The Short Answer: A synthesis of 31 studies found 77% of OR staff have experienced disrespect or abuse — yet only 7% confronted it. The authority gradient silences those most likely to spot errors. When names and roles are visible, people are harder to dismiss and harder to ignore.

The Evidence

Pattni et al. (2019) published a narrative synthesis of 31 studies on hierarchy and speaking-up behaviour in the British Journal of Anaesthesia. The findings were stark: 77% of healthcare professionals had experienced disrespect or abuse at work. Only 7% confronted the person responsible.

The biggest barrier was the authority gradient, the perceived power gap between senior and junior staff. In simulations where supervising doctors made deliberate errors, most trainees failed to challenge the mistake. Even when patient safety was clearly at risk, the hierarchy held.

This Is Not Theoretical

The Bristol Royal Infirmary Inquiry remains one of the most devastating case studies in British medicine. A steep hierarchy contributed to preventable paediatric cardiac deaths. Junior staff who recognised problems did not feel empowered to raise them. The power gradient was too steep, and children died as a result.

Across healthcare, the pattern repeats. People see problems but stay silent because of who is in the room. A scrub nurse notices a swab count discrepancy but hesitates to interrupt the consultant. A trainee spots wrong laterality but cannot bring themselves to challenge their supervisor. The cost is measured in patient harm.

Why Anonymity Makes It Worse

Hierarchy is harder to challenge when you are invisible. When a junior nurse is just “one of the scrub team,” anonymous behind a mask and gown, dismissing their concern is easy. They are a role, not a person.

But when their name and role are visible, they become a named individual with professional standing. It is harder to dismiss Sarah, the senior scrub nurse, than it is to dismiss an anonymous voice from behind a mask. Visibility confers a kind of professional weight that anonymity strips away.

Breaking the Gradient

Flattening OR hierarchy is a complex cultural challenge that requires sustained effort at every level. But one simple step is making everyone identifiable. A personalised scrub cap with a name and role is not a complete solution. But it removes one of the conditions that allows anonymity-enabled silence to persist.

When people are known, they are harder to ignore. When people are harder to ignore, patients are safer.