Table 3 Identified themes and sub-themes from semi-structured interviews with OR team members

Harassment and bullying

We have what we call a blue form, so you can blue form any employer, any staff, which means, it's like a warning. It's like any type of harassment or violence, or aggression, anything and it's done anonymously. There are a couple of handful of male surgeons that have been blue formed by their colleagues a number of times and they still keep doing whatever they’re doing. It’s like, oh it’s okay because it’s him. It’s so and so. That’s how he is. Well, that’s not an excuse for him to keep doing that. Right? - Woman RN 012

Having to accept “how it is”

I guess I’ve learned a lot about how to interact with male surgeons over the years... I remember when I started practice that it was definitely, you know, something you think about. I thought about it a lot and sort of how to... I learned a lot about that when I was younger… You know, just being pushed around. Yeah. Like, you know, you want to do this case and you want to do that, and what do you mean, you want to cancel, and why do you want to cancel. And I always sort of felt like defensive. And I don’t anymore at all. So, I just say, “This is how it is” … - Woman anesthesiologist 009

Proving yourself

You have to work so much harder to prove yourself, that you’re legit. You’re good at what you do and have people respect you. So, yeah, being a female and also being a nurse, nurses are always kind of underlooked. I think it makes it harder on us to communicate, to be respected, to be heard by everybody. – Woman RN 008

I think that, as a male surgeon, I probably got a bye early on. I think my female colleagues probably have more of an uphill battle in the early days to establish themselves as the, you know, surgeon in the room, the leader in the room. So, I think we start out… I think at the beginning of the career, the women are at a disadvantage… I think all comers first day in the OR, a man probably has an easier time. – Man surgeon 016

Women taken less seriously/not listened to

…I could be working on a case for three hours, telling the surgeon… “I’m concerned about the bowel.” And the surgeon’s, like, “Okay, okay, okay, okay.” And another Fellow... so exactly of my training, male, tall, would come in and, you know, chit-chat a little bit… And then the Fellow... would say, “Whoa, look at that valve! Look at the gradient!” And the surgeon’s, like, “What? Oh, I didn’t realize it was that bad.” And then, honestly? Change the entire surgical plan and go into fix that valve. And I found [it] infuriating because I was telling them that. And there were examples in Fellowship where... I can only say it was gender because other Fellows of my exact same training who were male would come in and say the exact same finding, and the surgeons would listen… And meanwhile, you know, I’m using all of my possible red flags of concern and they’re not listening… [and even] if I was with a female attending, honestly, we would have to call in a male attending sometimes to give the exact same finding for the surgeon to look into it, to change the surgical plan. – Woman anesthesiologist 003

…so I was loading up a new scalpel blade for [the surgeon] because he wanted a fresh one. While I was doing that, he asked for three other instruments and I was like, “Okay well give me a sec, let me load this up first, I can get that for you in just a sec.” …and he couldn't wait for a second. So, I look up for a quick second because I see three arms going across my surgical table and most people know you're not supposed to touch the scrub nurse's table. That's off-limits, you need to ask for permission. I just see three hands going over, the resident's and the fellow… and the next thing I knew I had cut myself with the blade because I didn't load it up properly because I was rushing to tend to them and to see what they were grabbing or whatever. So, now I have a deep laceration, I have seven stitches because of it. – Woman RN 002

Differential respect

Yeah…it still comes across as very kind of patriarchal sometimes when you look at how... I mean, especially the older physicians, 'cause that’s kind of the environment they were raised in, but... whether it’s speaking to the female nurses or other female physicians or whatever it is, sometimes they kind of come across as very... patriarchal as opposed to when a man is talking to a man, or when they talk to me, it’s this weird kind of like... like mutual respect, I guess? As like, “Oh, well, you’re... you’re also a man and so I can talk to you normally.” – Man RN 001

Lower confidence in decisions as a trainee

A lot of the time I have some clinical decisions that I have made in my mind, but I have some doubts regarding these decisions, and so I wait until I've discussed them with my staff before implementing the decision… so I have been told by many female staff that this hesitation is likely coming from being less confident… and that they felt the same way for many years before really deciding that they were going to speak up or they were going to do that or so on… as opposed to many, many male trainees who make a decision and right away act on it with a lot of confidence. – Woman anesthesiologist 005

“Boys club” mentality

[teamwork] It’s a... it’s a gender thing. It’s sort of, you know, it’s... it’s that, still, it’s a, you know, the boys club or something. Especially with the older male surgeons and, you know, and, or males in the OR sort of thing. – Man RN 003

Women are often outnumbered

I can’t think of any other contributor to why they wouldn’t listen to me and they would listen to the other, male Fellows. Working in an environment that’s, like, hugely male-dominant, there’s no female cardiac surgeon there. There’s [very few] female anesthesiologists [compared] to male anesthesiologists. – Woman anesthesiologist 001

Fear of speaking up to male surgeons

I would say watching a lot of the newer nurses come in, a lot of them are scared, terrified to speak up, to speak up to the surgeon. And I would say in a sense I’m still working on that, because there is that tension and that ‘oh he’s the surgeon', and whatever he says is going to be right. This may be a silly question, I'm afraid to ask. You know, that hesitancy you have... Terrified to talk to the surgeons or ask anything. Now after seven years, I’m going to ask and just be upfront. Sometimes it’s still hard, it depends on who it is, right? But definitely, for lots of new nurses and most of them are female, it is super hard. – Woman RN 013

Tension with women surgeons

… I find some females are trying so hard to put themselves and make themselves… assertive... I think because it's such a male-dominated field… I think they have to, like, assert themselves in that field, like, in their role, but it comes across as, like, almost b*tchiness, I don’t know if that’s the right term… and it’s like whoa, I’m a female too... like I get we’re working with all males, they don’t need to... they don’t need to be rude to me, I didn’t do anything. – Woman RN 015

Impression management; performativity

We say that, you know, as a female surgeon, you're either a pushover or you're a b*tch. Like you kind of have to be one or the other, that you can't just be neutral because you just sort of get… this sort of attitude of people are less willing to do things for you than your male colleagues… And I think being on staff you… there's a power dynamic that you have regardless but really trying hard not to be-- not to be labelled as being b*tchy and being overly demanding. I would say there's a lot of things that I do for myself that I am very sure that none of my male colleagues do for themselves… like getting equipment, planning ahead and making sure like if I need something extra that I will go do it myself or go get it myself to make sure it's there. Or if the case happens and you ask for it and people don’t listen, you just kind of have to ask again nicely. There's no… yelling for things. – Woman surgeon 010

Cases not prioritized

…the Plastic Surgeon I was telling you about… when it comes to urgent bookings, there’s a policy to it, right? Like how urgent is this case? …So, like the surgeons will fight at the desk, they’ll say, “Oh no, my patient needs to go ahead of yours because this is more urgent or because this and this.” I see it, this Plastic Surgeon, she oftentimes gets bumped by people. I mean, there’s one thing being bumped by just the nature of how sick the patient is. That’s understandable. But there’s another reason bumped because, ‘It’s Dr. [name]…’ I see a lot of male surgeons that talk bad about her behind her back because she’s got a loud personality and she’s so particular. – Woman RN 014

Assertive women surgeons are perceived negatively by others

I think... I’ll just say that I think at baseline that... for, if the same words, the same actions, that are performed or said by me, they are-- that are done by a female surgeon, that female surgeon can be viewed... I would be more likely to be viewed as assertive, authoritative or a strong leader, but a female surgeon is very much likely to be viewed as, you know, hostile... I’m not going say the ‘B’ word, but... you know, that’s all real. – Man surgeon 004

Tension with women nurses

… I find the assumption, when it’s like a female-to-female interaction, is that you are bossy or aggressive or think you know it all or think you’re better than them. And so if you kind of take the stance of, “I’m just gonna bring myself down,” then people kind of don’t see you as a threat. But it’s sad that you have to do that… Like, I have to consciously represent myself as, like, “Please help me. I don’t know what I’m doing.” As opposed to, like, any sort of confidence and expertise is perceived as a threat. And I think that, especially in the OR environment... and I will say especially a female Surgery resident. Often there’s a lot of kind of pushback from the Nursing staff and it becomes sort of important to kind of form an ally rather than have an enemy. … I think that also the interaction female-to-female is a much more difficult interaction than male-to-female or male-to-male. …you know, the stereotype of a surgeon is an old white male. And the stereotype of a nurse is a young female. And I think when there’s anyone that is not in those roles, the dynamic can be different. So, having a young female surgery resident… it’s more difficult and you have to be more sort of conscious in your efforts to form it than some of our male colleagues have to. – Woman surgeon 009

Adapting specific communication strategies

And I would say I’ve had to adapt different ways of engaging team members than maybe some of my other colleagues and that’s based on advice I’ve had from more senior female anesthesiologists. So using language more carefully as opposed to posture and sort of just implying that you’re in control. So escalating your language to be like ‘I am concerned,’ I think that… being very explicit. Other things that I had that work is if I stand on a step stool so that I’m higher (laughs). And just sort of like verbal and nonverbal cues that I don’t think my male colleagues are using. – Woman anesthesiologist 007

Not being perceived as physicians

It’ll be myself and a male medical student and, you know, I’ll tell the patient all about their surgery and then they’ll turn to the male and say, like, “What’s your opinion, doctor?” – Woman surgeon 005

Co-worker vs. friend

…when you have kind of two guy nurses working in the same room, it’s like working with your buddy as opposed to working with a co-worker more… yeah, it’s kind of a weird... when you’re a kid you have more guy friends than you do girlfriends and so when you enter a work environment and you’re working with another guy, it’s like, “Oh, yeah, you’re my…” like, you’re my buddy, you’re not my co-worker in the same... in the same sense as it would be with somebody of the opposite gender. – Man RN 004

Male nurse – male physician interaction

I’m a man nurse, which is, on its own, not as common, but we’re definitely a lower population. And so that... it kind of changes the dynamic being a male nurse in an environment where you’re different from everybody else who’s on your team, but then on the flip side, a majority of the surgeons and anesthesiologists are male, so I find, being a man in an environment where it’s primarily men, there’s kind of automatically that understanding, I find, or some innate communication style that men have with each other… it helps to communicate with the other teams, being a male, but then it also changes the dynamic... the dynamic because I’m a male who isn’t a doctor in that environment. And it’s kind of bizarre. ‘Cause it helps, but then it... it still puts me in kind of a weird position because a lot of the time they’re talking kind of man-to-man with other physicians and so, when I kind of enter that realm, it’s like I’m one of them but not one of them. – Man RN 001

Men communicate more directly

And so I don’t think it's an advantage, you know, it's getting better because there's more and more males working in the operating room here. One thing I do notice, there's less bickering when there's more males around. So there's more communication and it's more direct, to the point than p***ing around the pot. – Man RN 002

Men can be perceived by others as intimidating

So even though I’m not willingly, or hopefully not even unconsciously trying to behave in a way that influences teamwork, I might be perceived as intimidating. And my gender therefore would not help in that. If I’d be a petite woman with a soft voice, I’m sure I would not be as easily perceived as intimidating. So even though my intentions are not that way, I can see that being a man influences that. – Man anesthesiologist 004

Women can be perceived as less dominant

I always find it easier to interact with women in the operating theatre. I think that women are less likely to try and assume control or be domineering. – Man anesthesiologist 002

Women are soft-spoken; men are loud

Yeah, I think just, for me, personally, I am soft-spoken, but not all females are soft-spoken. There’s definitely some females that you can hear very loudly. But I think we, as a gender, females, are less loud than males. And that does affect teamwork. – Woman anesthesiologist 008

Different flow depending on who you are working with

Well I wouldn’t say, like, physically, because they’re females, they’re weak or something, but you know, but in terms of, like, when you’re working the Ortho, which is more, you know, like, there’s more demands about physical work, I’m not saying that some... some... I’m not saying that, you know, but you have, you know, older generations of coworkers that still works in Ortho and... so, but definitely the flow, the pacing, and when you work with someone, like, especially with males, and stuff. We work like... I don’t know... we’re not saying that I work faster than females but, you know, it’s just the physical attributes, I guess… - Man RPN 001

Accent/language

I have an example in mind, of fellows that come from distant lands, English is not their first language and I think a natural response that I witness in the OR, even if I try not to practice it myself, is if you talk to them and they don’t seem to understand, the first reaction is to talk louder and then to... there’s almost like… an irresistible urge to treat that person as less intelligent, as less competent. And, and, you know, you always make an effort not to do it, but I do witness it, 'cause we have a number of foreign graduates who work with us. And I think you have to be very, very careful to not let that interfere. – Man anesthesiologist 006

Age

Yeah, I feel like also my age, kind of, because I’m only 24. I’m the youngest nurse so even though I’ve been there two years, people that have started only six months ago that are in their 30’s, even if they’re brand new nurses too, they’re almost more listened to sometimes just because they look older and more mature. – Woman RN 011

Age and experience

I'm a little bit more senior so I think as I become more senior, I've been able to navigate those waters. You start to learn, you know, really that if someone’s upset it's not really about you…You learn these things as you get older. You become less self-centred perhaps. So I think age, I think a certain maturity in your clinical career, a certain comfort with your abilities brings a level of like stand down your anxieties a little bit, you know you can get through this case. –Woman surgeon 003

Age and gender

... you’re often taken less seriously. And I can’t separate whether that’s because I’m young or whether it’s because I’m a female... and I think it’s likely both. I think that young males are taken more seriously than young females are. But I think the older females are also taken more seriously than young females are, so you’re kind of like [expletive]. I think it also... and that’s from everyone, whether it’s kind of conscious or not. – Woman surgeon 008

Experience

...initially on, especially the first few months of residency or medical school or as a junior resident, it’s very difficult to be engaged and feel like you’re part of the team. It’s more like a fly on the wall, kind of how you feel. But with... as the training goes on and in the senior years, the biggest difference I’ve noticed is truly becoming part of the team and my input being valued by various team members and nurses and, and things like that. – Man surgeon 010

Gender and experience

I think junior, you know, when I was sort of being... felt a bit tested, and I don’t know if it was because of a gender thing or if it was because of a junior thing, and I do think that gender had part of it to do with it. It was... these were, you know, older, senior, male surgeons that were doing those sorts of things [challenging decisions]. – Woman anesthesiologist 004

Gender and profession

So, yeah, being a female and also being a nurse, nurses are always kind of underlooked. I think it makes it harder on us to communicate, to be respected, to be heard by everybody. – Woman RN 003

I was an orderly before, I’ve been with the hospital for 25 years, so but before I became a nurse and stuff. But as a nurse... being a male nurse, I think, compared to being a female nurse, I have an easier time with the dynamics of the surgeons and stuff in the sense that, I have an easier time saying, “Do this. Do that.” And I find there’s still that male/female sort of thing out there in our field, that I get more respect from them and I get less flak from them when I say, you know, “If you want this quicker, do it.” You know, “Stop complaining.”… where I’ve sat there, and I’ve watched my female counterparts sort of do the same thing and they totally brush them off. – Man RN 005

Gender and ethnicity

Well sometimes with a male they can be more dominant…We, let’s say especially Filipinos, we’re more just generally… more of an inferior kind of culture, more of like a humble type low profile, if I may say. So, I guess that also kind of affects how we work in the OR. Not all but just learning to develop a voice in the OR, so sometimes we’re afraid to speak up and speak out, even if we know something is not right. Sometimes we might feel like “Oh this guy won’t listen to me.” – Woman RN 010

Location of training (international medical graduates)

The surgeons might be more welcoming or not as stern with that certain resident [who trained here]… Rather than someone who’s an IMG, like an International Medical Graduate. Doing some sort of, fellowship here… It might be just a subtle practice. People may not even think that they’re doing that. Yeah. Kind of sort of conversations, I’m thinking of conversations or sort of the way they do treat one person over the other. – Woman RPN 009

Ethnicity and language/accent

Yeah. I have witnessed… because we supervise more junior residents and medical students. I would say that there are some cultural barriers as well if there’s a perception that you were not trained within the Canadian system, and often that assumption is made on the basis of race, accent, English as second language sort of perceptions. I would say that there’s more hesitancy towards engaging that person training. – Woman anesthesiologist 002

The influence of gender will change with more women in medicine

But things are definitely changing. As there are more and more women in medicine and few... fewer men... I think we don’t have a choice to... to... to... to accept that. To... to... to implement that new reality, basically. – Man anesthesiologist 003

OR culture is improving but there are still inappropriate comments

I think historically I’ve heard more of those kinds of tantrum behaviours and physical outbursts and things that we don’t hear so much of anymore. Of people throwing things and screaming and saying things, yes. That isn’t acceptable. I think to some degree, I mean there might not be those kinds of outrageous acts but I think sometimes there is maybe communications between male doctors and maybe female nurses that still aren’t acceptable. – Woman RN 004

Gender becomes less important once you know each other

And I’d say when people know me more, I think it’s not the case, but I can’t know everyone well and I’d say it’s usually when you’ve… so I’m a subspecialist in thoracic anesthesia so when I work more often with the thoracic surgeon and with the nurses that do more regularly thoracic, I think things work well and there’s no such a thing [as a gender hierarchy]. But sometimes I work in an environment that I don’t go very regularly, and I get… I notice that sometimes… I mean it’s not the same. It’s not like we’re with friends. – Man anesthesiologist 008

Recognition of (white) male privilege

Again, possibly, as a 32-year-old white dude, I’m not... I don’t suffer from, like, a lot of these... not a lot of stereotypes or anything that is affected by my ethnicity or gender or anything like that... it’s something I’ve literally never once in my entire life been like ‘oh, I’ve just been treated that way because I’m a 30-year-old white man’ other than probably good things, other than probably unfair good things, where I’m like, oh, nobody questioned me or bothered me and because... so, it’s something that I’ve noticed, because it’s almost probably universally positive. Unfair, but positive responses that I get directed towards me. – Man surgeon 013

Men can stand up to help women in the OR

So, because the... there’s quite a few females there, like, I was one of maybe five guys in the O.R there. I think me coming in and me sort of standing up for myself about things that they would’ve never done... I think that sort of allowed them to be more comfortable with trying it on their own as well. I think... I think if anything, they’re... you know, trying to stick up for themselves a little bit more... it’s hard to be the only one going against the whole wave of doctors and surgeons, right? But... so I think having more people and sort of teaming up, it... I think it helps. – Man RN 002

Managing unconscious bias

I think that even though there are a lot of people who say that they’re not biased one way or the other sex, I think there’s always an element of potential unconscious bias there. And I think we always need to be aware of and try to manage. – Man anesthesiologist 001