’s authority.

The principal criticisms of Hofling’s study lie in the ethical issues:-

• the nurses were deceived and had no opportunity to give informed consent
• it could be argued the nurses suffered psychological harm – in the debriefs nurses admitted to feeling shame, guilt, embarrassment and that their professionalism had been undermined

Steven Rank & Cardell Jacobson (1977) queried the facts that the nurses had no knowledge of the drug involved and that they had no opportunity to seek advice from anyone of equal or higher status. (Both of which would apply in most hospital situations.)

They replicated Hofling’s experiment but the instruction was to administer Valium at 3 times the recommended level, the telephoned instruction came from a real, known doctor on the hospital staff and the nurses were able to consult with other nurses before proceeding. Under these conditions, only 2 out of 18 nurses prepared the medication as requested.

Rank & Jacobsen concluded:  “nurses aware of the toxic effects of a drug and allowed to interact naturally – will not administer a medication overdose merely because a physician orders it.”

However, Eliot Smith & Diane MacKie (1995) reported that there is a daily 12% error rate in US hospitals and that “many researchers attribute such problems largely to the unquestioning deference to authority that doctors demand and nurses accept.”

The same year Annamarie Krackow & Thomas Blass gave a questionnaire to 68 nurses which asked about the last time they had disagreed with a doctor’s order. 2 factors emerged as key to whether the nurses would or wouldn’t obey. Most importantly was whether the nurses recognised the doctor as a legitimate authority with the right to make the decision in question. However, the nurses were also influenced by the consequences for the patient; if these would be serious, the nurses were more likely to take responsibility and challenge the order.