Aim
Charles K. Hofling (1966) created a more realistic study of obedience than Milgram’s by conducting field studies on nurses unaware that they were involved in an experiment.
The main aim of the Hofling Hospital Experiment was to investigate obedience to authority in a real-world setting, specifically within a hospital environment.
The experiment was designed to test the extent to which the nurses would obey the doctor’s commands, even if they were asked to perform an action that could potentially harm a patient.
Method
An unknown “doctor” (actually a confederate in the experiment) called the hospital and ordered the nurses to administer a dangerously high dose of a (fictional) drug to a patient. The dose was twice the maximum daily limit stated on the drug’s label.
The procedure involved a field experiment involving 22 (real) night nurses. Dr. Smith (the researcher) phoned the nurses at a psychiatric hospital (on night duty) and asked them to check the medicine cabinet to see if they had the drug astroten.
When the nurse checks, she sees that the maximum dosage is supposed to be 10mg. When they speak with the ‘Doctor’, they are told to administer 20mg of the drug to a patient called ‘Mr. Jones’. Dr. Smith is in a desperate hurry, and he will sign the authorization form when he comes to see Mr. Jones later.
The phone call ended when the nurse either (i) obeyed the doctor’s order; (ii) resisted the order; (iii) went to get advice; (iv) became upset; (v) could not find the medication; (vi) or if the call lasted longer than 10 minutes.
The medication was not real, though the nurses thought it was. The drug itself was a harmless sugar pill (it was a placebo) invented just for the experiment.
An observer on the ward stopped the study when the nurse got the medication and approached the patient; the nurse began to contact another professional, or it had been over 10 minutes since the call.
If the nurse administers the drug, they will have broken three hospital rules:
1. They are not allowed to accept instructions over the phone.
2. The dose was double the maximum limit stated on the box.
3. The medicine itself as unauthorized, i.e. not on the ward stock list.
The study also used a control group to compare the findings from the experimental group.
In another hospital, 21 student nurses and 12 graduate nurses were asked to complete a questionnaire about what they would do if confronted with the experimental situation.
These participants were not exposed to the actual experimental situation (the doctor’s phone call).
Instead, they were given a questionnaire asking them how they would respond if faced with the same scenario described in the experiment.
Results
In the experimental group, 21 out of 22 (95%) nurses obeyed the doctor’s orders and were about to administer the medication to the patient when a hidden observer stopped them.
Only one nurse questioned the identity of the researcher (“Doctor Smith”) and why he was on the ward.
The nurses were not supposed to take instructions by phone, let alone exceed the allowed dose.
11 nurses who went to administer the drug admitted to being aware of the dosage for Astroten. The other 10 did not notice but judged that it was safe as a doctor had ordered them to do so.
When other nurses were asked to discuss what they would do in a similar situation (i.e. a control group), 31 out of 33 said they would not comply with the order.
Conclusion
Hofling et al. demonstrated that people are very unwilling to question supposed ‘authority’, even when they might have good reason to.
When the nurses were interviewed later, they pointed out that many doctors were in the habit of giving orders by telephone and became seriously annoyed if they were not obeyed.
Although such obedience was against regulations, the unequal power relations between doctors and nurses meant life would be very difficult if nurses did not do what they were told.
Hofling’s study showed how the social pressure brought about by the imbalance of power could lead to a nurse actually putting a patient at risk, rather than disobeying orders.
Strengths
High ecological validity
A strength of this study is its high ecological validity, which is due to the fact that it was conducted in a real-life environment.
The study was conducted in a real hospital environment, and the nurses were unaware they were participating in an experiment, so there were no demand characteristics as they did their everyday jobs, acting normally.
Replicability
Another strength of the Hofling Hospital Experiment is its high level of replicability. Replicability refers to the ability of a study to be repeated by other researchers.
In this study, the procedure was standardized, with the “doctor” giving the same scripted instructions to each nurse over the phone so it could be replicated.
Furthermore, the decision of when to end the phone call was operationalized, meaning that there was a clear, objective criterion for determining when the call should be terminated. This operationalization contributes to the replicability of the study, as other researchers can follow the same procedure and criteria when conducting a replication.
The high level of replicability in the Hofling Hospital Experiment allows for further testing of the findings and helps to establish the reliability of the results.
Control group
The inclusion of a control group in the Hofling Hospital Experiment is another strength of the study. The control group, consisting of nurses who were not exposed to the experimental manipulation (the doctor’s phone call), allowed for comparisons to be made between the experimental and control conditions.
The nurses in the experimental and control groups were closely matched on various participant variables, such as age, sex, marital status, length of working week, professional experience, and area of origin. This matching process, known as matched participants, helps minimize the influence of individual differences on the results.
Weaknesses
Attrition
The control group was comprised of 33 nurses, whereas there was only data for 22 nurses in the experiment. This indicates that the study had a high rate of attrition (i.e., high dropout rate).
Ethical issues
The study broke the ethical guideline of deception, as the doctor was real. Also, some nurses were left distressed by the study, so they lacked protection from harm.
The experiment placed the nurses in a highly stressful situation, where they faced a conflict between obeying the doctor’s orders and adhering to hospital rules and their own training. This stress could have had negative psychological consequences for the participants.
While the nurses were debriefed within 30 minutes of the phone call, this does not necessarily negate the potential harm caused by the deception and stress experienced during the experiment.
Lacks reliability
Rank and Jacobson (1977) tried to replicate Hoflings study using a real drug which the nurses had heard of, but did not get similar results.
They believed that the nurse’s knowledge of the drug, specifically the consequence of an overdose, meant they could justify their defiance to the doctor more easily.
This knowledge provided them with a stronger justification to defy the doctor’s orders, as they could cite the potential harm to the patient as a reason for not complying.
This variation in findings between the original study and the replication attempt indicates low reliability, as reliability refers to the consistency of results when a study is repeated under similar conditions.
References
Hofling, C. K., Brotzman, E., Dalrymple, S., Graves, N. & Bierce, C. (1966). An experimental study of nurse-physician relations. Journal of Nervous and Mental Disease, 143, 171-180.
Rank, S. G., & Jacobson, C. K. (1977). Hospital nurses” compliance with medication overdose orders: a failure to replicate. Journal of Health and Social Behavior, 188-193.
